Joyce Frieden

Salt Wars: Revenge of CSPI

First the federal government was sued for taking too seriously data concluding that high salt intake contributes to heart disease. Now it's being sued for not taking those data seriously enough. In the latest suit, filed in the U.S. Court of Appeals for the District of Columbia Circuit, the Center for Science in the Public Interest alleges that the Food and Drug Administration has unreasonably delayed recognizing salt as a food additive and regulating its use in processed foods. “There is no way the FDA can look at the science and say with a straight face that salt is 'generally recognized as safe,'” said Michael Jacobson, of CSPI. The Salt Institute, which sued the Department of Health and Human Services for failing to release the data supporting its recommendation of cutting down on salt intake as a way to avoid heart attacks and strokes, took a dim view of CSPI's action. “Mr. Jacobson says that diets too high in salt are responsible for 150,000 premature deaths each year in the United States,” said institute president Richard L. Hanneman. “There is no evidence supporting this claim.”

Alzheimer's Bill Introduced

Rep. Christopher Smith (R-N.J.) has introduced H.R. 1262, the Ronald Reagan Alzheimer's Breakthrough Act. The measure would double funding for Alzheimer's disease research at the National Institutes of Health from $700 million to $1.4 billion and increase funding for gerontology training, patient education, and caregiver support programs. The act “offers a comprehensive approach for treating current Alzheimer's patients and researching potential cures to reduce the number of those who will struggle with this disease in the future,” Rep. Smith said in a statement. “We will be working overtime to secure passage of this critical legislation.” The House measure is cosponsored by Rep. Ed Markey (D-Mass.) and Rep. Mike Burgess (R-Tex.); a companion bill was introduced in the Senate by Sen. Kit Bond (R-Mo.) and Sen. Barbara Mikulski (D-Md.).

CMS on Diabetic Neuropathy

The Centers for Medicare and Medicaid Services has issued instructions to carriers explaining how to reimburse physicians for diagnosing and treating diabetic neuropathy. The instructions note that Medicare covers evaluations of the feet “no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and loss of protective sensation (LOPS), as long as the beneficiary has not seen a foot care specialist for some other reason in the interim.” LOPS should be diagnosed with a 5.07 monofilament using established guidelines. The instructions also note that “once a beneficiary's condition has progressed to the point where routine foot care becomes a covered service, payment will no longer be made for LOPS evaluation and management services.” The instructions can be viewed online at

http://www.cms.hhs.gov/manuals/pm_trans/R498CP.pdf

Autism Education Costs High

The cost of educating children with autism is almost triple that of educating children who receive no special education services, according to a report from the Government Accountability Office. The GAO reviewed data from the Special Education Expenditure Project funded by the Department of Education and found that the average cost of educating a child with autism was $18,000 in the 1999-2000 school year. That estimate “was among the highest per-pupil expenditures for school-age children receiving special education services in public schools,” the report stated. It also noted that the number of children with autism who were given special education services has increased by more than 500% in the last decade.

Pay-for-Performance Principles

Any “pay-for-performance” program should offer voluntary physician participation and foster the relationship between physician and patient, the American Medical Association asserted in a new set of principles for such programs. Such a program should also use accurate data and fair reporting, provide program incentives, and ensure quality of care, the AMA stated. If done improperly, “some so-called pay- for-performance programs are a lose-lose proposition for patients and their physicians with the only benefit accruing to health insurers,” AMA Secretary John H. Armstrong, M.D., said in a statement. Both private and public sector organizations have started offering incentive payments to physicians based on an appraisal of their performance. Before taking on such reforms, however, Congress should try to fix Medicare's flawed payment formula, according to recent AMA testimony.

Conflict-of-Interest Rules Targeted

People with direct financial conflicts of interest should not be put on Food and Drug Administration advisory committees, a coalition of public interest groups has recommended. Financial conflicts undermine “the public's faith in the fairness and credibility of the panel's work,” the Center for Science in the Public Interest, the National Women's Health Network, the U.S. Cochrane Center Consumer Coalition, and eight other groups said in a letter to Acting FDA Commissioner Lester Crawford, D.V.M., Ph.D. The groups cited the FDA advisory committee that recently reviewed the safety of cyclooxygenase-2 inhibitors, noting that 10 of the 32 members had direct financial conflicts. In addition to prohibiting scientists, physicians, and clinicians with relevant conflicts of interest from serving on advisory committees, the groups also recommended that people with any industry ties make up no more than half of a committee.

Salt Wars: Revenge of CSPI

First the federal government was sued for taking too seriously data concluding that high salt intake contributes to heart disease. Now it's being sued for not taking those data seriously enough. In the latest suit, filed in the U.S. Court of Appeals for the District of Columbia Circuit, the Center for Science in the Public Interest alleges that the Food and Drug Administration has unreasonably delayed recognizing salt as a food additive and regulating its use in processed foods. “There is no way the FDA can look at the science and say with a straight face that salt is 'generally recognized as safe,'” said Michael Jacobson, of CSPI. The Salt Institute, which sued the Department of Health and Human Services for failing to release the data supporting its recommendation of cutting down on salt intake as a way to avoid heart attacks and strokes, took a dim view of CSPI's action. “Mr. Jacobson says that diets too high in salt are responsible for 150,000 premature deaths each year in the United States,” said institute president Richard L. Hanneman. “There is no evidence supporting this claim.”

Alzheimer's Bill Introduced

Rep. Christopher Smith (R-N.J.) has introduced H.R. 1262, the Ronald Reagan Alzheimer's Breakthrough Act. The measure would double funding for Alzheimer's disease research at the National Institutes of Health from $700 million to $1.4 billion and increase funding for gerontology training, patient education, and caregiver support programs. The act “offers a comprehensive approach for treating current Alzheimer's patients and researching potential cures to reduce the number of those who will struggle with this disease in the future,” Rep. Smith said in a statement. “We will be working overtime to secure passage of this critical legislation.” The House measure is cosponsored by Rep. Ed Markey (D-Mass.) and Rep. Mike Burgess (R-Tex.); a companion bill was introduced in the Senate by Sen. Kit Bond (R-Mo.) and Sen. Barbara Mikulski (D-Md.).

CMS on Diabetic Neuropathy

The Centers for Medicare and Medicaid Services has issued instructions to carriers explaining how to reimburse physicians for diagnosing and treating diabetic neuropathy. The instructions note that Medicare covers evaluations of the feet “no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and loss of protective sensation (LOPS), as long as the beneficiary has not seen a foot care specialist for some other reason in the interim.” LOPS should be diagnosed with a 5.07 monofilament using established guidelines. The instructions also note that “once a beneficiary's condition has progressed to the point where routine foot care becomes a covered service, payment will no longer be made for LOPS evaluation and management services.” The instructions can be viewed online at

http://www.cms.hhs.gov/manuals/pm_trans/R498CP.pdf

Autism Education Costs High

The cost of educating children with autism is almost triple that of educating children who receive no special education services, according to a report from the Government Accountability Office. The GAO reviewed data from the Special Education Expenditure Project funded by the Department of Education and found that the average cost of educating a child with autism was $18,000 in the 1999-2000 school year. That estimate “was among the highest per-pupil expenditures for school-age children receiving special education services in public schools,” the report stated. It also noted that the number of children with autism who were given special education services has increased by more than 500% in the last decade.

Pay-for-Performance Principles

Any “pay-for-performance” program should offer voluntary physician participation and foster the relationship between physician and patient, the American Medical Association asserted in a new set of principles for such programs. Such a program should also use accurate data and fair reporting, provide program incentives, and ensure quality of care, the AMA stated. If done improperly, “some so-called pay- for-performance programs are a lose-lose proposition for patients and their physicians with the only benefit accruing to health insurers,” AMA Secretary John H. Armstrong, M.D., said in a statement. Both private and public sector organizations have started offering incentive payments to physicians based on an appraisal of their performance. Before taking on such reforms, however, Congress should try to fix Medicare's flawed payment formula, according to recent AMA testimony.

Conflict-of-Interest Rules Targeted

People with direct financial conflicts of interest should not be put on Food and Drug Administration advisory committees, a coalition of public interest groups has recommended. Financial conflicts undermine “the public's faith in the fairness and credibility of the panel's work,” the Center for Science in the Public Interest, the National Women's Health Network, the U.S. Cochrane Center Consumer Coalition, and eight other groups said in a letter to Acting FDA Commissioner Lester Crawford, D.V.M., Ph.D. The groups cited the FDA advisory committee that recently reviewed the safety of cyclooxygenase-2 inhibitors, noting that 10 of the 32 members had direct financial conflicts. In addition to prohibiting scientists, physicians, and clinicians with relevant conflicts of interest from serving on advisory committees, the groups also recommended that people with any industry ties make up no more than half of a committee.

Salt Wars: Revenge of CSPI

First the federal government was sued for taking too seriously data concluding that high salt intake contributes to heart disease. Now it's being sued for not taking those data seriously enough. In the latest suit, filed in the U.S. Court of Appeals for the District of Columbia Circuit, the Center for Science in the Public Interest alleges that the Food and Drug Administration has unreasonably delayed recognizing salt as a food additive and regulating its use in processed foods. “There is no way the FDA can look at the science and say with a straight face that salt is 'generally recognized as safe,'” said Michael Jacobson, of CSPI. The Salt Institute, which sued the Department of Health and Human Services for failing to release the data supporting its recommendation of cutting down on salt intake as a way to avoid heart attacks and strokes, took a dim view of CSPI's action. “Mr. Jacobson says that diets too high in salt are responsible for 150,000 premature deaths each year in the United States,” said institute president Richard L. Hanneman. “There is no evidence supporting this claim.”

Alzheimer's Bill Introduced

Rep. Christopher Smith (R-N.J.) has introduced H.R. 1262, the Ronald Reagan Alzheimer's Breakthrough Act. The measure would double funding for Alzheimer's disease research at the National Institutes of Health from $700 million to $1.4 billion and increase funding for gerontology training, patient education, and caregiver support programs. The act “offers a comprehensive approach for treating current Alzheimer's patients and researching potential cures to reduce the number of those who will struggle with this disease in the future,” Rep. Smith said in a statement. “We will be working overtime to secure passage of this critical legislation.” The House measure is cosponsored by Rep. Ed Markey (D-Mass.) and Rep. Mike Burgess (R-Tex.); a companion bill was introduced in the Senate by Sen. Kit Bond (R-Mo.) and Sen. Barbara Mikulski (D-Md.).

CMS on Diabetic Neuropathy

The Centers for Medicare and Medicaid Services has issued instructions to carriers explaining how to reimburse physicians for diagnosing and treating diabetic neuropathy. The instructions note that Medicare covers evaluations of the feet “no more often than every six months for individuals with a documented diagnosis of diabetic sensory neuropathy and loss of protective sensation (LOPS), as long as the beneficiary has not seen a foot care specialist for some other reason in the interim.” LOPS should be diagnosed with a 5.07 monofilament using established guidelines. The instructions also note that “once a beneficiary's condition has progressed to the point where routine foot care becomes a covered service, payment will no longer be made for LOPS evaluation and management services.” The instructions can be viewed online at

http://www.cms.hhs.gov/manuals/pm_trans/R498CP.pdf

Autism Education Costs High

The cost of educating children with autism is almost triple that of educating children who receive no special education services, according to a report from the Government Accountability Office. The GAO reviewed data from the Special Education Expenditure Project funded by the Department of Education and found that the average cost of educating a child with autism was $18,000 in the 1999-2000 school year. That estimate “was among the highest per-pupil expenditures for school-age children receiving special education services in public schools,” the report stated. It also noted that the number of children with autism who were given special education services has increased by more than 500% in the last decade.

Pay-for-Performance Principles

Any “pay-for-performance” program should offer voluntary physician participation and foster the relationship between physician and patient, the American Medical Association asserted in a new set of principles for such programs. Such a program should also use accurate data and fair reporting, provide program incentives, and ensure quality of care, the AMA stated. If done improperly, “some so-called pay- for-performance programs are a lose-lose proposition for patients and their physicians with the only benefit accruing to health insurers,” AMA Secretary John H. Armstrong, M.D., said in a statement. Both private and public sector organizations have started offering incentive payments to physicians based on an appraisal of their performance. Before taking on such reforms, however, Congress should try to fix Medicare's flawed payment formula, according to recent AMA testimony.

