Joyce Frieden

A prominent reproductive health researcher has removed his name from the list of authors of a study on prayer and in vitro fertilization published in 2001, but the controversy over the study continues.

The study “Does Prayer Influence the Success of In Vitro Fertilization-Embryo Transfer?” was published in the September 2001 issue of the Journal of Reproductive Medicine (J. Reprod. Med. 2001;46:781-7). The authors studied the use of prayer on 219 Korean women who underwent IVF over a 4-month period. The pregnancy rate was nearly twice as high in the women who had been prayed for, compared with those who had not been prayed for (50% vs. 26%), a statistically significant difference.

The study was removed from the Web site nearly 3 years later after the journal received a number of letters and e-mails critical of the research. The journal's editor-in-chief, Lawrence Devoe, M.D., said the study was removed from the Web site because it generated more traffic than the office could handle. Critics of the study questioned its methodology—involving several “tiers” of people, some praying for the study subjects and others praying for those doing the praying—as well as the fact that no informed consent was obtained.

The study recently was returned to the Web site, and the journal also published a defense of the work by one of its authors, Kwang Y. Cha, M.D. (J. Reprod. Med. 2004;49:944-5).

Dr. Cha noted that the study was approved “by our local institutional review board with full knowledge that patients would not be signing informed consent forms. … We thought that the requirement of written informed consent would introduce a bias or variable in the study by encouraging patients to pray for themselves or not, depending on their own religious persuasion. This might have interfered with the potential effects, if any, of intercessory prayer as an independent variable in our study.”

Dr. Cha also noted that some people doubted whether the prayer groups were actually ever established. “While this author did not have information about the composition and conduct of the prayer groups during the study (a design consideration to avoid potential investigator bias), there is no reason to think that [my colleague] would have been motivated not to organize prayer groups when such groups are his area of interest,” he said.

Dr. Cha's colleague, Daniel Wirth, is a lawyer with a background in paranormal studies. Last May, Mr. Wirth pled guilty in a federal court in Pennsylvania to several counts of bank and mail fraud. He was sentenced last November to 5 years in prison and 3 years of probation.

In his letter, Dr. Cha called Mr. Wirth's legal troubles “regrettable” but said they were “entirely unrelated” to the study. “The study was completely blinded, and it is impossible for Mr. Wirth to have influenced the outcome,” he added.

But Bruce L. Flamm, M.D., area research chairman at the Kaiser Permanente Medical Center in Riverside, Calif., and a longtime critic of the study, maintained that Mr. Wirth's fraud conviction does cast doubt on the believability of the data.

“Dr. Cha defended the study's design by stating that Mr. Wirth thought it was the best design to use. This is an argument from authority,” he wrote in a letter published in the journal's January issue. “However, in this case the authority is a convicted felon” (J. Reprod. Med. 2005;50:71).

The third coauthor of the study, Rogerio Lobo, M.D., professor of ob.gyn. at Columbia University, New York, recently decided to remove his name from the paper. Columbia University Medical Center issued a press release saying that it “supported” Dr. Lobo's decision. “Dr. Lobo decided to remove his name in order to more accurately represent his role in the study,” the release noted. “Although listed as a senior author, Dr. Lobo provided only stylistic guidance and editorial review.”

The release also noted that as a result of Dr. Lobo's move, the medical center was dropping its investigation into the matter. Dr. Lobo declined to be interviewed for this article. Dr. Devoe did not return a phone call seeking comment, and Dr. Cha could not be reached.

Dr. Flamm said he was concerned that both Columbia and Dr. Lobo seemed to feel that removing Dr. Lobo's name from the paper ended the controversy. “The flawed, and possibly fraudulent, paper is apparently not going to be retracted, it will stay on the journal's Internet site, and it will be cited as a valid scientific study that supposedly proves that supernatural or paranormal phenomena occurred.”

A prominent reproductive health researcher has removed his name from the list of authors of a study on prayer and in vitro fertilization published in 2001, but the controversy over the study continues.

The study “Does Prayer Influence the Success of In Vitro Fertilization-Embryo Transfer?” was published in the September 2001 issue of the Journal of Reproductive Medicine (J. Reprod. Med. 2001;46:781-7). The authors studied the use of prayer on 219 Korean women who underwent IVF over a 4-month period. The pregnancy rate was nearly twice as high in the women who had been prayed for, compared with those who had not been prayed for (50% vs. 26%), a statistically significant difference.

The study was removed from the Web site nearly 3 years later after the journal received a number of letters and e-mails critical of the research. The journal's editor-in-chief, Lawrence Devoe, M.D., said the study was removed from the Web site because it generated more traffic than the office could handle. Critics of the study questioned its methodology—involving several “tiers” of people, some praying for the study subjects and others praying for those doing the praying—as well as the fact that no informed consent was obtained.

The study recently was returned to the Web site, and the journal also published a defense of the work by one of its authors, Kwang Y. Cha, M.D. (J. Reprod. Med. 2004;49:944-5).