Conflict-of-Interest Rules Targeted

People with direct financial conflicts of interest should not be put on Food and Drug Administration advisory committees, a coalition of public interest groups has recommended. Financial conflicts undermine “the public's faith in the fairness and credibility of the panel's work,” the Center for Science in the Public Interest, the National Women's Health Network, the U.S. Cochrane Center Consumer Coalition, and eight other groups said in a letter to Acting FDA Commissioner Lester Crawford, D.V.M., Ph.D. The groups cited the FDA advisory committee that recently reviewed the safety of cyclooxygenase-2 inhibitors, noting that 10 of the 32 members had direct financial conflicts. In addition to prohibiting scientists, physicians, and clinicians with relevant conflicts of interest from serving on advisory committees, the groups also recommended that people with any industry ties make up no more than half of a committee.

WASHINGTON — A congressional committee wrestled with whether or how much to regulate or impose standards on imaging procedures at a hearing last month on managing Medicare's imaging costs.

“I'm concerned about putting in a whole group of new structures [to monitor imaging procedures] because the system is structure-heavy already,” said Rep. Nancy Johnson (R-Conn.), chair of the health subcommittee of the House Ways and Means Committee. “I'm not sure putting in more oversight is really what we need.”

Mark Miller, Ph.D., executive director of the Medicare Payment Advisory Commission (MedPAC), testified that the growth in the volume of imaging services such as PET scans, CT scans, and MRIs performed on Medicare beneficiaries “is growing at twice the rate of all physician services.” And what worries MedPAC, he continued, is that increasing the amount of imaging being done does not necessarily mean the quality of care is getting any better.

“There is a threefold variation in the use of these services among the Medicare population, and it's not linked to health care quality,” Dr. Miller said. “It's more [related to the] availability of services and practice style.”

MedPAC also is concerned about the wide variability in imaging quality, he said. “There is variation in the quality of the images produced and in the quality of image interpretation.” He said the 17 MedPAC commissioners would like to see the Department of Health and Human Services set quality standards for imaging providers.

“Some people characterize this recommendation as directed toward limiting imaging to radiologists only and billing for imaging to radiologists only,” Dr. Miller said, alluding to the perceived “turf war” going on between radiologists and other imaging providers. “That is not correct. We believe the standard should apply to all physicians” who do imaging.

Subcommittee member Rep. Jim Ramstad (R-Minn.) said he was happy to hear that imaging would not be restricted to radiologists. “I would hate to see this become nothing more than a turf battle,” he said. “It seems to me that overutilization is a complex issue, involving factors like defensive medicine, provider preference, and consumer demand for the best test.”

The subcommittee also heard from representatives for cardiology and radiology groups, each of which took opposing positions on the increase in imaging volume. “We are deeply concerned with the exponential growth in office-based imaging by those who may lack the education, training, equipment, and clinical personnel to safely and effectively use these studies,” said James Borgstede, M.D., chair of the American College of Radiology's board of chancellors. “For this reason, the ACR supports many of the MedPAC recommendations that link Medicare reimbursement to quality, safety, and training standards for physicians and facilities which provide medical imaging services.”

The subcommittee also considered the issue of whether to lower reimbursement for multiple imaging procedures performed in the same visit—specifically, lowering the amount paid for each subsequent image after the first one. Dr. Borgstede noted that the American Medical Association's CPT Editorial Panel has recommended such a reduction, but it will apply to the first image as well. That change will take effect next January, he said.

WASHINGTON — A congressional committee wrestled with whether or how much to regulate or impose standards on imaging procedures at a hearing last month on managing Medicare's imaging costs.

“I'm concerned about putting in a whole group of new structures [to monitor imaging procedures] because the system is structure-heavy already,” said Rep. Nancy Johnson (R-Conn.), chair of the health subcommittee of the House Ways and Means Committee. “I'm not sure putting in more oversight is really what we need.”

Mark Miller, Ph.D., executive director of the Medicare Payment Advisory Commission (MedPAC), testified that the growth in the volume of imaging services such as PET scans, CT scans, and MRIs performed on Medicare beneficiaries “is growing at twice the rate of all physician services.” And what worries MedPAC, he continued, is that increasing the amount of imaging being done does not necessarily mean the quality of care is getting any better.

“There is a threefold variation in the use of these services among the Medicare population, and it's not linked to health care quality,” Dr. Miller said. “It's more [related to the] availability of services and practice style.”

MedPAC also is concerned about the wide variability in imaging quality, he said. “There is variation in the quality of the images produced and in the quality of image interpretation.” He said the 17 MedPAC commissioners would like to see the Department of Health and Human Services set quality standards for imaging providers.

“Some people characterize this recommendation as directed toward limiting imaging to radiologists only and billing for imaging to radiologists only,” Dr. Miller said, alluding to the perceived “turf war” going on between radiologists and other imaging providers. “That is not correct. We believe the standard should apply to all physicians” who do imaging.

Subcommittee member Rep. Jim Ramstad (R-Minn.) said he was happy to hear that imaging would not be restricted to radiologists. “I would hate to see this become nothing more than a turf battle,” he said. “It seems to me that overutilization is a complex issue, involving factors like defensive medicine, provider preference, and consumer demand for the best test.”

The subcommittee also heard from representatives for cardiology and radiology groups, each of which took opposing positions on the increase in imaging volume. “We are deeply concerned with the exponential growth in office-based imaging by those who may lack the education, training, equipment, and clinical personnel to safely and effectively use these studies,” said James Borgstede, M.D., chair of the American College of Radiology's board of chancellors. “For this reason, the ACR supports many of the MedPAC recommendations that link Medicare reimbursement to quality, safety, and training standards for physicians and facilities which provide medical imaging services.”

The subcommittee also considered the issue of whether to lower reimbursement for multiple imaging procedures performed in the same visit—specifically, lowering the amount paid for each subsequent image after the first one. Dr. Borgstede noted that the American Medical Association's CPT Editorial Panel has recommended such a reduction, but it will apply to the first image as well. That change will take effect next January, he said.

WASHINGTON — A congressional committee wrestled with whether or how much to regulate or impose standards on imaging procedures at a hearing last month on managing Medicare's imaging costs.

“I'm concerned about putting in a whole group of new structures [to monitor imaging procedures] because the system is structure-heavy already,” said Rep. Nancy Johnson (R-Conn.), chair of the health subcommittee of the House Ways and Means Committee. “I'm not sure putting in more oversight is really what we need.”

Mark Miller, Ph.D., executive director of the Medicare Payment Advisory Commission (MedPAC), testified that the growth in the volume of imaging services such as PET scans, CT scans, and MRIs performed on Medicare beneficiaries “is growing at twice the rate of all physician services.” And what worries MedPAC, he continued, is that increasing the amount of imaging being done does not necessarily mean the quality of care is getting any better.

“There is a threefold variation in the use of these services among the Medicare population, and it's not linked to health care quality,” Dr. Miller said. “It's more [related to the] availability of services and practice style.”

MedPAC also is concerned about the wide variability in imaging quality, he said. “There is variation in the quality of the images produced and in the quality of image interpretation.” He said the 17 MedPAC commissioners would like to see the Department of Health and Human Services set quality standards for imaging providers.

“Some people characterize this recommendation as directed toward limiting imaging to radiologists only and billing for imaging to radiologists only,” Dr. Miller said, alluding to the perceived “turf war” going on between radiologists and other imaging providers. “That is not correct. We believe the standard should apply to all physicians” who do imaging.

Subcommittee member Rep. Jim Ramstad (R-Minn.) said he was happy to hear that imaging would not be restricted to radiologists. “I would hate to see this become nothing more than a turf battle,” he said. “It seems to me that overutilization is a complex issue, involving factors like defensive medicine, provider preference, and consumer demand for the best test.”

The subcommittee also heard from representatives for cardiology and radiology groups, each of which took opposing positions on the increase in imaging volume. “We are deeply concerned with the exponential growth in office-based imaging by those who may lack the education, training, equipment, and clinical personnel to safely and effectively use these studies,” said James Borgstede, M.D., chair of the American College of Radiology's board of chancellors. “For this reason, the ACR supports many of the MedPAC recommendations that link Medicare reimbursement to quality, safety, and training standards for physicians and facilities which provide medical imaging services.”

The subcommittee also considered the issue of whether to lower reimbursement for multiple imaging procedures performed in the same visit—specifically, lowering the amount paid for each subsequent image after the first one. Dr. Borgstede noted that the American Medical Association's CPT Editorial Panel has recommended such a reduction, but it will apply to the first image as well. That change will take effect next January, he said.

Some may quibble about their cause, but what is certain is that rapidly rising imaging costs have health insurers scrambling for creative approaches to contain expenditures.

On average, costs of imaging—especially high-tech procedures like MRI, CT, and magnetic resonance angiograms (MRAs)—have been going up 20% annually for the last several years, according to Thomas Dehn, M.D., cofounder of National Imaging Associates, a radiology utilization management firm in Hackensack, N.J.

“Some will say it's the aging of the population, but the key issue is really demand,” said Dr. Dehn, who is the company's executive vice president and chief medical officer. “Patients are bright; they're good consumers. They want a shoulder MRI if their shoulder hurts.”

Physician demand is also an important part of the equation. “If you have physicians who want increased [patient volume] in their office, it is possible that rather than spending cognitive time for which they're poorly reimbursed, they may choose to use a technical alternative.”

For example, a doctor trying to figure out the source of a patient's chronic headaches “may get frustrated and refer the patient for an MRI of the brain, just to show them they're normal,” Dr. Dehn said. “The treating physicians knows in the back of his mind that there isn't going to be anything [there], but it will calm the patient down.”

As to which physicians are responsible for this increase, the answer depends on whom you ask. “We have the perspective that this growth is largely occurring because of outpatient imaging performed by nonradiologists,” said James Borgstede, M.D., chairman of the board of chancellors at the American College of Radiology (ACR). And studies show that physicians who own their own imaging equipment—which most radiologists don't—tend to order more imaging than those who have to refer out for it, he said.

Not so, say subspecialists. “What they're talking about is self-referral,” said Jack Greenberg, M.D., past president of the American Society of Neuroimaging. “Twenty percent of self-referral is done by radiologists, when they 'Repeat in 1 month' or advise a CT scan.”

Dr. Greenberg said that the analysis by the Lewin Group, a consulting firm located in Falls Church, Va., showed that the average growth rate for CT from 2001 to 2003 was 16% with radiologists doing 84% of all CT scans. The average growth rate for MRI during the same time period was 19% with radiologists dominating 65% of use. Because MRI and CT are dominated by radiologists, these results show that removing neurologists, cardiologists, and other specialists from the imaging arena is no protection against the growth in utilization,” he said.

The ACR's recent attempts to develop criteria for imaging providers are really a way for the college to protect its turf, which is diminishing, he continued. “The intent of this is to take all of imaging and create a larger monopoly, so radiologists can control everything that has to do with imaging. All you're going to do is shift scans done in the neurologist's office to the radiologist” without lowering overall imaging costs.

But the ACR says it is just trying to make sure that imaging as a whole does not suffer from attempts to rein in the amount being done. A very simple solution would be to reimburse less for each imaging procedure regardless of which specialist performs it, said Dr. Borgstede, who is also clinical professor of radiology at the University of Colorado, Denver. “But that could be a disaster for everyone doing imaging. If you drive the reimbursement so low, pretty soon everyone will be out of the [outpatient] imaging business, and all the imaging will be done in the hospital where it's more expensive.”

Whatever the reason that more scans are being done, insurers have decided they've had enough. Take Highmark Blue Cross and Blue Shield, a Pittsburgh-based insurer whose imaging costs have risen to $500 million annually in the last few years.

One Highmark strategy for paring down its imaging costs is to develop a smaller network of imaging providers. To be included in Highmark's network, outpatient imaging centers must now offer multiple imaging modalities, such as mammography, MRIs, CTs, and bone densitometry.

“We were seeing many facilities that were single modality—just CT or just MRI,” said Cary Vinson, M.D., Highmark's vice president of quality and medical performance management. “They were being set up by for-profit companies to siphon away high-margin procedures from hospitals and other multimodality freestanding facilities. We were seeing access problems for referring physicians because the single modality centers were outcompeting the multimodality centers, and they couldn't keep up.”

In addition to credentialing the imaging centers, Highmark is going to start requiring providers to preauthorize all CT, MRI, and PET scans. At first, while everyone adapts to the new system, the preauthorization procedure will be voluntary and no procedures will be denied. But eventually—perhaps by the end of this year—the preauthorization will become mandatory, Dr. Vinson said.

Harvard Pilgrim Health Care (HPHC), a health plan based in Wellesley, Mass., is taking a slightly different approach. Instead of mandatory preauthorization, HPHC is using a “soft denial” process in which physicians must call for imaging preauthorization, but they can overrule a negative decision if they want to.

“We made a decision based on our network being a very sophisticated, highly academic referral environment, that a hard denial program might not be best way to go,” said William Corwin, M.D., the plan's medical director for utilization management and clinical policy. “Instead, we elected to use a more consultative approach.” The program started in July, so no concrete results are available yet, he noted.

Plans that start a preauthorization program must first figure out who should be authorized to perform scans. At Highmark, the plan tried to be as inclusive as possible, Dr. Vinson said.

“In some cases within a specialty, we tried to determine who was qualified and who was not,” he said. “For instance, for breast ultrasound, we listed radiologists, but we also included surgeons with breast ultrasound certification from the American Society of Breast Surgeons.”

As might be expected, Highmark ran into a turf battle as it tried to credential providers. In this case, the American College of Cardiology and the ACR “definitely have differences of opinion about who's qualified and who's not” when it comes to cardiology-related imaging exams, Dr. Vinson said.

“Highmark took the approach of accepting either society's qualifications. They clearly wanted us to decide between the two, and we would not do that.”

Some may quibble about their cause, but what is certain is that rapidly rising imaging costs have health insurers scrambling for creative approaches to contain expenditures.

On average, costs of imaging—especially high-tech procedures like MRI, CT, and magnetic resonance angiograms (MRAs)—have been going up 20% annually for the last several years, according to Thomas Dehn, M.D., cofounder of National Imaging Associates, a radiology utilization management firm in Hackensack, N.J.

“Some will say it's the aging of the population, but the key issue is really demand,” said Dr. Dehn, who is the company's executive vice president and chief medical officer. “Patients are bright; they're good consumers. They want a shoulder MRI if their shoulder hurts.”

Physician demand is also an important part of the equation. “If you have physicians who want increased [patient volume] in their office, it is possible that rather than spending cognitive time for which they're poorly reimbursed, they may choose to use a technical alternative.”

For example, a doctor trying to figure out the source of a patient's chronic headaches “may get frustrated and refer the patient for an MRI of the brain, just to show them they're normal,” Dr. Dehn said. “The treating physicians knows in the back of his mind that there isn't going to be anything [there], but it will calm the patient down.”

As to which physicians are responsible for this increase, the answer depends on whom you ask. “We have the perspective that this growth is largely occurring because of outpatient imaging performed by nonradiologists,” said James Borgstede, M.D., chairman of the board of chancellors at the American College of Radiology (ACR). And studies show that physicians who own their own imaging equipment—which most radiologists don't—tend to order more imaging than those who have to refer out for it, he said.

Not so, say subspecialists. “What they're talking about is self-referral,” said Jack Greenberg, M.D., past president of the American Society of Neuroimaging. “Twenty percent of self-referral is done by radiologists, when they 'Repeat in 1 month' or advise a CT scan.”

Dr. Greenberg said that the analysis by the Lewin Group, a consulting firm located in Falls Church, Va., showed that the average growth rate for CT from 2001 to 2003 was 16% with radiologists doing 84% of all CT scans. The average growth rate for MRI during the same time period was 19% with radiologists dominating 65% of use. Because MRI and CT are dominated by radiologists, these results show that removing neurologists, cardiologists, and other specialists from the imaging arena is no protection against the growth in utilization,” he said.

The ACR's recent attempts to develop criteria for imaging providers are really a way for the college to protect its turf, which is diminishing, he continued. “The intent of this is to take all of imaging and create a larger monopoly, so radiologists can control everything that has to do with imaging. All you're going to do is shift scans done in the neurologist's office to the radiologist” without lowering overall imaging costs.

But the ACR says it is just trying to make sure that imaging as a whole does not suffer from attempts to rein in the amount being done. A very simple solution would be to reimburse less for each imaging procedure regardless of which specialist performs it, said Dr. Borgstede, who is also clinical professor of radiology at the University of Colorado, Denver. “But that could be a disaster for everyone doing imaging. If you drive the reimbursement so low, pretty soon everyone will be out of the [outpatient] imaging business, and all the imaging will be done in the hospital where it's more expensive.”

Whatever the reason that more scans are being done, insurers have decided they've had enough. Take Highmark Blue Cross and Blue Shield, a Pittsburgh-based insurer whose imaging costs have risen to $500 million annually in the last few years.

One Highmark strategy for paring down its imaging costs is to develop a smaller network of imaging providers. To be included in Highmark's network, outpatient imaging centers must now offer multiple imaging modalities, such as mammography, MRIs, CTs, and bone densitometry.

“We were seeing many facilities that were single modality—just CT or just MRI,” said Cary Vinson, M.D., Highmark's vice president of quality and medical performance management. “They were being set up by for-profit companies to siphon away high-margin procedures from hospitals and other multimodality freestanding facilities. We were seeing access problems for referring physicians because the single modality centers were outcompeting the multimodality centers, and they couldn't keep up.”

In addition to credentialing the imaging centers, Highmark is going to start requiring providers to preauthorize all CT, MRI, and PET scans. At first, while everyone adapts to the new system, the preauthorization procedure will be voluntary and no procedures will be denied. But eventually—perhaps by the end of this year—the preauthorization will become mandatory, Dr. Vinson said.

Harvard Pilgrim Health Care (HPHC), a health plan based in Wellesley, Mass., is taking a slightly different approach. Instead of mandatory preauthorization, HPHC is using a “soft denial” process in which physicians must call for imaging preauthorization, but they can overrule a negative decision if they want to.

“We made a decision based on our network being a very sophisticated, highly academic referral environment, that a hard denial program might not be best way to go,” said William Corwin, M.D., the plan's medical director for utilization management and clinical policy. “Instead, we elected to use a more consultative approach.” The program started in July, so no concrete results are available yet, he noted.

Plans that start a preauthorization program must first figure out who should be authorized to perform scans. At Highmark, the plan tried to be as inclusive as possible, Dr. Vinson said.

“In some cases within a specialty, we tried to determine who was qualified and who was not,” he said. “For instance, for breast ultrasound, we listed radiologists, but we also included surgeons with breast ultrasound certification from the American Society of Breast Surgeons.”

As might be expected, Highmark ran into a turf battle as it tried to credential providers. In this case, the American College of Cardiology and the ACR “definitely have differences of opinion about who's qualified and who's not” when it comes to cardiology-related imaging exams, Dr. Vinson said.

“Highmark took the approach of accepting either society's qualifications. They clearly wanted us to decide between the two, and we would not do that.”

Some may quibble about their cause, but what is certain is that rapidly rising imaging costs have health insurers scrambling for creative approaches to contain expenditures.

On average, costs of imaging—especially high-tech procedures like MRI, CT, and magnetic resonance angiograms (MRAs)—have been going up 20% annually for the last several years, according to Thomas Dehn, M.D., cofounder of National Imaging Associates, a radiology utilization management firm in Hackensack, N.J.

“Some will say it's the aging of the population, but the key issue is really demand,” said Dr. Dehn, who is the company's executive vice president and chief medical officer. “Patients are bright; they're good consumers. They want a shoulder MRI if their shoulder hurts.”

Physician demand is also an important part of the equation. “If you have physicians who want increased [patient volume] in their office, it is possible that rather than spending cognitive time for which they're poorly reimbursed, they may choose to use a technical alternative.”

For example, a doctor trying to figure out the source of a patient's chronic headaches “may get frustrated and refer the patient for an MRI of the brain, just to show them they're normal,” Dr. Dehn said. “The treating physicians knows in the back of his mind that there isn't going to be anything [there], but it will calm the patient down.”

As to which physicians are responsible for this increase, the answer depends on whom you ask. “We have the perspective that this growth is largely occurring because of outpatient imaging performed by nonradiologists,” said James Borgstede, M.D., chairman of the board of chancellors at the American College of Radiology (ACR). And studies show that physicians who own their own imaging equipment—which most radiologists don't—tend to order more imaging than those who have to refer out for it, he said.

Not so, say subspecialists. “What they're talking about is self-referral,” said Jack Greenberg, M.D., past president of the American Society of Neuroimaging. “Twenty percent of self-referral is done by radiologists, when they 'Repeat in 1 month' or advise a CT scan.”

Dr. Greenberg said that the analysis by the Lewin Group, a consulting firm located in Falls Church, Va., showed that the average growth rate for CT from 2001 to 2003 was 16% with radiologists doing 84% of all CT scans. The average growth rate for MRI during the same time period was 19% with radiologists dominating 65% of use. Because MRI and CT are dominated by radiologists, these results show that removing neurologists, cardiologists, and other specialists from the imaging arena is no protection against the growth in utilization,” he said.

The ACR's recent attempts to develop criteria for imaging providers are really a way for the college to protect its turf, which is diminishing, he continued. “The intent of this is to take all of imaging and create a larger monopoly, so radiologists can control everything that has to do with imaging. All you're going to do is shift scans done in the neurologist's office to the radiologist” without lowering overall imaging costs.

But the ACR says it is just trying to make sure that imaging as a whole does not suffer from attempts to rein in the amount being done. A very simple solution would be to reimburse less for each imaging procedure regardless of which specialist performs it, said Dr. Borgstede, who is also clinical professor of radiology at the University of Colorado, Denver. “But that could be a disaster for everyone doing imaging. If you drive the reimbursement so low, pretty soon everyone will be out of the [outpatient] imaging business, and all the imaging will be done in the hospital where it's more expensive.”

Whatever the reason that more scans are being done, insurers have decided they've had enough. Take Highmark Blue Cross and Blue Shield, a Pittsburgh-based insurer whose imaging costs have risen to $500 million annually in the last few years.

One Highmark strategy for paring down its imaging costs is to develop a smaller network of imaging providers. To be included in Highmark's network, outpatient imaging centers must now offer multiple imaging modalities, such as mammography, MRIs, CTs, and bone densitometry.

“We were seeing many facilities that were single modality—just CT or just MRI,” said Cary Vinson, M.D., Highmark's vice president of quality and medical performance management. “They were being set up by for-profit companies to siphon away high-margin procedures from hospitals and other multimodality freestanding facilities. We were seeing access problems for referring physicians because the single modality centers were outcompeting the multimodality centers, and they couldn't keep up.”

In addition to credentialing the imaging centers, Highmark is going to start requiring providers to preauthorize all CT, MRI, and PET scans. At first, while everyone adapts to the new system, the preauthorization procedure will be voluntary and no procedures will be denied. But eventually—perhaps by the end of this year—the preauthorization will become mandatory, Dr. Vinson said.

Harvard Pilgrim Health Care (HPHC), a health plan based in Wellesley, Mass., is taking a slightly different approach. Instead of mandatory preauthorization, HPHC is using a “soft denial” process in which physicians must call for imaging preauthorization, but they can overrule a negative decision if they want to.

“We made a decision based on our network being a very sophisticated, highly academic referral environment, that a hard denial program might not be best way to go,” said William Corwin, M.D., the plan's medical director for utilization management and clinical policy. “Instead, we elected to use a more consultative approach.” The program started in July, so no concrete results are available yet, he noted.

Plans that start a preauthorization program must first figure out who should be authorized to perform scans. At Highmark, the plan tried to be as inclusive as possible, Dr. Vinson said.

“In some cases within a specialty, we tried to determine who was qualified and who was not,” he said. “For instance, for breast ultrasound, we listed radiologists, but we also included surgeons with breast ultrasound certification from the American Society of Breast Surgeons.”

As might be expected, Highmark ran into a turf battle as it tried to credential providers. In this case, the American College of Cardiology and the ACR “definitely have differences of opinion about who's qualified and who's not” when it comes to cardiology-related imaging exams, Dr. Vinson said.

“Highmark took the approach of accepting either society's qualifications. They clearly wanted us to decide between the two, and we would not do that.”

WASHINGTON — Consumer-driven health care may be all the rage right now, but there's no single cure for the nation's ailing health care system, several experts said at a health care congress sponsored by the Wall Street Journal and CNBC.

“There are no silver bullets,” said Douglas Holtz-Eakin, Ph.D., director of the Congressional Budget Office (CBO). “There is no single item—technology, disease management, tort law—that is likely to prove to be the answer to aligning incentives, providing high-quality care at reasonable costs, and financing it in a way that's economically viable. More likely, we'll have a series of incremental changes” that will shore up the system.

Rising health care costs represent the central domestic issue at this time,” Dr. Holtz-Eakin said. For example, over the next 50 years, if nothing is done, “the cost of Medicare and Medicaid will rise from 4% of the gross domestic product to 20%—the current size of the entire federal budget.”

Because the population is aging, “we indeed may spend more than we do now” on health care, Dr. Holtz-Eakin continued. “But the key issue is to make sure we do not overspend, that the dollars per unit of high-quality care match up with our desires.”