Dr. Cha noted that the study was approved “by our local institutional review board with full knowledge that patients would not be signing informed consent forms. … We thought that the requirement of written informed consent would introduce a bias or variable in the study by encouraging patients to pray for themselves or not, depending on their own religious persuasion. This might have interfered with the potential effects, if any, of intercessory prayer as an independent variable in our study.”

Dr. Cha also noted that some people doubted whether the prayer groups were actually ever established. “While this author did not have information about the composition and conduct of the prayer groups during the study (a design consideration to avoid potential investigator bias), there is no reason to think that [my colleague] would have been motivated not to organize prayer groups when such groups are his area of interest,” he said.

Dr. Cha's colleague, Daniel Wirth, is a lawyer with a background in paranormal studies. Last May, Mr. Wirth pled guilty in a federal court in Pennsylvania to several counts of bank and mail fraud. He was sentenced last November to 5 years in prison and 3 years of probation.

In his letter, Dr. Cha called Mr. Wirth's legal troubles “regrettable” but said they were “entirely unrelated” to the study. “The study was completely blinded, and it is impossible for Mr. Wirth to have influenced the outcome,” he added.

But Bruce L. Flamm, M.D., area research chairman at the Kaiser Permanente Medical Center in Riverside, Calif., and a longtime critic of the study, maintained that Mr. Wirth's fraud conviction does cast doubt on the believability of the data.

“Dr. Cha defended the study's design by stating that Mr. Wirth thought it was the best design to use. This is an argument from authority,” he wrote in a letter published in the journal's January issue. “However, in this case the authority is a convicted felon” (J. Reprod. Med. 2005;50:71).

The third coauthor of the study, Rogerio Lobo, M.D., professor of ob.gyn. at Columbia University, New York, recently decided to remove his name from the paper. Columbia University Medical Center issued a press release saying that it “supported” Dr. Lobo's decision. “Dr. Lobo decided to remove his name in order to more accurately represent his role in the study,” the release noted. “Although listed as a senior author, Dr. Lobo provided only stylistic guidance and editorial review.”

The release also noted that as a result of Dr. Lobo's move, the medical center was dropping its investigation into the matter. Dr. Lobo declined to be interviewed for this article. Dr. Devoe did not return a phone call seeking comment, and Dr. Cha could not be reached.

Dr. Flamm said he was concerned that both Columbia and Dr. Lobo seemed to feel that removing Dr. Lobo's name from the paper ended the controversy. “The flawed, and possibly fraudulent, paper is apparently not going to be retracted, it will stay on the journal's Internet site, and it will be cited as a valid scientific study that supposedly proves that supernatural or paranormal phenomena occurred.”

A prominent reproductive health researcher has removed his name from the list of authors of a study on prayer and in vitro fertilization published in 2001, but the controversy over the study continues.

The study “Does Prayer Influence the Success of In Vitro Fertilization-Embryo Transfer?” was published in the September 2001 issue of the Journal of Reproductive Medicine (J. Reprod. Med. 2001;46:781-7). The authors studied the use of prayer on 219 Korean women who underwent IVF over a 4-month period. The pregnancy rate was nearly twice as high in the women who had been prayed for, compared with those who had not been prayed for (50% vs. 26%), a statistically significant difference.

The study was removed from the Web site nearly 3 years later after the journal received a number of letters and e-mails critical of the research. The journal's editor-in-chief, Lawrence Devoe, M.D., said the study was removed from the Web site because it generated more traffic than the office could handle. Critics of the study questioned its methodology—involving several “tiers” of people, some praying for the study subjects and others praying for those doing the praying—as well as the fact that no informed consent was obtained.

The study recently was returned to the Web site, and the journal also published a defense of the work by one of its authors, Kwang Y. Cha, M.D. (J. Reprod. Med. 2004;49:944-5).

Dr. Cha noted that the study was approved “by our local institutional review board with full knowledge that patients would not be signing informed consent forms. … We thought that the requirement of written informed consent would introduce a bias or variable in the study by encouraging patients to pray for themselves or not, depending on their own religious persuasion. This might have interfered with the potential effects, if any, of intercessory prayer as an independent variable in our study.”

Dr. Cha also noted that some people doubted whether the prayer groups were actually ever established. “While this author did not have information about the composition and conduct of the prayer groups during the study (a design consideration to avoid potential investigator bias), there is no reason to think that [my colleague] would have been motivated not to organize prayer groups when such groups are his area of interest,” he said.

Dr. Cha's colleague, Daniel Wirth, is a lawyer with a background in paranormal studies. Last May, Mr. Wirth pled guilty in a federal court in Pennsylvania to several counts of bank and mail fraud. He was sentenced last November to 5 years in prison and 3 years of probation.

In his letter, Dr. Cha called Mr. Wirth's legal troubles “regrettable” but said they were “entirely unrelated” to the study. “The study was completely blinded, and it is impossible for Mr. Wirth to have influenced the outcome,” he added.

But Bruce L. Flamm, M.D., area research chairman at the Kaiser Permanente Medical Center in Riverside, Calif., and a longtime critic of the study, maintained that Mr. Wirth's fraud conviction does cast doubt on the believability of the data.