Robert Reischauer, Ph.D., a former CBO director who is now president of the Urban Institute, noted that Medicare was a particular concern, since Medicare spending is expected to grow very rapidly over the next 10 years. He listed four possible solutions for the Medicare budget crisis.

The first possibility is to reduce the scope of coverage, but “that isn't a practical course of action,” he said. “All forces are moving in just the opposite direction.”

Another option is to restrain the growth in payments to providers, but already, Medicare is considered “not too generous,” compared with private payers, since it pays on average only about 80% of the private rate. “[Payment restraint] is clearly not going to happen,” he said.

The third option is to make beneficiaries pay more for care in the form of higher premiums, deductibles, and cost sharing.

“Some people think that will cause beneficiaries to purchase more rationally and cut out low-value services, but we have to remember, the vast bulk of spending is on individuals who are very sick, have many chronic conditions, and aren't in a position to comparison-shop,” he said. “Moreover, the services that they're purchasing are extremely complex and confusing, and providers play a very significant role in determining the demand for and type of services received by beneficiaries.

“Before we bet the ranch on this approach,” he continued, “we're going to have to see what happens to spending patterns among the under-65 population as they are faced with high-deductible plans, health savings accounts, consumer-driven health plans, and other approaches to incentivize them to purchase more rationally. If this proves to be a successful approach for the under-65 population, one can see it gradually angling into the bag of tools that Medicare has.”

However, Dr. Reischauer noted, the potential for shifting more costs onto beneficiaries is limited, “because they already spend a considerable amount of their incomes on Medicare cost-sharing of one sort or another. By 2025, the average 65-year-old Medicare beneficiary will be paying more than the size of their Social Security check in cost-sharing and deductibles.”

A fourth approach is to restructure Medicare in ways to generate competition among providers, Dr. Reischauer said. This would mean emphasizing technologies that improve efficiency, such as electronic health records and electronic prescribing. It also would involve decreasing the volume of unneeded services being provided.

He noted that researchers at Dartmouth University have looked at health care utilization across geographic areas and found that beneficiaries receiving higher volumes of services generally have poorer health outcomes, even after differences in their health status are accounted for.

“It's conceivable that as our ability to measure differences in quality and to reward quality effectively improves, the Medicare system could be transformed into one that pays only for care which is both necessary and beneficial, but this is likely to be a long and difficult row to hoe,” he said.

Gail Wilensky, a former administrator of the Centers for Medicare and Medicaid Services who is now a senior fellow at Project HOPE, in Bethesda, Md., expressed disappointment that Congress did not do more to address the issue of rising costs when it passed the Medicare Modernization Act of 2003.

That law “is a good example of eating dessert first,” she said. “There was an opportunity to try and slow down spending in a significant way while a new benefit was being introduced, but primarily, what [the law] does is provide a new benefit and some additional payments to providers of services, but not very much in terms of trying to restructure Medicare for the future.”

One little-known provision of the law does attempt to address the cost issue, she added. “Starting in 2007, Part B will be much more related to income. The subsidy will start declining significantly for those with higher incomes. As the baby boomers begin to retire, some of them with higher incomes and assets, this is at least one opportunity” to help with the cost problem.

Americans are going to need to rethink the entire issue of retirement, Dr. Wilensky predicted.

WASHINGTON — Consumer-driven health care may be all the rage right now, but there's no single cure for the nation's ailing health care system, several experts said at a health care congress sponsored by the Wall Street Journal and CNBC.

“There are no silver bullets,” said Douglas Holtz-Eakin, Ph.D., director of the Congressional Budget Office (CBO). “There is no single item—technology, disease management, tort law—that is likely to prove to be the answer to aligning incentives, providing high-quality care at reasonable costs, and financing it in a way that's economically viable. More likely, we'll have a series of incremental changes” that will shore up the system.

Rising health care costs represent the central domestic issue at this time,” Dr. Holtz-Eakin said. For example, over the next 50 years, if nothing is done, “the cost of Medicare and Medicaid will rise from 4% of the gross domestic product to 20%—the current size of the entire federal budget.”

Because the population is aging, “we indeed may spend more than we do now” on health care, Dr. Holtz-Eakin continued. “But the key issue is to make sure we do not overspend, that the dollars per unit of high-quality care match up with our desires.”

Robert Reischauer, Ph.D., a former CBO director who is now president of the Urban Institute, noted that Medicare was a particular concern, since Medicare spending is expected to grow very rapidly over the next 10 years. He listed four possible solutions for the Medicare budget crisis.

The first possibility is to reduce the scope of coverage, but “that isn't a practical course of action,” he said. “All forces are moving in just the opposite direction.”

Another option is to restrain the growth in payments to providers, but already, Medicare is considered “not too generous,” compared with private payers, since it pays on average only about 80% of the private rate. “[Payment restraint] is clearly not going to happen,” he said.

The third option is to make beneficiaries pay more for care in the form of higher premiums, deductibles, and cost sharing.

“Some people think that will cause beneficiaries to purchase more rationally and cut out low-value services, but we have to remember, the vast bulk of spending is on individuals who are very sick, have many chronic conditions, and aren't in a position to comparison-shop,” he said. “Moreover, the services that they're purchasing are extremely complex and confusing, and providers play a very significant role in determining the demand for and type of services received by beneficiaries.

“Before we bet the ranch on this approach,” he continued, “we're going to have to see what happens to spending patterns among the under-65 population as they are faced with high-deductible plans, health savings accounts, consumer-driven health plans, and other approaches to incentivize them to purchase more rationally. If this proves to be a successful approach for the under-65 population, one can see it gradually angling into the bag of tools that Medicare has.”

However, Dr. Reischauer noted, the potential for shifting more costs onto beneficiaries is limited, “because they already spend a considerable amount of their incomes on Medicare cost-sharing of one sort or another. By 2025, the average 65-year-old Medicare beneficiary will be paying more than the size of their Social Security check in cost-sharing and deductibles.”

A fourth approach is to restructure Medicare in ways to generate competition among providers, Dr. Reischauer said. This would mean emphasizing technologies that improve efficiency, such as electronic health records and electronic prescribing. It also would involve decreasing the volume of unneeded services being provided.

He noted that researchers at Dartmouth University have looked at health care utilization across geographic areas and found that beneficiaries receiving higher volumes of services generally have poorer health outcomes, even after differences in their health status are accounted for.

“It's conceivable that as our ability to measure differences in quality and to reward quality effectively improves, the Medicare system could be transformed into one that pays only for care which is both necessary and beneficial, but this is likely to be a long and difficult row to hoe,” he said.

Gail Wilensky, a former administrator of the Centers for Medicare and Medicaid Services who is now a senior fellow at Project HOPE, in Bethesda, Md., expressed disappointment that Congress did not do more to address the issue of rising costs when it passed the Medicare Modernization Act of 2003.

That law “is a good example of eating dessert first,” she said. “There was an opportunity to try and slow down spending in a significant way while a new benefit was being introduced, but primarily, what [the law] does is provide a new benefit and some additional payments to providers of services, but not very much in terms of trying to restructure Medicare for the future.”

One little-known provision of the law does attempt to address the cost issue, she added. “Starting in 2007, Part B will be much more related to income. The subsidy will start declining significantly for those with higher incomes. As the baby boomers begin to retire, some of them with higher incomes and assets, this is at least one opportunity” to help with the cost problem.

Americans are going to need to rethink the entire issue of retirement, Dr. Wilensky predicted.

WASHINGTON — Consumer-driven health care may be all the rage right now, but there's no single cure for the nation's ailing health care system, several experts said at a health care congress sponsored by the Wall Street Journal and CNBC.

“There are no silver bullets,” said Douglas Holtz-Eakin, Ph.D., director of the Congressional Budget Office (CBO). “There is no single item—technology, disease management, tort law—that is likely to prove to be the answer to aligning incentives, providing high-quality care at reasonable costs, and financing it in a way that's economically viable. More likely, we'll have a series of incremental changes” that will shore up the system.

Rising health care costs represent the central domestic issue at this time,” Dr. Holtz-Eakin said. For example, over the next 50 years, if nothing is done, “the cost of Medicare and Medicaid will rise from 4% of the gross domestic product to 20%—the current size of the entire federal budget.”

Because the population is aging, “we indeed may spend more than we do now” on health care, Dr. Holtz-Eakin continued. “But the key issue is to make sure we do not overspend, that the dollars per unit of high-quality care match up with our desires.”

Robert Reischauer, Ph.D., a former CBO director who is now president of the Urban Institute, noted that Medicare was a particular concern, since Medicare spending is expected to grow very rapidly over the next 10 years. He listed four possible solutions for the Medicare budget crisis.

The first possibility is to reduce the scope of coverage, but “that isn't a practical course of action,” he said. “All forces are moving in just the opposite direction.”

Another option is to restrain the growth in payments to providers, but already, Medicare is considered “not too generous,” compared with private payers, since it pays on average only about 80% of the private rate. “[Payment restraint] is clearly not going to happen,” he said.

The third option is to make beneficiaries pay more for care in the form of higher premiums, deductibles, and cost sharing.

“Some people think that will cause beneficiaries to purchase more rationally and cut out low-value services, but we have to remember, the vast bulk of spending is on individuals who are very sick, have many chronic conditions, and aren't in a position to comparison-shop,” he said. “Moreover, the services that they're purchasing are extremely complex and confusing, and providers play a very significant role in determining the demand for and type of services received by beneficiaries.

“Before we bet the ranch on this approach,” he continued, “we're going to have to see what happens to spending patterns among the under-65 population as they are faced with high-deductible plans, health savings accounts, consumer-driven health plans, and other approaches to incentivize them to purchase more rationally. If this proves to be a successful approach for the under-65 population, one can see it gradually angling into the bag of tools that Medicare has.”

However, Dr. Reischauer noted, the potential for shifting more costs onto beneficiaries is limited, “because they already spend a considerable amount of their incomes on Medicare cost-sharing of one sort or another. By 2025, the average 65-year-old Medicare beneficiary will be paying more than the size of their Social Security check in cost-sharing and deductibles.”

A fourth approach is to restructure Medicare in ways to generate competition among providers, Dr. Reischauer said. This would mean emphasizing technologies that improve efficiency, such as electronic health records and electronic prescribing. It also would involve decreasing the volume of unneeded services being provided.

He noted that researchers at Dartmouth University have looked at health care utilization across geographic areas and found that beneficiaries receiving higher volumes of services generally have poorer health outcomes, even after differences in their health status are accounted for.

“It's conceivable that as our ability to measure differences in quality and to reward quality effectively improves, the Medicare system could be transformed into one that pays only for care which is both necessary and beneficial, but this is likely to be a long and difficult row to hoe,” he said.

Gail Wilensky, a former administrator of the Centers for Medicare and Medicaid Services who is now a senior fellow at Project HOPE, in Bethesda, Md., expressed disappointment that Congress did not do more to address the issue of rising costs when it passed the Medicare Modernization Act of 2003.

That law “is a good example of eating dessert first,” she said. “There was an opportunity to try and slow down spending in a significant way while a new benefit was being introduced, but primarily, what [the law] does is provide a new benefit and some additional payments to providers of services, but not very much in terms of trying to restructure Medicare for the future.”

One little-known provision of the law does attempt to address the cost issue, she added. “Starting in 2007, Part B will be much more related to income. The subsidy will start declining significantly for those with higher incomes. As the baby boomers begin to retire, some of them with higher incomes and assets, this is at least one opportunity” to help with the cost problem.

Americans are going to need to rethink the entire issue of retirement, Dr. Wilensky predicted.

WASHINGTON — Partially in response to survey findings showing the public's low confidence in the Food and Drug Administration, Congress is considering giving the agency more authority over the pharmaceutical companies it deals with, but some legislators are warning against doing too much too fast.

The survey of 1,000 adults nationwide was performed by pollster Celinda Lake and sponsored by a coalition of consumer groups. The results showed that only 14% of respondents had a great deal of confidence in the agency's ability to ensure the safety of prescription drugs. And 48% of respondents believed the FDA was too influenced by the industries over which it has jurisdiction.

Sandra Kweder, M.D., deputy director of the Office of New Drugs at the FDA's Center for Drug Evaluation and Research, told the Senate that in order to ensure drug safety, it would be helpful if the FDA had more clout. At a hearing on FDA oversight she noted that it took more than a year and a lot of back-and-forth haggling just to get warnings added to the Vioxx label.

Sen. Edward Kennedy (D-Mass.), also spoke in favor of giving the agency greater labeling authority. “The FDA needs clear authority to require relabeling of a drug after approval once a risk is found,” he said.

Some observers noted that such changes would only go so far. “We all know product labeling does not change provider behavior very much,” said Arthur Levin, director of the Center for Medical Consumers in New York and the consumer representative on the FDA's Drug Safety and Risk Management advisory committee. Even if FDA does get more labeling authority, “we shouldn't count on it protecting the public from harm,” Mr. Levin said at a teleconference on the survey results.

WASHINGTON — Partially in response to survey findings showing the public's low confidence in the Food and Drug Administration, Congress is considering giving the agency more authority over the pharmaceutical companies it deals with, but some legislators are warning against doing too much too fast.

The survey of 1,000 adults nationwide was performed by pollster Celinda Lake and sponsored by a coalition of consumer groups. The results showed that only 14% of respondents had a great deal of confidence in the agency's ability to ensure the safety of prescription drugs. And 48% of respondents believed the FDA was too influenced by the industries over which it has jurisdiction.

Sandra Kweder, M.D., deputy director of the Office of New Drugs at the FDA's Center for Drug Evaluation and Research, told the Senate that in order to ensure drug safety, it would be helpful if the FDA had more clout. At a hearing on FDA oversight she noted that it took more than a year and a lot of back-and-forth haggling just to get warnings added to the Vioxx label.

Sen. Edward Kennedy (D-Mass.), also spoke in favor of giving the agency greater labeling authority. “The FDA needs clear authority to require relabeling of a drug after approval once a risk is found,” he said.

Some observers noted that such changes would only go so far. “We all know product labeling does not change provider behavior very much,” said Arthur Levin, director of the Center for Medical Consumers in New York and the consumer representative on the FDA's Drug Safety and Risk Management advisory committee. Even if FDA does get more labeling authority, “we shouldn't count on it protecting the public from harm,” Mr. Levin said at a teleconference on the survey results.

WASHINGTON — Partially in response to survey findings showing the public's low confidence in the Food and Drug Administration, Congress is considering giving the agency more authority over the pharmaceutical companies it deals with, but some legislators are warning against doing too much too fast.

The survey of 1,000 adults nationwide was performed by pollster Celinda Lake and sponsored by a coalition of consumer groups. The results showed that only 14% of respondents had a great deal of confidence in the agency's ability to ensure the safety of prescription drugs. And 48% of respondents believed the FDA was too influenced by the industries over which it has jurisdiction.

Sandra Kweder, M.D., deputy director of the Office of New Drugs at the FDA's Center for Drug Evaluation and Research, told the Senate that in order to ensure drug safety, it would be helpful if the FDA had more clout. At a hearing on FDA oversight she noted that it took more than a year and a lot of back-and-forth haggling just to get warnings added to the Vioxx label.

Sen. Edward Kennedy (D-Mass.), also spoke in favor of giving the agency greater labeling authority. “The FDA needs clear authority to require relabeling of a drug after approval once a risk is found,” he said.

Some observers noted that such changes would only go so far. “We all know product labeling does not change provider behavior very much,” said Arthur Levin, director of the Center for Medical Consumers in New York and the consumer representative on the FDA's Drug Safety and Risk Management advisory committee. Even if FDA does get more labeling authority, “we shouldn't count on it protecting the public from harm,” Mr. Levin said at a teleconference on the survey results.

WASHINGTON — People who have suffered adverse outcomes due to drugs or medical devices may face more delays in suing manufacturers for damages now that federal class-action lawsuit legislation has been signed into law.

The law, known as the Class Action Fairness Act of 2005, would move from state court to federal court any class-action lawsuit in which the amount of damages claimed was greater than $5 million and involved citizens in different states.

In addition, the new law also spells out the circumstances in which federal courts can decline to hear class-action cases.

Proponents of the law, which passed in both the House and Senate in record time, argue that the legislation will help decrease the number of “junk lawsuits” that are clogging up the state courts.

“America's employers and consumers are the big winners,” Tom Donohue, president and CEO of the U.S. Chamber of Commerce, said in a statement.

“Reform of the class action lawsuit system will reduce frivolous lawsuits, spur business investment, and help restore sanity to our nation's legal system,” Mr. Donohue continued.

Critics of the bill, however, say that it will deprive citizens of their right to sue when they are injured by a defective product. “There are only 678 federal trial judges in the system, but there are 9,200 state judges in courts of general jurisdiction,” said Jillian Aldebron, counsel and communications coordinator for Public Citizen's Congress Watch, a citizen watchdog group.

“So you're talking about cases ordinarily divided up among 9,200 judges and squeezing them into the courtrooms of 678 judges. Even if they are willing to hear the cases, it's going to take years, and these cases take years in state court [already].”

Many physician organizations, including the American Medical Association and the American College of Physicians, have declined to take a stand on the legislation. Instead, the efforts of such organizations are more focused on tort reform legislation affecting medical malpractice cases.

However, a few consumer groups, such as the Campaign for Tobacco-Free Kids, lamented the effect the bill would have on health care-related cases.

“Class-action lawsuits have been an important tool in efforts to hold the tobacco industry accountable,” the group's president, Matthew L. Myers, said in a statement.

“This bill will deprive citizens of a state of the right to have their cases heard in their own courts, further overburden the federal courts, and make it more difficult for tobacco companies to be held accountable for years of misleading Americans about the dangers of tobacco,” he continued.

Senior citizens' lobby AARP also opposed the bill. “We felt that there wasn't an adequate basis for consumers no longer having the option of bringing a multistate case in state court,” said Larry White, senior legislative representative.

“We acknowledge there are abuses on both sides in the system, but when you in essence say that the federal courts will have jurisdiction of these cases … knowing the federal courts oftentimes don't certify those cases, you're in essence saying people who have been genuinely harmed don't have options,” Mr. White continued.

According to the Bush administration, the law will help consumers.

“The bill will remove significant burdens on class-action litigants and provide greater protections for the victims whom the class-action device originally was designed to benefit,” according to an official statement issued by the Bush administration.

The law would affect only cases filed after the bill was signed, noted Ms. Aldebron.

WASHINGTON — People who have suffered adverse outcomes due to drugs or medical devices may face more delays in suing manufacturers for damages now that federal class-action lawsuit legislation has been signed into law.

The law, known as the Class Action Fairness Act of 2005, would move from state court to federal court any class-action lawsuit in which the amount of damages claimed was greater than $5 million and involved citizens in different states.

In addition, the new law also spells out the circumstances in which federal courts can decline to hear class-action cases.

Proponents of the law, which passed in both the House and Senate in record time, argue that the legislation will help decrease the number of “junk lawsuits” that are clogging up the state courts.

“America's employers and consumers are the big winners,” Tom Donohue, president and CEO of the U.S. Chamber of Commerce, said in a statement.

“Reform of the class action lawsuit system will reduce frivolous lawsuits, spur business investment, and help restore sanity to our nation's legal system,” Mr. Donohue continued.

Critics of the bill, however, say that it will deprive citizens of their right to sue when they are injured by a defective product. “There are only 678 federal trial judges in the system, but there are 9,200 state judges in courts of general jurisdiction,” said Jillian Aldebron, counsel and communications coordinator for Public Citizen's Congress Watch, a citizen watchdog group.

“So you're talking about cases ordinarily divided up among 9,200 judges and squeezing them into the courtrooms of 678 judges. Even if they are willing to hear the cases, it's going to take years, and these cases take years in state court [already].”

Many physician organizations, including the American Medical Association and the American College of Physicians, have declined to take a stand on the legislation. Instead, the efforts of such organizations are more focused on tort reform legislation affecting medical malpractice cases.

However, a few consumer groups, such as the Campaign for Tobacco-Free Kids, lamented the effect the bill would have on health care-related cases.

“Class-action lawsuits have been an important tool in efforts to hold the tobacco industry accountable,” the group's president, Matthew L. Myers, said in a statement.

“This bill will deprive citizens of a state of the right to have their cases heard in their own courts, further overburden the federal courts, and make it more difficult for tobacco companies to be held accountable for years of misleading Americans about the dangers of tobacco,” he continued.

Senior citizens' lobby AARP also opposed the bill. “We felt that there wasn't an adequate basis for consumers no longer having the option of bringing a multistate case in state court,” said Larry White, senior legislative representative.

“We acknowledge there are abuses on both sides in the system, but when you in essence say that the federal courts will have jurisdiction of these cases … knowing the federal courts oftentimes don't certify those cases, you're in essence saying people who have been genuinely harmed don't have options,” Mr. White continued.

According to the Bush administration, the law will help consumers.

“The bill will remove significant burdens on class-action litigants and provide greater protections for the victims whom the class-action device originally was designed to benefit,” according to an official statement issued by the Bush administration.

The law would affect only cases filed after the bill was signed, noted Ms. Aldebron.

WASHINGTON — People who have suffered adverse outcomes due to drugs or medical devices may face more delays in suing manufacturers for damages now that federal class-action lawsuit legislation has been signed into law.

The law, known as the Class Action Fairness Act of 2005, would move from state court to federal court any class-action lawsuit in which the amount of damages claimed was greater than $5 million and involved citizens in different states.

In addition, the new law also spells out the circumstances in which federal courts can decline to hear class-action cases.

Proponents of the law, which passed in both the House and Senate in record time, argue that the legislation will help decrease the number of “junk lawsuits” that are clogging up the state courts.

“America's employers and consumers are the big winners,” Tom Donohue, president and CEO of the U.S. Chamber of Commerce, said in a statement.

“Reform of the class action lawsuit system will reduce frivolous lawsuits, spur business investment, and help restore sanity to our nation's legal system,” Mr. Donohue continued.

Critics of the bill, however, say that it will deprive citizens of their right to sue when they are injured by a defective product. “There are only 678 federal trial judges in the system, but there are 9,200 state judges in courts of general jurisdiction,” said Jillian Aldebron, counsel and communications coordinator for Public Citizen's Congress Watch, a citizen watchdog group.

“So you're talking about cases ordinarily divided up among 9,200 judges and squeezing them into the courtrooms of 678 judges. Even if they are willing to hear the cases, it's going to take years, and these cases take years in state court [already].”

Many physician organizations, including the American Medical Association and the American College of Physicians, have declined to take a stand on the legislation. Instead, the efforts of such organizations are more focused on tort reform legislation affecting medical malpractice cases.

However, a few consumer groups, such as the Campaign for Tobacco-Free Kids, lamented the effect the bill would have on health care-related cases.

“Class-action lawsuits have been an important tool in efforts to hold the tobacco industry accountable,” the group's president, Matthew L. Myers, said in a statement.

“This bill will deprive citizens of a state of the right to have their cases heard in their own courts, further overburden the federal courts, and make it more difficult for tobacco companies to be held accountable for years of misleading Americans about the dangers of tobacco,” he continued.

Senior citizens' lobby AARP also opposed the bill. “We felt that there wasn't an adequate basis for consumers no longer having the option of bringing a multistate case in state court,” said Larry White, senior legislative representative.

“We acknowledge there are abuses on both sides in the system, but when you in essence say that the federal courts will have jurisdiction of these cases … knowing the federal courts oftentimes don't certify those cases, you're in essence saying people who have been genuinely harmed don't have options,” Mr. White continued.

According to the Bush administration, the law will help consumers.

“The bill will remove significant burdens on class-action litigants and provide greater protections for the victims whom the class-action device originally was designed to benefit,” according to an official statement issued by the Bush administration.

The law would affect only cases filed after the bill was signed, noted Ms. Aldebron.

WASHINGTON — Despite their growing popularity, health savings accounts are not a good solution to the problem of rising health care costs, at least not for California state employees and retirees, Fred Buenrostro said at a health care congress sponsored by the Wall Street Journal and CNBC.

Mr. Buenrostro is chief executive officer at the California Public Employees' Retirement System (CalPERS), the second largest health care purchaser in the country. CalPERS, based in Sacramento, provides health benefits to more than 1.2 million employees, retirees, and family members.

In California, out-of-pocket health care premiums have nearly tripled in 5 years, and Republican Gov. Arnold Schwarzenegger is seeking to cut the amount of premium assistance the state gives to employees and retirees. So “CalPERS, like other employers, is hearing the call of consumer-driven health care,” Mr. Buenrostro said.

“We are resisting it because we don't want our highway workers, our police officers, our firefighters, our office workers, to switch from our defined benefits health care model to a defined contribution model. We oppose putting our members at risk in such a complex, broken market,” he said.

Under a defined benefit plan like those that CalPERS offers, employers agree to pay for a particular level of benefits, no matter what the cost of the plan is. But under a defined contribution plan, the employer pays only a certain amount toward the cost of an insurance policy; any additional costs must be paid by the enrollee.