“Dr. Cha defended the study's design by stating that Mr. Wirth thought it was the best design to use. This is an argument from authority,” he wrote in a letter published in the journal's January issue. “However, in this case the authority is a convicted felon” (J. Reprod. Med. 2005;50:71).

The third coauthor of the study, Rogerio Lobo, M.D., professor of ob.gyn. at Columbia University, New York, recently decided to remove his name from the paper. Columbia University Medical Center issued a press release saying that it “supported” Dr. Lobo's decision. “Dr. Lobo decided to remove his name in order to more accurately represent his role in the study,” the release noted. “Although listed as a senior author, Dr. Lobo provided only stylistic guidance and editorial review.”

The release also noted that as a result of Dr. Lobo's move, the medical center was dropping its investigation into the matter. Dr. Lobo declined to be interviewed for this article. Dr. Devoe did not return a phone call seeking comment, and Dr. Cha could not be reached.

Dr. Flamm said he was concerned that both Columbia and Dr. Lobo seemed to feel that removing Dr. Lobo's name from the paper ended the controversy. “The flawed, and possibly fraudulent, paper is apparently not going to be retracted, it will stay on the journal's Internet site, and it will be cited as a valid scientific study that supposedly proves that supernatural or paranormal phenomena occurred.”

WASHINGTON — More programs need to be developed to address the specific health needs of minority women, Elena Cohen said at the annual meeting of the American Public Health Association.

“Racial minorities are projected to make up almost half the population by 2050,” said Ms. Cohen, senior counsel at the nonprofit National Women's Law Center. “But there's not much analysis of [health data on] racial and ethnic groups by gender.”

To further examine the issue, the center analyzed data and published the results in a report titled, “Making the Grade on Women's Health,” that outlines disparities in women's health care in different states.

For example, black women have the highest rate of Pap smears and the lowest rate of osteoporosis, but also have the shortest life expectancy, the highest poverty rate, and are least likely to get prenatal care. They also have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer.

Latinas have the lowest mortality rate from stroke but are the second-least likely group to be screened for cervical cancer, and they fare worse in cervical cancer incidence and mortality, she said. This group has the highest percentage of uninsured women and the highest percentage of women who do no physical activity in their leisure time, “which is very important for obesity issues.”

American Indian and Alaskan Native women had the second-lowest morality rate from stroke, but they fared worst of all groups for smoking, binge drinking, mortality from cirrhosis, and violence against them, Ms. Cohen said.

“The Asian American/Pacific Islander group fared best in preventive health behaviors and in avoiding obesity and smoking,” she added. But these women are disproportionately affected by cervical and ovarian cancer and are also the second-least likely group to have had a mammogram within the last 2 years.

Because each group's problems are different, identifying interventions can be tricky. “One way is to encourage research that is analyzed and reported by race and ethnicity, and then further by gender,” said Ms. Cohen. “Another idea is to develop targeted programs to address ethnic and racial issues.”

WASHINGTON — More programs need to be developed to address the specific health needs of minority women, Elena Cohen said at the annual meeting of the American Public Health Association.

“Racial minorities are projected to make up almost half the population by 2050,” said Ms. Cohen, senior counsel at the nonprofit National Women's Law Center. “But there's not much analysis of [health data on] racial and ethnic groups by gender.”

To further examine the issue, the center analyzed data and published the results in a report titled, “Making the Grade on Women's Health,” that outlines disparities in women's health care in different states.

For example, black women have the highest rate of Pap smears and the lowest rate of osteoporosis, but also have the shortest life expectancy, the highest poverty rate, and are least likely to get prenatal care. They also have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer.

Latinas have the lowest mortality rate from stroke but are the second-least likely group to be screened for cervical cancer, and they fare worse in cervical cancer incidence and mortality, she said. This group has the highest percentage of uninsured women and the highest percentage of women who do no physical activity in their leisure time, “which is very important for obesity issues.”

American Indian and Alaskan Native women had the second-lowest morality rate from stroke, but they fared worst of all groups for smoking, binge drinking, mortality from cirrhosis, and violence against them, Ms. Cohen said.

“The Asian American/Pacific Islander group fared best in preventive health behaviors and in avoiding obesity and smoking,” she added. But these women are disproportionately affected by cervical and ovarian cancer and are also the second-least likely group to have had a mammogram within the last 2 years.

Because each group's problems are different, identifying interventions can be tricky. “One way is to encourage research that is analyzed and reported by race and ethnicity, and then further by gender,” said Ms. Cohen. “Another idea is to develop targeted programs to address ethnic and racial issues.”

WASHINGTON — More programs need to be developed to address the specific health needs of minority women, Elena Cohen said at the annual meeting of the American Public Health Association.

“Racial minorities are projected to make up almost half the population by 2050,” said Ms. Cohen, senior counsel at the nonprofit National Women's Law Center. “But there's not much analysis of [health data on] racial and ethnic groups by gender.”

To further examine the issue, the center analyzed data and published the results in a report titled, “Making the Grade on Women's Health,” that outlines disparities in women's health care in different states.