So CalPERS is trying other ways to cut health care costs. One technique is to avoid providers that the plan perceives to be too costly. “Two years ago, we dropped two big HMO partners because their prices went over the top,” Mr. Buenrostro said.

The plan is also using generic drugs in 95% of cases, and giving members incentives to buy mail-order drugs. CalPERS has extended the length of its PPO contracts to improve its negotiating position, and is encouraging members to use “centers of excellence” for various procedures.

CalPERS also is talking with other purchasers about price inequities of health care in local markets, and plans to convene a conference of purchasers on this issue later in the year.

One big part of controlling CalPERS' costs has been getting the best price for hospital services. Between 2001 and 2003, hospital prices rose 60%, which was “just unaffordable,” he said. CalPERS partnered with California Blue Shield to do an analysis of the costs.

“Blue Shield came up with what was then a shocking discovery: In many cases there was no correlation between price and quality,” he continued. “I thought they were kidding.” For example, they found that the cost of chemotherapy could range from $135,000 to $300,000.

As a result of the analysis, CalPERS notified 38 hospitals and 17 physician practices that they were in danger of being dropped from CalPERS' provider network unless they dropped their costs and agreed to undergo performance assessments. The change would have saved $36 million in the first year and $50 million for the next few years.

CalPERS ended up dropping 24 hospitals and several physician practices as of January, forcing 32,000 members to switch their primary care physicians. Although the move resulted in complaints from members as well as the California legislature, Mr. Buenrostro has no regrets.

“It will save tens of millions of dollars for our members and the taxpayers [who pay our salaries], and the decision helped us keep our HMO and PPO premium increases for members under 65 at 9.9% without any takeaways or any increases in copays or deductibles,” Mr. Buenrostro said. “We're pretty proud of that.”

Despite CalPERS' success, it can't solve the long-range health care cost problem by acting on its own, he said, “We can only solve this problem if we get a national solution.”

WASHINGTON — Despite their growing popularity, health savings accounts are not a good solution to the problem of rising health care costs, at least not for California state employees and retirees, Fred Buenrostro said at a health care congress sponsored by the Wall Street Journal and CNBC.

Mr. Buenrostro is chief executive officer at the California Public Employees' Retirement System (CalPERS), the second largest health care purchaser in the country. CalPERS, based in Sacramento, provides health benefits to more than 1.2 million employees, retirees, and family members.

In California, out-of-pocket health care premiums have nearly tripled in 5 years, and Republican Gov. Arnold Schwarzenegger is seeking to cut the amount of premium assistance the state gives to employees and retirees. So “CalPERS, like other employers, is hearing the call of consumer-driven health care,” Mr. Buenrostro said.

“We are resisting it because we don't want our highway workers, our police officers, our firefighters, our office workers, to switch from our defined benefits health care model to a defined contribution model. We oppose putting our members at risk in such a complex, broken market,” he said.

Under a defined benefit plan like those that CalPERS offers, employers agree to pay for a particular level of benefits, no matter what the cost of the plan is. But under a defined contribution plan, the employer pays only a certain amount toward the cost of an insurance policy; any additional costs must be paid by the enrollee.

So CalPERS is trying other ways to cut health care costs. One technique is to avoid providers that the plan perceives to be too costly. “Two years ago, we dropped two big HMO partners because their prices went over the top,” Mr. Buenrostro said.

The plan is also using generic drugs in 95% of cases, and giving members incentives to buy mail-order drugs. CalPERS has extended the length of its PPO contracts to improve its negotiating position, and is encouraging members to use “centers of excellence” for various procedures.

CalPERS also is talking with other purchasers about price inequities of health care in local markets, and plans to convene a conference of purchasers on this issue later in the year.

One big part of controlling CalPERS' costs has been getting the best price for hospital services. Between 2001 and 2003, hospital prices rose 60%, which was “just unaffordable,” he said. CalPERS partnered with California Blue Shield to do an analysis of the costs.

“Blue Shield came up with what was then a shocking discovery: In many cases there was no correlation between price and quality,” he continued. “I thought they were kidding.” For example, they found that the cost of chemotherapy could range from $135,000 to $300,000.

As a result of the analysis, CalPERS notified 38 hospitals and 17 physician practices that they were in danger of being dropped from CalPERS' provider network unless they dropped their costs and agreed to undergo performance assessments. The change would have saved $36 million in the first year and $50 million for the next few years.

CalPERS ended up dropping 24 hospitals and several physician practices as of January, forcing 32,000 members to switch their primary care physicians. Although the move resulted in complaints from members as well as the California legislature, Mr. Buenrostro has no regrets.

“It will save tens of millions of dollars for our members and the taxpayers [who pay our salaries], and the decision helped us keep our HMO and PPO premium increases for members under 65 at 9.9% without any takeaways or any increases in copays or deductibles,” Mr. Buenrostro said. “We're pretty proud of that.”

Despite CalPERS' success, it can't solve the long-range health care cost problem by acting on its own, he said, “We can only solve this problem if we get a national solution.”

WASHINGTON — Despite their growing popularity, health savings accounts are not a good solution to the problem of rising health care costs, at least not for California state employees and retirees, Fred Buenrostro said at a health care congress sponsored by the Wall Street Journal and CNBC.

Mr. Buenrostro is chief executive officer at the California Public Employees' Retirement System (CalPERS), the second largest health care purchaser in the country. CalPERS, based in Sacramento, provides health benefits to more than 1.2 million employees, retirees, and family members.

In California, out-of-pocket health care premiums have nearly tripled in 5 years, and Republican Gov. Arnold Schwarzenegger is seeking to cut the amount of premium assistance the state gives to employees and retirees. So “CalPERS, like other employers, is hearing the call of consumer-driven health care,” Mr. Buenrostro said.

“We are resisting it because we don't want our highway workers, our police officers, our firefighters, our office workers, to switch from our defined benefits health care model to a defined contribution model. We oppose putting our members at risk in such a complex, broken market,” he said.

Under a defined benefit plan like those that CalPERS offers, employers agree to pay for a particular level of benefits, no matter what the cost of the plan is. But under a defined contribution plan, the employer pays only a certain amount toward the cost of an insurance policy; any additional costs must be paid by the enrollee.

So CalPERS is trying other ways to cut health care costs. One technique is to avoid providers that the plan perceives to be too costly. “Two years ago, we dropped two big HMO partners because their prices went over the top,” Mr. Buenrostro said.

The plan is also using generic drugs in 95% of cases, and giving members incentives to buy mail-order drugs. CalPERS has extended the length of its PPO contracts to improve its negotiating position, and is encouraging members to use “centers of excellence” for various procedures.

CalPERS also is talking with other purchasers about price inequities of health care in local markets, and plans to convene a conference of purchasers on this issue later in the year.

One big part of controlling CalPERS' costs has been getting the best price for hospital services. Between 2001 and 2003, hospital prices rose 60%, which was “just unaffordable,” he said. CalPERS partnered with California Blue Shield to do an analysis of the costs.

“Blue Shield came up with what was then a shocking discovery: In many cases there was no correlation between price and quality,” he continued. “I thought they were kidding.” For example, they found that the cost of chemotherapy could range from $135,000 to $300,000.

As a result of the analysis, CalPERS notified 38 hospitals and 17 physician practices that they were in danger of being dropped from CalPERS' provider network unless they dropped their costs and agreed to undergo performance assessments. The change would have saved $36 million in the first year and $50 million for the next few years.

CalPERS ended up dropping 24 hospitals and several physician practices as of January, forcing 32,000 members to switch their primary care physicians. Although the move resulted in complaints from members as well as the California legislature, Mr. Buenrostro has no regrets.

“It will save tens of millions of dollars for our members and the taxpayers [who pay our salaries], and the decision helped us keep our HMO and PPO premium increases for members under 65 at 9.9% without any takeaways or any increases in copays or deductibles,” Mr. Buenrostro said. “We're pretty proud of that.”

Despite CalPERS' success, it can't solve the long-range health care cost problem by acting on its own, he said, “We can only solve this problem if we get a national solution.”

WASHINGTON — People who have suffered adverse outcomes due to drugs or medical devices may face more delays in suing manufacturers for damages now that federal class-action lawsuit legislation has been signed into law.

The law, known as the Class Action Fairness Act of 2005, would move from state court to federal court any class-action lawsuit in which the amount of damages claimed exceeded $5 million and involved citizens in different states. The law also outlines circumstances in which federal courts can decline to hear class-action cases.

Proponents of the law, which passed quickly in both the House and Senate, say it will help decrease the number of “junk lawsuits” that are clogging the state courts.

“America's employers and consumers are the big winners,” Tom Donohue, president and CEO of the U.S. Chamber of Commerce, said in a statement. “Reform of the class action lawsuit system will reduce frivolous lawsuits, spur business investment, and help restore sanity to our nation's legal system.”

Critics of the bill, however, say that it will deprive citizens of their right to sue when they are injured by a defective product. “There are only 678 federal trial judges in the system, but there are 9,200 state judges in courts of general jurisdiction,” said Jillian Aldebron, counsel and communications coordinator for Public Citizen's Congress Watch, a citizen watchdog group. “So you're talking about cases ordinarily divided up among 9,200 judges and squeezing them into the courtrooms of 678 judges. Even if they are willing to hear the cases, it's going to take years, and these cases take years in state court [already].”

Physician organizations, including the American Medical Association and the American College of Physicians, have declined to take a stand on the bill; their efforts are more focused on tort reform legislation affecting medical malpractice cases. But consumer groups, such as the Campaign for Tobacco-Free Kids, lamented the effect the bill would have on health care-related cases. “Class-action lawsuits have been an important tool in efforts to hold the tobacco industry accountable,” the group's president, Matthew L. Myers, said in a statement. “This bill will deprive citizens of a state of the right to have their cases heard in their own courts, further overburden the federal courts, and make it more difficult for tobacco companies to be held accountable for years of misleading Americans about the dangers of tobacco.”

Senior citizens' lobby AARP also opposed the bill. “There wasn't an adequate basis for consumers no longer having the option of bringing a multistate case in state court,” said Larry White, senior legislative representative. “When you in essence say that the federal courts will have jurisdiction … knowing the federal courts oftentimes don't certify those cases, you're in essence saying people who have been genuinely harmed don't have options.”

According to the Bush administration, the law will help consumers. “The bill will remove significant burdens on class-action litigants and provide greater protections for the victims whom the class-action device originally was designed to benefit,” the administration said in a statement.

WASHINGTON — People who have suffered adverse outcomes due to drugs or medical devices may face more delays in suing manufacturers for damages now that federal class-action lawsuit legislation has been signed into law.

The law, known as the Class Action Fairness Act of 2005, would move from state court to federal court any class-action lawsuit in which the amount of damages claimed exceeded $5 million and involved citizens in different states. The law also outlines circumstances in which federal courts can decline to hear class-action cases.

Proponents of the law, which passed quickly in both the House and Senate, say it will help decrease the number of “junk lawsuits” that are clogging the state courts.

“America's employers and consumers are the big winners,” Tom Donohue, president and CEO of the U.S. Chamber of Commerce, said in a statement. “Reform of the class action lawsuit system will reduce frivolous lawsuits, spur business investment, and help restore sanity to our nation's legal system.”

Critics of the bill, however, say that it will deprive citizens of their right to sue when they are injured by a defective product. “There are only 678 federal trial judges in the system, but there are 9,200 state judges in courts of general jurisdiction,” said Jillian Aldebron, counsel and communications coordinator for Public Citizen's Congress Watch, a citizen watchdog group. “So you're talking about cases ordinarily divided up among 9,200 judges and squeezing them into the courtrooms of 678 judges. Even if they are willing to hear the cases, it's going to take years, and these cases take years in state court [already].”

Physician organizations, including the American Medical Association and the American College of Physicians, have declined to take a stand on the bill; their efforts are more focused on tort reform legislation affecting medical malpractice cases. But consumer groups, such as the Campaign for Tobacco-Free Kids, lamented the effect the bill would have on health care-related cases. “Class-action lawsuits have been an important tool in efforts to hold the tobacco industry accountable,” the group's president, Matthew L. Myers, said in a statement. “This bill will deprive citizens of a state of the right to have their cases heard in their own courts, further overburden the federal courts, and make it more difficult for tobacco companies to be held accountable for years of misleading Americans about the dangers of tobacco.”

Senior citizens' lobby AARP also opposed the bill. “There wasn't an adequate basis for consumers no longer having the option of bringing a multistate case in state court,” said Larry White, senior legislative representative. “When you in essence say that the federal courts will have jurisdiction … knowing the federal courts oftentimes don't certify those cases, you're in essence saying people who have been genuinely harmed don't have options.”