For example, black women have the highest rate of Pap smears and the lowest rate of osteoporosis, but also have the shortest life expectancy, the highest poverty rate, and are least likely to get prenatal care. They also have the highest mortality rates for coronary heart disease, stroke, and diabetes, and the highest incidence of AIDS and lung cancer.

Latinas have the lowest mortality rate from stroke but are the second-least likely group to be screened for cervical cancer, and they fare worse in cervical cancer incidence and mortality, she said. This group has the highest percentage of uninsured women and the highest percentage of women who do no physical activity in their leisure time, “which is very important for obesity issues.”

American Indian and Alaskan Native women had the second-lowest morality rate from stroke, but they fared worst of all groups for smoking, binge drinking, mortality from cirrhosis, and violence against them, Ms. Cohen said.

“The Asian American/Pacific Islander group fared best in preventive health behaviors and in avoiding obesity and smoking,” she added. But these women are disproportionately affected by cervical and ovarian cancer and are also the second-least likely group to have had a mammogram within the last 2 years.

Because each group's problems are different, identifying interventions can be tricky. “One way is to encourage research that is analyzed and reported by race and ethnicity, and then further by gender,” said Ms. Cohen. “Another idea is to develop targeted programs to address ethnic and racial issues.”

Interested parties have until March 21 to comment on an interim policy statement on dispensing controlled substances for pain. A Federal Register statement outlines several inaccuracies that were included in an August 2004 “frequently asked questions” document that appeared on the Drug Enforcement Administration Web site. The statement also notes that the DEA plans to publish a document “aimed at providing guidance and reassurance to physicians who engage in legitimate pain treatment while deterring the unlawful conduct of a small number of physicians” Information on submitting comments can be found in a Federal Register notice published on Jan. 18; that notice is online at www.access.gpo.gov/su_docs/fedreg/a050118c.html

Interested parties have until March 21 to comment on an interim policy statement on dispensing controlled substances for pain. A Federal Register statement outlines several inaccuracies that were included in an August 2004 “frequently asked questions” document that appeared on the Drug Enforcement Administration Web site. The statement also notes that the DEA plans to publish a document “aimed at providing guidance and reassurance to physicians who engage in legitimate pain treatment while deterring the unlawful conduct of a small number of physicians” Information on submitting comments can be found in a Federal Register notice published on Jan. 18; that notice is online at www.access.gpo.gov/su_docs/fedreg/a050118c.html

Interested parties have until March 21 to comment on an interim policy statement on dispensing controlled substances for pain. A Federal Register statement outlines several inaccuracies that were included in an August 2004 “frequently asked questions” document that appeared on the Drug Enforcement Administration Web site. The statement also notes that the DEA plans to publish a document “aimed at providing guidance and reassurance to physicians who engage in legitimate pain treatment while deterring the unlawful conduct of a small number of physicians” Information on submitting comments can be found in a Federal Register notice published on Jan. 18; that notice is online at www.access.gpo.gov/su_docs/fedreg/a050118c.html

WASHINGTON — The Centers for Medicare and Medicaid Services is experimenting with “pay-for-performance” programs, and observers say it looks as if the agency is really serious about it this time.

“This is not the first time that CMS has come around saying they wanted to pay for performance,” Denis Cortese, M.D., said at a health care congress sponsored by the Wall Street Journal and CNBC. “It's the third time that we've been involved in that in 10 years. The other two faded away. This one looks real … and I think Congress is interested in seeing something happen. [But] whether they'll put additional money on the table to make it work has yet to be seen.”

Earlier at the same meeting, CMS administrator Mark McClellan, M.D., announced that the agency was implementing its pilot pay-for-performance project. Under the project, 10 large physician group practices will be rewarded by the agency for improving outcomes among Medicare beneficiaries.

The physicians will continue to be paid on a fee-for-service basis as usual, but CMS also will make additional payments based on quality and outcome measures for patients with chronic illnesses such as congestive heart failure, coronary artery disease, diabetes, and hypertension. The agency also will look at the practices' use of preventive services such as influenza and pneumococcal vaccinations, as well as the prevention of complications in patients with chronic illnesses.

Dr. McClellan emphasized that he was not suggesting that physician spending was a major cost problem for Medicare.

“Physicians account for a small fraction of total costs, but doctors have a lot of good ideas and they have the knowledge it takes to get more results for what we actually spend,” he said. “I think [pay-for-performance] can potentially save significant amounts of money. At the same time, we're also going to be paying attention to clinical quality, so for diabetic patients, we'll be looking at hemoglobin A1c levels and other well-validated measures of quality. Those will be included along with financial performance measures.”

Dr. Cortese, president and CEO, Mayo Clinic, Rochester, Minn, expressed some skepticism about the way pay-for-performance will be implemented. “I noticed that performance was defined as reducing costs,” he said. “I was tempted to ask, 'What happens if the quality goes up and the cost goes up with it?' If the value rises higher than cost, are they really going to pay for it? I don't believe they will.”

Other groups also offered mixed reactions. Robert Doherty, senior vice president for governmental affairs and public policy for the American College of Physicians, said CMS should be commended on its efforts to test physician performance and provide a model to improve care of chronic disease.

The problem is that some of these demonstration projects are limited in scope, he said during a press briefing to release the ACP's 2005 policy framework. For example, the new physician group practice demonstration project “puts all of its eggs” in one basket by focusing solely on large group practices, he said. ACP is advocating that Congress authorize a pilot test of a new model for improving the care of patients with chronic diseases in small and medium-sized practices, where patients with chronic diseases would be encouraged to select a physician as their medical “home.”

The Medicare Modernization Act of 2003 authorized a performance-based demonstration project for small physician practices, although the project is limited to just a few hundred practices in four states. “Expanding the program will give CMS a much larger universe of experience and evidence on how to tailor physician incentive programs to be most effective,” Mr. Doherty said.

Physicians are not the only recipients of Medicare funds to be affected by the move toward pay-for-performance programs. CMS also is changing to performance-based incentives for its claims processors, beginning in fiscal 2005. The agency also plans to reduce the number of processors from 51 to 23 and have all contractors processing both Part A and Part B claims.

Jennifer Silverman, Associate Editor, Practice Trends, contributed to this report.

WASHINGTON — The Centers for Medicare and Medicaid Services is experimenting with “pay-for-performance” programs, and observers say it looks as if the agency is really serious about it this time.

“This is not the first time that CMS has come around saying they wanted to pay for performance,” Denis Cortese, M.D., said at a health care congress sponsored by the Wall Street Journal and CNBC. “It's the third time that we've been involved in that in 10 years. The other two faded away. This one looks real … and I think Congress is interested in seeing something happen. [But] whether they'll put additional money on the table to make it work has yet to be seen.”

Earlier at the same meeting, CMS administrator Mark McClellan, M.D., announced that the agency was implementing its pilot pay-for-performance project. Under the project, 10 large physician group practices will be rewarded by the agency for improving outcomes among Medicare beneficiaries.

The physicians will continue to be paid on a fee-for-service basis as usual, but CMS also will make additional payments based on quality and outcome measures for patients with chronic illnesses such as congestive heart failure, coronary artery disease, diabetes, and hypertension. The agency also will look at the practices' use of preventive services such as influenza and pneumococcal vaccinations, as well as the prevention of complications in patients with chronic illnesses.

Dr. McClellan emphasized that he was not suggesting that physician spending was a major cost problem for Medicare.

“Physicians account for a small fraction of total costs, but doctors have a lot of good ideas and they have the knowledge it takes to get more results for what we actually spend,” he said. “I think [pay-for-performance] can potentially save significant amounts of money. At the same time, we're also going to be paying attention to clinical quality, so for diabetic patients, we'll be looking at hemoglobin A1c levels and other well-validated measures of quality. Those will be included along with financial performance measures.”

Dr. Cortese, president and CEO, Mayo Clinic, Rochester, Minn, expressed some skepticism about the way pay-for-performance will be implemented. “I noticed that performance was defined as reducing costs,” he said. “I was tempted to ask, 'What happens if the quality goes up and the cost goes up with it?' If the value rises higher than cost, are they really going to pay for it? I don't believe they will.”

Other groups also offered mixed reactions. Robert Doherty, senior vice president for governmental affairs and public policy for the American College of Physicians, said CMS should be commended on its efforts to test physician performance and provide a model to improve care of chronic disease.

The problem is that some of these demonstration projects are limited in scope, he said during a press briefing to release the ACP's 2005 policy framework. For example, the new physician group practice demonstration project “puts all of its eggs” in one basket by focusing solely on large group practices, he said. ACP is advocating that Congress authorize a pilot test of a new model for improving the care of patients with chronic diseases in small and medium-sized practices, where patients with chronic diseases would be encouraged to select a physician as their medical “home.”

The Medicare Modernization Act of 2003 authorized a performance-based demonstration project for small physician practices, although the project is limited to just a few hundred practices in four states. “Expanding the program will give CMS a much larger universe of experience and evidence on how to tailor physician incentive programs to be most effective,” Mr. Doherty said.

Physicians are not the only recipients of Medicare funds to be affected by the move toward pay-for-performance programs. CMS also is changing to performance-based incentives for its claims processors, beginning in fiscal 2005. The agency also plans to reduce the number of processors from 51 to 23 and have all contractors processing both Part A and Part B claims.

Jennifer Silverman, Associate Editor, Practice Trends, contributed to this report.

WASHINGTON — The Centers for Medicare and Medicaid Services is experimenting with “pay-for-performance” programs, and observers say it looks as if the agency is really serious about it this time.

“This is not the first time that CMS has come around saying they wanted to pay for performance,” Denis Cortese, M.D., said at a health care congress sponsored by the Wall Street Journal and CNBC. “It's the third time that we've been involved in that in 10 years. The other two faded away. This one looks real … and I think Congress is interested in seeing something happen. [But] whether they'll put additional money on the table to make it work has yet to be seen.”

Earlier at the same meeting, CMS administrator Mark McClellan, M.D., announced that the agency was implementing its pilot pay-for-performance project. Under the project, 10 large physician group practices will be rewarded by the agency for improving outcomes among Medicare beneficiaries.