According to the Bush administration, the law will help consumers. “The bill will remove significant burdens on class-action litigants and provide greater protections for the victims whom the class-action device originally was designed to benefit,” the administration said in a statement.

WASHINGTON — People who have suffered adverse outcomes due to drugs or medical devices may face more delays in suing manufacturers for damages now that federal class-action lawsuit legislation has been signed into law.

The law, known as the Class Action Fairness Act of 2005, would move from state court to federal court any class-action lawsuit in which the amount of damages claimed exceeded $5 million and involved citizens in different states. The law also outlines circumstances in which federal courts can decline to hear class-action cases.

Proponents of the law, which passed quickly in both the House and Senate, say it will help decrease the number of “junk lawsuits” that are clogging the state courts.

“America's employers and consumers are the big winners,” Tom Donohue, president and CEO of the U.S. Chamber of Commerce, said in a statement. “Reform of the class action lawsuit system will reduce frivolous lawsuits, spur business investment, and help restore sanity to our nation's legal system.”

Critics of the bill, however, say that it will deprive citizens of their right to sue when they are injured by a defective product. “There are only 678 federal trial judges in the system, but there are 9,200 state judges in courts of general jurisdiction,” said Jillian Aldebron, counsel and communications coordinator for Public Citizen's Congress Watch, a citizen watchdog group. “So you're talking about cases ordinarily divided up among 9,200 judges and squeezing them into the courtrooms of 678 judges. Even if they are willing to hear the cases, it's going to take years, and these cases take years in state court [already].”

Physician organizations, including the American Medical Association and the American College of Physicians, have declined to take a stand on the bill; their efforts are more focused on tort reform legislation affecting medical malpractice cases. But consumer groups, such as the Campaign for Tobacco-Free Kids, lamented the effect the bill would have on health care-related cases. “Class-action lawsuits have been an important tool in efforts to hold the tobacco industry accountable,” the group's president, Matthew L. Myers, said in a statement. “This bill will deprive citizens of a state of the right to have their cases heard in their own courts, further overburden the federal courts, and make it more difficult for tobacco companies to be held accountable for years of misleading Americans about the dangers of tobacco.”

Senior citizens' lobby AARP also opposed the bill. “There wasn't an adequate basis for consumers no longer having the option of bringing a multistate case in state court,” said Larry White, senior legislative representative. “When you in essence say that the federal courts will have jurisdiction … knowing the federal courts oftentimes don't certify those cases, you're in essence saying people who have been genuinely harmed don't have options.”

According to the Bush administration, the law will help consumers. “The bill will remove significant burdens on class-action litigants and provide greater protections for the victims whom the class-action device originally was designed to benefit,” the administration said in a statement.

WASHINGTON — A congressional committee wrestled with whether or how much to regulate or impose standards on imaging procedures at a hearing last month on managing Medicare's imaging costs.

“I'm concerned about putting in a whole group of new structures [to monitor imaging procedures] because the system is structure-heavy already,” said Rep. Nancy Johnson (R-Conn.), chair of the health subcommittee of the House Ways and Means Committee. “I'm not sure putting in more oversight is really what we need.”

Mark Miller, Ph.D., executive director of the Medicare Payment Advisory Commission (MedPAC), testified that the growth in the volume of imaging services such as PET scans, CT scans, and MRIs performed on Medicare beneficiaries “is growing at twice the rate of all physician services.” And what worries MedPAC, he continued, is that increasing the amount of imaging being done doesn't necessarily mean the quality of care is getting any better.

“There is a threefold variation in the use of these services among the Medicare population, and it's not linked to health care quality,” Dr. Miller said. “It's more [related to the] availability of services and practice style.”

MedPAC also is concerned about the wide variability in imaging quality, he said. “There is variation in the quality of the images produced and in the quality of image interpretation.” He said the 17 MedPAC commissioners would like to see the Department of Health and Human Services set quality standards for imaging providers, referring to recommendations submitted to Congress earlier this year (CARDIOLOGY NEWS, March 2005, p. 6).

“Some people characterize this recommendation as directed toward limiting imaging to radiologists only and billing for imaging to radiologists only,” Dr. Miller said, alluding to the perceived “turf war” going on between radiologists and other imaging providers. “That is not correct. We believe the standard should apply to all physicians” who do imaging.

Subcommittee member Rep. Jim Ramstad (R-Minn.) said he was happy to hear that imaging would not be restricted to radiologists. “I would hate to see this become nothing more than a turf battle,” he said. “It seems to me that overutilization is a complex issue, involving factors like defensive medicine, provider preference, and consumer demand for the best test.”

The subcommittee also heard from representatives for cardiology and radiology groups, each of which took opposing positions on the increase in imaging volume. “We are deeply concerned with the exponential growth in office-based imaging by those who may lack the education, training, equipment, and clinical personnel to safely and effectively use these studies,” said James Borgstede, M.D., chair of the American College of Radiology's board of chancellors. “For this reason, the ACR supports many of the MedPAC recommendations that link Medicare reimbursement to quality, safety, and training standards for physicians and facilities which provide medical imaging services.”

Kim Williams, M.D., speaking on behalf of the American College of Cardiology, said there was “no credible evidence” to support the idea that office-based imaging was of poor quality. “Patients are really the issue, not the turf wars frequently discussed in the literature of the American College of Radiology,” he said. “Office-based medical imaging performed by well-trained specialists is good patient care.”

Cardiologists are especially concerned about a MedPAC recommendation involving ownership of imaging equipment. Under the current laws against physician self-referral, physicians cannot refer patients to an imaging center in which they have direct ownership. Dr. Williams urged the subcommittee not to remove a provision in the law that exempts nuclear medicine.

The subcommittee also considered the issue of whether to lower reimbursement for multiple imaging procedures performed in the same visit—specifically, lowering the amount paid for each subsequent image after the first one. Dr. Borgstede noted that the American Medical Association's CPT Editorial Panel has recommended such a reduction, but it will apply to the first image as well. That change will take effect next January, he said.

“We're at a stage where we have to rethink the way we pay physicians,” Rep. Johnson said to the two physicians on the panel. “Think about it, and get back to us about what you'd like to see in terms of … steps in the quality ladder.”

WASHINGTON — A congressional committee wrestled with whether or how much to regulate or impose standards on imaging procedures at a hearing last month on managing Medicare's imaging costs.

“I'm concerned about putting in a whole group of new structures [to monitor imaging procedures] because the system is structure-heavy already,” said Rep. Nancy Johnson (R-Conn.), chair of the health subcommittee of the House Ways and Means Committee. “I'm not sure putting in more oversight is really what we need.”

Mark Miller, Ph.D., executive director of the Medicare Payment Advisory Commission (MedPAC), testified that the growth in the volume of imaging services such as PET scans, CT scans, and MRIs performed on Medicare beneficiaries “is growing at twice the rate of all physician services.” And what worries MedPAC, he continued, is that increasing the amount of imaging being done doesn't necessarily mean the quality of care is getting any better.

“There is a threefold variation in the use of these services among the Medicare population, and it's not linked to health care quality,” Dr. Miller said. “It's more [related to the] availability of services and practice style.”

MedPAC also is concerned about the wide variability in imaging quality, he said. “There is variation in the quality of the images produced and in the quality of image interpretation.” He said the 17 MedPAC commissioners would like to see the Department of Health and Human Services set quality standards for imaging providers, referring to recommendations submitted to Congress earlier this year (CARDIOLOGY NEWS, March 2005, p. 6).

“Some people characterize this recommendation as directed toward limiting imaging to radiologists only and billing for imaging to radiologists only,” Dr. Miller said, alluding to the perceived “turf war” going on between radiologists and other imaging providers. “That is not correct. We believe the standard should apply to all physicians” who do imaging.

Subcommittee member Rep. Jim Ramstad (R-Minn.) said he was happy to hear that imaging would not be restricted to radiologists. “I would hate to see this become nothing more than a turf battle,” he said. “It seems to me that overutilization is a complex issue, involving factors like defensive medicine, provider preference, and consumer demand for the best test.”

The subcommittee also heard from representatives for cardiology and radiology groups, each of which took opposing positions on the increase in imaging volume. “We are deeply concerned with the exponential growth in office-based imaging by those who may lack the education, training, equipment, and clinical personnel to safely and effectively use these studies,” said James Borgstede, M.D., chair of the American College of Radiology's board of chancellors. “For this reason, the ACR supports many of the MedPAC recommendations that link Medicare reimbursement to quality, safety, and training standards for physicians and facilities which provide medical imaging services.”

Kim Williams, M.D., speaking on behalf of the American College of Cardiology, said there was “no credible evidence” to support the idea that office-based imaging was of poor quality. “Patients are really the issue, not the turf wars frequently discussed in the literature of the American College of Radiology,” he said. “Office-based medical imaging performed by well-trained specialists is good patient care.”

Cardiologists are especially concerned about a MedPAC recommendation involving ownership of imaging equipment. Under the current laws against physician self-referral, physicians cannot refer patients to an imaging center in which they have direct ownership. Dr. Williams urged the subcommittee not to remove a provision in the law that exempts nuclear medicine.

The subcommittee also considered the issue of whether to lower reimbursement for multiple imaging procedures performed in the same visit—specifically, lowering the amount paid for each subsequent image after the first one. Dr. Borgstede noted that the American Medical Association's CPT Editorial Panel has recommended such a reduction, but it will apply to the first image as well. That change will take effect next January, he said.

“We're at a stage where we have to rethink the way we pay physicians,” Rep. Johnson said to the two physicians on the panel. “Think about it, and get back to us about what you'd like to see in terms of … steps in the quality ladder.”

WASHINGTON — A congressional committee wrestled with whether or how much to regulate or impose standards on imaging procedures at a hearing last month on managing Medicare's imaging costs.

“I'm concerned about putting in a whole group of new structures [to monitor imaging procedures] because the system is structure-heavy already,” said Rep. Nancy Johnson (R-Conn.), chair of the health subcommittee of the House Ways and Means Committee. “I'm not sure putting in more oversight is really what we need.”

Mark Miller, Ph.D., executive director of the Medicare Payment Advisory Commission (MedPAC), testified that the growth in the volume of imaging services such as PET scans, CT scans, and MRIs performed on Medicare beneficiaries “is growing at twice the rate of all physician services.” And what worries MedPAC, he continued, is that increasing the amount of imaging being done doesn't necessarily mean the quality of care is getting any better.

“There is a threefold variation in the use of these services among the Medicare population, and it's not linked to health care quality,” Dr. Miller said. “It's more [related to the] availability of services and practice style.”

MedPAC also is concerned about the wide variability in imaging quality, he said. “There is variation in the quality of the images produced and in the quality of image interpretation.” He said the 17 MedPAC commissioners would like to see the Department of Health and Human Services set quality standards for imaging providers, referring to recommendations submitted to Congress earlier this year (CARDIOLOGY NEWS, March 2005, p. 6).

“Some people characterize this recommendation as directed toward limiting imaging to radiologists only and billing for imaging to radiologists only,” Dr. Miller said, alluding to the perceived “turf war” going on between radiologists and other imaging providers. “That is not correct. We believe the standard should apply to all physicians” who do imaging.

Subcommittee member Rep. Jim Ramstad (R-Minn.) said he was happy to hear that imaging would not be restricted to radiologists. “I would hate to see this become nothing more than a turf battle,” he said. “It seems to me that overutilization is a complex issue, involving factors like defensive medicine, provider preference, and consumer demand for the best test.”

The subcommittee also heard from representatives for cardiology and radiology groups, each of which took opposing positions on the increase in imaging volume. “We are deeply concerned with the exponential growth in office-based imaging by those who may lack the education, training, equipment, and clinical personnel to safely and effectively use these studies,” said James Borgstede, M.D., chair of the American College of Radiology's board of chancellors. “For this reason, the ACR supports many of the MedPAC recommendations that link Medicare reimbursement to quality, safety, and training standards for physicians and facilities which provide medical imaging services.”

Kim Williams, M.D., speaking on behalf of the American College of Cardiology, said there was “no credible evidence” to support the idea that office-based imaging was of poor quality. “Patients are really the issue, not the turf wars frequently discussed in the literature of the American College of Radiology,” he said. “Office-based medical imaging performed by well-trained specialists is good patient care.”

Cardiologists are especially concerned about a MedPAC recommendation involving ownership of imaging equipment. Under the current laws against physician self-referral, physicians cannot refer patients to an imaging center in which they have direct ownership. Dr. Williams urged the subcommittee not to remove a provision in the law that exempts nuclear medicine.