The physicians will continue to be paid on a fee-for-service basis as usual, but CMS also will make additional payments based on quality and outcome measures for patients with chronic illnesses such as congestive heart failure, coronary artery disease, diabetes, and hypertension. The agency also will look at the practices' use of preventive services such as influenza and pneumococcal vaccinations, as well as the prevention of complications in patients with chronic illnesses.

Dr. McClellan emphasized that he was not suggesting that physician spending was a major cost problem for Medicare.

“Physicians account for a small fraction of total costs, but doctors have a lot of good ideas and they have the knowledge it takes to get more results for what we actually spend,” he said. “I think [pay-for-performance] can potentially save significant amounts of money. At the same time, we're also going to be paying attention to clinical quality, so for diabetic patients, we'll be looking at hemoglobin A1c levels and other well-validated measures of quality. Those will be included along with financial performance measures.”

Dr. Cortese, president and CEO, Mayo Clinic, Rochester, Minn, expressed some skepticism about the way pay-for-performance will be implemented. “I noticed that performance was defined as reducing costs,” he said. “I was tempted to ask, 'What happens if the quality goes up and the cost goes up with it?' If the value rises higher than cost, are they really going to pay for it? I don't believe they will.”

Other groups also offered mixed reactions. Robert Doherty, senior vice president for governmental affairs and public policy for the American College of Physicians, said CMS should be commended on its efforts to test physician performance and provide a model to improve care of chronic disease.

The problem is that some of these demonstration projects are limited in scope, he said during a press briefing to release the ACP's 2005 policy framework. For example, the new physician group practice demonstration project “puts all of its eggs” in one basket by focusing solely on large group practices, he said. ACP is advocating that Congress authorize a pilot test of a new model for improving the care of patients with chronic diseases in small and medium-sized practices, where patients with chronic diseases would be encouraged to select a physician as their medical “home.”

The Medicare Modernization Act of 2003 authorized a performance-based demonstration project for small physician practices, although the project is limited to just a few hundred practices in four states. “Expanding the program will give CMS a much larger universe of experience and evidence on how to tailor physician incentive programs to be most effective,” Mr. Doherty said.

Physicians are not the only recipients of Medicare funds to be affected by the move toward pay-for-performance programs. CMS also is changing to performance-based incentives for its claims processors, beginning in fiscal 2005. The agency also plans to reduce the number of processors from 51 to 23 and have all contractors processing both Part A and Part B claims.

Jennifer Silverman, Associate Editor, Practice Trends, contributed to this report.

WASHINGTON—Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease, he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum. It doesn't start to even out until you get to the ninth decade of life.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in blacks, including the idea that blacks rarely had MIs or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” he noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Medicare data on diabetes care show that something is clearly “amiss,” he added. “For example, despite the greater prevalence and risk associated with it, African Americans are less likely to undergo hemoglobin A1c testing, or to have their lipids tested, or to have vaccinations. And this is in the Medicare population, where coverage is not the issue.”

In another instance of disparities in diabetes care, “African Americans are 12% of the population, but fully a third or more of the [end-stage renal disease] population,” he said. “They also are less likely to receive a kidney transplant and less likely to be referred for a transplant, or to be placed on a transplant waiting list. Those are decisions that someone has to make.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter … that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

Dr. Gavin said he didn't agree with the idea of “cultural competency.” “It's not something I'm convinced we ever become competent at. It's always a work in progress. But [we] can work to become more self-aware of our own cultural norms and values that will quickly lead us to misjudge or miscommunicate with others.”

Cultural competency training can confer a false level of confidence, he noted. “We think we can go to one workshop and come out culturally competent, when in fact it's lifelong learning.”

WASHINGTON—Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease, he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum. It doesn't start to even out until you get to the ninth decade of life.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in blacks, including the idea that blacks rarely had MIs or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” he noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Medicare data on diabetes care show that something is clearly “amiss,” he added. “For example, despite the greater prevalence and risk associated with it, African Americans are less likely to undergo hemoglobin A1c testing, or to have their lipids tested, or to have vaccinations. And this is in the Medicare population, where coverage is not the issue.”

In another instance of disparities in diabetes care, “African Americans are 12% of the population, but fully a third or more of the [end-stage renal disease] population,” he said. “They also are less likely to receive a kidney transplant and less likely to be referred for a transplant, or to be placed on a transplant waiting list. Those are decisions that someone has to make.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter … that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

Dr. Gavin said he didn't agree with the idea of “cultural competency.” “It's not something I'm convinced we ever become competent at. It's always a work in progress. But [we] can work to become more self-aware of our own cultural norms and values that will quickly lead us to misjudge or miscommunicate with others.”

Cultural competency training can confer a false level of confidence, he noted. “We think we can go to one workshop and come out culturally competent, when in fact it's lifelong learning.”

WASHINGTON—Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease, he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum. It doesn't start to even out until you get to the ninth decade of life.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in blacks, including the idea that blacks rarely had MIs or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” he noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Medicare data on diabetes care show that something is clearly “amiss,” he added. “For example, despite the greater prevalence and risk associated with it, African Americans are less likely to undergo hemoglobin A1c testing, or to have their lipids tested, or to have vaccinations. And this is in the Medicare population, where coverage is not the issue.”

In another instance of disparities in diabetes care, “African Americans are 12% of the population, but fully a third or more of the [end-stage renal disease] population,” he said. “They also are less likely to receive a kidney transplant and less likely to be referred for a transplant, or to be placed on a transplant waiting list. Those are decisions that someone has to make.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter … that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

Dr. Gavin said he didn't agree with the idea of “cultural competency.” “It's not something I'm convinced we ever become competent at. It's always a work in progress. But [we] can work to become more self-aware of our own cultural norms and values that will quickly lead us to misjudge or miscommunicate with others.”

Cultural competency training can confer a false level of confidence, he noted. “We think we can go to one workshop and come out culturally competent, when in fact it's lifelong learning.”

WASHINGTON — The trend toward consumer-driven health care would ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, professor and chair of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry. The automotive industry, which already is consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership.

The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people who do not even have health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts. For instance, Henry Ford, founder of the Ford Motor Co., created a new, less expensive form of steel from which to make cars. “Within a decade, car ownership went from 10,000 to 1 million,” Dr. Herzlinger added.

Although Mr. Ford and other automotive industry pioneers were rewarded, innovation in health care is not well-rewarded, Dr. Herzlinger continued at the meeting.

As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing health care teams. “In one year, he lowered the costs by 40%,” Dr. Herzlinger explained.

And what was his reward for doing so? “He lost the entire savings, because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products would be developed to respond to the needs of different consumers, she continued. And insurers would realize they could be rewarded for considering consumers' longer-term health care needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger commented. Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams would be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians would be paid based on outcomes, and there would be “long-term contracts so you don't look at your patients in a 1-year kind of window,” she said. “Investments in self-care early on” would be rewarded.

One big driver behind consumer-driven health care are the aging baby boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States.

The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

Dr. Herzlinger took issue with the notion that consumer-driven health care plans would be disadvantageous to sick people. “Quite the contrary. It will finally focus attention on sick people. Right now it's in the incentive of the insurers to get rid of sick people and not to pay people who treat sick people well. But if you go to a consumer-driven system with risk-adjusted prices,” the sick would be “very attractive kinds of entities.”

Dr. Herzlinger also challenged the notion that only those individuals who could afford high-cost health plans would receive the highest quality of health care.

In the automobile industry, “What is the best car in the U.S.? Toyota,” she said. However, as Dr. Herzlinger pointed out, Toyota is not the highest-cost car. “Not by a long shot.” Instead, it's the best quality car “because that's where all the money is. That's the mass market.”

WASHINGTON — The trend toward consumer-driven health care would ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, professor and chair of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry. The automotive industry, which already is consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership.

The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people who do not even have health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts. For instance, Henry Ford, founder of the Ford Motor Co., created a new, less expensive form of steel from which to make cars. “Within a decade, car ownership went from 10,000 to 1 million,” Dr. Herzlinger added.

Although Mr. Ford and other automotive industry pioneers were rewarded, innovation in health care is not well-rewarded, Dr. Herzlinger continued at the meeting.

As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing health care teams. “In one year, he lowered the costs by 40%,” Dr. Herzlinger explained.

And what was his reward for doing so? “He lost the entire savings, because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products would be developed to respond to the needs of different consumers, she continued. And insurers would realize they could be rewarded for considering consumers' longer-term health care needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger commented. Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams would be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians would be paid based on outcomes, and there would be “long-term contracts so you don't look at your patients in a 1-year kind of window,” she said. “Investments in self-care early on” would be rewarded.

One big driver behind consumer-driven health care are the aging baby boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States.

The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

Dr. Herzlinger took issue with the notion that consumer-driven health care plans would be disadvantageous to sick people. “Quite the contrary. It will finally focus attention on sick people. Right now it's in the incentive of the insurers to get rid of sick people and not to pay people who treat sick people well. But if you go to a consumer-driven system with risk-adjusted prices,” the sick would be “very attractive kinds of entities.”

Dr. Herzlinger also challenged the notion that only those individuals who could afford high-cost health plans would receive the highest quality of health care.

In the automobile industry, “What is the best car in the U.S.? Toyota,” she said. However, as Dr. Herzlinger pointed out, Toyota is not the highest-cost car. “Not by a long shot.” Instead, it's the best quality car “because that's where all the money is. That's the mass market.”

WASHINGTON — The trend toward consumer-driven health care would ultimately improve overall health care quality, Regina Herzlinger, Ph.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

Dr. Herzlinger, professor and chair of business administration at Harvard Business School, in Boston, contrasted the health care industry with the automotive industry. The automotive industry, which already is consumer-driven, is deflationary and features increasing product quality, lots of available product information, and widespread ownership.

The health care industry, on the other hand, is not consumer-driven and is characterized by inflation, unknown quality of care, and 46 million people who do not even have health insurance.