The subcommittee also considered the issue of whether to lower reimbursement for multiple imaging procedures performed in the same visit—specifically, lowering the amount paid for each subsequent image after the first one. Dr. Borgstede noted that the American Medical Association's CPT Editorial Panel has recommended such a reduction, but it will apply to the first image as well. That change will take effect next January, he said.

“We're at a stage where we have to rethink the way we pay physicians,” Rep. Johnson said to the two physicians on the panel. “Think about it, and get back to us about what you'd like to see in terms of … steps in the quality ladder.”

As the public focuses on problems with the safety and cost of prescription drugs, insurers are training their sights on a different cost issue: imaging procedures.

On average, costs of imaging—especially high-tech procedures, such as MRI, CT, and magnetic resonance angiograms—have been going up 20% a year for the last several years, according to Thomas Dehn, M.D., cofounder of National Imaging Associates, a radiology utilization-management firm in Hackensack, N.J.

“Some will say it's the aging of the population, but the key issue is really demand,” said Dr. Dehn, the company's executive vice president and chief medical officer. “Patients are bright. They're good consumers. They want a shoulder MRI if their shoulder hurts.”

Physician demand is also an important part of the equation, he said. “If you have physicians who want increased [patient volume] in their offices, it is possible that rather than spending cognitive time, for which they're poorly reimbursed, they may choose to use a technical alternative.”

For example, a doctor trying to figure out the source of a patient's chronic headaches “may get frustrated and refer the patient for an MRI of the brain, just to show them they're normal,” Dr. Dehn said. “The treating physician knows in the back of his mind that there isn't going to be anything [on the imaging], but it will calm the patient down.”

As to which physicians are responsible for the increase in imaging, the answer depends on whom you ask. The American College of Radiology contends that the growth is largely due to self-referral by nonradiologists who have bought their own imaging equipment. But others say that all specialties are doing more imaging, largely because of improved technology and the improvement in care that it brings.

Whatever the reason that more scans are being done, insurers have decided they've had enough. Take Highmark Blue Cross and Blue Shield, a Pittsburgh-based insurer whose imaging costs have risen to $500 million annually in the last few years.

One Highmark strategy for paring down its imaging costs is to develop a smaller network of imaging providers. To be included in Highmark's network, outpatient imaging centers must now offer multiple imaging modalities, such as mammography, MRIs, CTs, and bone densitometry.

“We were seeing many facilities that were single modality—just CT or just MRI,” said Cary Vinson, M.D., Highmark's vice president of quality and medical performance management. “They were being set up by for-profit companies to siphon away high-margin procedures from hospitals and other multimodality freestanding facilities. We were seeing access problems for referring physicians because the single modality centers were outcompeting the multimodality centers, and they couldn't keep up.”

In addition to credentialing the imaging centers, Highmark is going to start requiring providers to preauthorize all CT, MRI, and PET scans. At first, while everyone adapts to the new system, the preauthorization procedure will be voluntary and no procedures will be denied. But eventually—perhaps by the end of this year—the preauthorization will become mandatory, Dr. Vinson said.

Harvard Pilgrim Health Care (HPHC) of Wellesley, Mass., is taking a slightly different approach. Instead of mandatory preauthorization, HPHC is using a “soft denial” process in which physicians must call for imaging preauthorization, but they can overrule a negative decision if they want to.

“We made a decision based on our network being a very sophisticated, highly academic referral environment, that a hard denial program might not be best way to go,” said William Corwin, M.D., the plan's medical director for utilization management and clinical policy. “Instead, we elected to use a more consultative approach.” The program started in July, so no concrete results are available yet, he noted.

Plans that start a preauthorization program must first figure out who should be authorized to perform scans. At Highmark, the plan tried to be as inclusive as possible, Dr. Vinson said.

“In some cases within a specialty, we tried to determine who was qualified and who was not,” he said. “For instance, for breast ultrasound, we listed radiologists, but we also included surgeons with breast ultrasound certification from the American Society of Breast Surgeons.”

Highmark ran into a turf battle as it tried to credential providers. In this case, the American College of Cardiology and the American College of Radiology “definitely have differences of opinion about who's qualified and who's not” when it comes to cardiology-related imaging exams, Dr. Vinson said. “Highmark took the approach of accepting either society's qualifications. They clearly wanted us to decide between the two, and we would not do that.”

To design their preauthorization programs, both Highmark and Harvard Pilgrim worked with National Imaging Associates, which now has “more than two dozen” clients nationwide and is active in 32 states, according to Dr. Dehn.

He predicts that at least one more specialty will come into the picture, as more and more molecular imaging is being done to design tumor-specific antibodies. “You may have immunologists who are doing diagnostic imaging,” he said.

As the public focuses on problems with the safety and cost of prescription drugs, insurers are training their sights on a different cost issue: imaging procedures.

On average, costs of imaging—especially high-tech procedures, such as MRI, CT, and magnetic resonance angiograms—have been going up 20% a year for the last several years, according to Thomas Dehn, M.D., cofounder of National Imaging Associates, a radiology utilization-management firm in Hackensack, N.J.

“Some will say it's the aging of the population, but the key issue is really demand,” said Dr. Dehn, the company's executive vice president and chief medical officer. “Patients are bright. They're good consumers. They want a shoulder MRI if their shoulder hurts.”

Physician demand is also an important part of the equation, he said. “If you have physicians who want increased [patient volume] in their offices, it is possible that rather than spending cognitive time, for which they're poorly reimbursed, they may choose to use a technical alternative.”

For example, a doctor trying to figure out the source of a patient's chronic headaches “may get frustrated and refer the patient for an MRI of the brain, just to show them they're normal,” Dr. Dehn said. “The treating physician knows in the back of his mind that there isn't going to be anything [on the imaging], but it will calm the patient down.”

As to which physicians are responsible for the increase in imaging, the answer depends on whom you ask. The American College of Radiology contends that the growth is largely due to self-referral by nonradiologists who have bought their own imaging equipment. But others say that all specialties are doing more imaging, largely because of improved technology and the improvement in care that it brings.

Whatever the reason that more scans are being done, insurers have decided they've had enough. Take Highmark Blue Cross and Blue Shield, a Pittsburgh-based insurer whose imaging costs have risen to $500 million annually in the last few years.

One Highmark strategy for paring down its imaging costs is to develop a smaller network of imaging providers. To be included in Highmark's network, outpatient imaging centers must now offer multiple imaging modalities, such as mammography, MRIs, CTs, and bone densitometry.

“We were seeing many facilities that were single modality—just CT or just MRI,” said Cary Vinson, M.D., Highmark's vice president of quality and medical performance management. “They were being set up by for-profit companies to siphon away high-margin procedures from hospitals and other multimodality freestanding facilities. We were seeing access problems for referring physicians because the single modality centers were outcompeting the multimodality centers, and they couldn't keep up.”

In addition to credentialing the imaging centers, Highmark is going to start requiring providers to preauthorize all CT, MRI, and PET scans. At first, while everyone adapts to the new system, the preauthorization procedure will be voluntary and no procedures will be denied. But eventually—perhaps by the end of this year—the preauthorization will become mandatory, Dr. Vinson said.

Harvard Pilgrim Health Care (HPHC) of Wellesley, Mass., is taking a slightly different approach. Instead of mandatory preauthorization, HPHC is using a “soft denial” process in which physicians must call for imaging preauthorization, but they can overrule a negative decision if they want to.

“We made a decision based on our network being a very sophisticated, highly academic referral environment, that a hard denial program might not be best way to go,” said William Corwin, M.D., the plan's medical director for utilization management and clinical policy. “Instead, we elected to use a more consultative approach.” The program started in July, so no concrete results are available yet, he noted.

Plans that start a preauthorization program must first figure out who should be authorized to perform scans. At Highmark, the plan tried to be as inclusive as possible, Dr. Vinson said.

“In some cases within a specialty, we tried to determine who was qualified and who was not,” he said. “For instance, for breast ultrasound, we listed radiologists, but we also included surgeons with breast ultrasound certification from the American Society of Breast Surgeons.”

Highmark ran into a turf battle as it tried to credential providers. In this case, the American College of Cardiology and the American College of Radiology “definitely have differences of opinion about who's qualified and who's not” when it comes to cardiology-related imaging exams, Dr. Vinson said. “Highmark took the approach of accepting either society's qualifications. They clearly wanted us to decide between the two, and we would not do that.”

To design their preauthorization programs, both Highmark and Harvard Pilgrim worked with National Imaging Associates, which now has “more than two dozen” clients nationwide and is active in 32 states, according to Dr. Dehn.

He predicts that at least one more specialty will come into the picture, as more and more molecular imaging is being done to design tumor-specific antibodies. “You may have immunologists who are doing diagnostic imaging,” he said.

As the public focuses on problems with the safety and cost of prescription drugs, insurers are training their sights on a different cost issue: imaging procedures.

On average, costs of imaging—especially high-tech procedures, such as MRI, CT, and magnetic resonance angiograms—have been going up 20% a year for the last several years, according to Thomas Dehn, M.D., cofounder of National Imaging Associates, a radiology utilization-management firm in Hackensack, N.J.

“Some will say it's the aging of the population, but the key issue is really demand,” said Dr. Dehn, the company's executive vice president and chief medical officer. “Patients are bright. They're good consumers. They want a shoulder MRI if their shoulder hurts.”

Physician demand is also an important part of the equation, he said. “If you have physicians who want increased [patient volume] in their offices, it is possible that rather than spending cognitive time, for which they're poorly reimbursed, they may choose to use a technical alternative.”

For example, a doctor trying to figure out the source of a patient's chronic headaches “may get frustrated and refer the patient for an MRI of the brain, just to show them they're normal,” Dr. Dehn said. “The treating physician knows in the back of his mind that there isn't going to be anything [on the imaging], but it will calm the patient down.”

As to which physicians are responsible for the increase in imaging, the answer depends on whom you ask. The American College of Radiology contends that the growth is largely due to self-referral by nonradiologists who have bought their own imaging equipment. But others say that all specialties are doing more imaging, largely because of improved technology and the improvement in care that it brings.

Whatever the reason that more scans are being done, insurers have decided they've had enough. Take Highmark Blue Cross and Blue Shield, a Pittsburgh-based insurer whose imaging costs have risen to $500 million annually in the last few years.

One Highmark strategy for paring down its imaging costs is to develop a smaller network of imaging providers. To be included in Highmark's network, outpatient imaging centers must now offer multiple imaging modalities, such as mammography, MRIs, CTs, and bone densitometry.

“We were seeing many facilities that were single modality—just CT or just MRI,” said Cary Vinson, M.D., Highmark's vice president of quality and medical performance management. “They were being set up by for-profit companies to siphon away high-margin procedures from hospitals and other multimodality freestanding facilities. We were seeing access problems for referring physicians because the single modality centers were outcompeting the multimodality centers, and they couldn't keep up.”

In addition to credentialing the imaging centers, Highmark is going to start requiring providers to preauthorize all CT, MRI, and PET scans. At first, while everyone adapts to the new system, the preauthorization procedure will be voluntary and no procedures will be denied. But eventually—perhaps by the end of this year—the preauthorization will become mandatory, Dr. Vinson said.

Harvard Pilgrim Health Care (HPHC) of Wellesley, Mass., is taking a slightly different approach. Instead of mandatory preauthorization, HPHC is using a “soft denial” process in which physicians must call for imaging preauthorization, but they can overrule a negative decision if they want to.

“We made a decision based on our network being a very sophisticated, highly academic referral environment, that a hard denial program might not be best way to go,” said William Corwin, M.D., the plan's medical director for utilization management and clinical policy. “Instead, we elected to use a more consultative approach.” The program started in July, so no concrete results are available yet, he noted.

Plans that start a preauthorization program must first figure out who should be authorized to perform scans. At Highmark, the plan tried to be as inclusive as possible, Dr. Vinson said.

“In some cases within a specialty, we tried to determine who was qualified and who was not,” he said. “For instance, for breast ultrasound, we listed radiologists, but we also included surgeons with breast ultrasound certification from the American Society of Breast Surgeons.”

Highmark ran into a turf battle as it tried to credential providers. In this case, the American College of Cardiology and the American College of Radiology “definitely have differences of opinion about who's qualified and who's not” when it comes to cardiology-related imaging exams, Dr. Vinson said. “Highmark took the approach of accepting either society's qualifications. They clearly wanted us to decide between the two, and we would not do that.”

To design their preauthorization programs, both Highmark and Harvard Pilgrim worked with National Imaging Associates, which now has “more than two dozen” clients nationwide and is active in 32 states, according to Dr. Dehn.

He predicts that at least one more specialty will come into the picture, as more and more molecular imaging is being done to design tumor-specific antibodies. “You may have immunologists who are doing diagnostic imaging,” he said.