She noted that what helped the automotive industry along was the presence of entrepreneurs, who ended up being richly rewarded for their efforts. For instance, Henry Ford, founder of the Ford Motor Co., created a new, less expensive form of steel from which to make cars. “Within a decade, car ownership went from 10,000 to 1 million,” Dr. Herzlinger added.

Although Mr. Ford and other automotive industry pioneers were rewarded, innovation in health care is not well-rewarded, Dr. Herzlinger continued at the meeting.

As an example, she cited the case of Ralph Snyderman, M.D., who came up with the idea of integrating the care of patients with heart failure by organizing health care teams. “In one year, he lowered the costs by 40%,” Dr. Herzlinger explained.

And what was his reward for doing so? “He lost the entire savings, because the health care system does not pay for making sick people better. It pays for days in the hospital, for doctor visits, for components of care. So the healthier he made people, the fewer people went to the hospital, the fewer doctor visits there were, and the more money he lost. Right now, if you're a Henry Ford, you're punished, and we have very poor quality,” she said.

With consumer-driven health care, different products would be developed to respond to the needs of different consumers, she continued. And insurers would realize they could be rewarded for considering consumers' longer-term health care needs.

“I want a 5-year insurance policy. I want my insurer to really care about my long-term health,” Dr. Herzlinger commented. Switzerland has 5-year insurance policies, she noted, “and if, at the end of the 5 years, you're healthier than would have been predicted at the beginning, you get 45% of your money back. How's that for a good deal for the insurer, the provider, and the customer?”

Dr. Herzlinger predicted that it will become commonplace for insurers to offer integrated team care for chronic diseases. The teams “will be wired, they'll be focused, and they're going to be paid for the fact that they're dealing with sicker people,” she said.

Offering such teams would be a matter of “simple economics,” she continued. “You're the insurer; 80% [of your money] goes for sick people. If you want to make it cheaper and better, how better to make it cheaper and better than to go to these organizations?”

Under a consumer-driven health care system, physicians would be paid based on outcomes, and there would be “long-term contracts so you don't look at your patients in a 1-year kind of window,” she said. “Investments in self-care early on” would be rewarded.

One big driver behind consumer-driven health care are the aging baby boomers, a group that Dr. Herzlinger called “the most narcissistic, self-centered, empowered, and effective cohort we've ever had in the United States.

The idea that this group isn't going to get what it wants, that's fantasy. They want [doctors] to integrate themselves, seize control of the system, and help patients care for their chronic diseases.”

Dr. Herzlinger took issue with the notion that consumer-driven health care plans would be disadvantageous to sick people. “Quite the contrary. It will finally focus attention on sick people. Right now it's in the incentive of the insurers to get rid of sick people and not to pay people who treat sick people well. But if you go to a consumer-driven system with risk-adjusted prices,” the sick would be “very attractive kinds of entities.”

Dr. Herzlinger also challenged the notion that only those individuals who could afford high-cost health plans would receive the highest quality of health care.

In the automobile industry, “What is the best car in the U.S.? Toyota,” she said. However, as Dr. Herzlinger pointed out, Toyota is not the highest-cost car. “Not by a long shot.” Instead, it's the best quality car “because that's where all the money is. That's the mass market.”

WASHINGTON — Computerized prescribing could greatly reduce the number of medical errors, especially when it comes to adverse drug events, David Bates, M.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

In his own health care research at Brigham and Women's Hospital in Boston, where he is chief of general medicine, Dr. Bates and colleagues looked at more than 10,000 medication orders and found 530 errors, an average of 1.4 per hospital admission. Included among those were 35 potential adverse drug events and five preventable adverse drug events.

These data suggest that “about 1 in 100 medication errors results in an [adverse drug event], and 7 in 100 have the potential to do so,” said Dr. Bates, who also serves as medical director of clinical and quality analysis at Partners HealthCare, in Boston.

When do the errors occur? In another study, Dr. Bates and colleagues found that about half of prescribing errors (49%) occur at the ordering stage, followed by 26% at the administration stage, 14% at the dispensing stage, and 11% at the transcribing stage.

Although transcribing accounted for the smallest percentage of errors, it can still be a big problem. Dr. Bates showed a sample of a handwritten prescription for Avandia (rosiglitazone) that was mistakenly dispensed as Coumadin (warfarin). Such problems could be reduced or eliminated by the use of prescribing software, Dr. Bates said.

Ambulatory care settings are particularly ripe for prescribing errors, for several reasons, he said. “There is a long feedback loop, because often you don't hear from patients for a long time, and there are limited resources and redundancy,” he said. In addition, “the average primary care encounter is 12 minutes, and the average time to the first interruption is 18 seconds. And 75% of patients leave with unanswered questions.”

He cited a study by Tejal K. Gandhi, M.D., and colleagues showing that of 661 outpatients, 162 (25%) had adverse drug events, for a total of 181 events. Of those, 13% were serious and 11% were preventable (N. Engl. J. Med. 2003;348:1556-64).

Computerized prescribing can reduce errors in several ways, Dr. Bates said:

▸ Preventing errors from occurring in the first place.

▸ Catching them more quickly after they have occurred.

▸ Tracking the errors themselves.

▸ Providing feedback.

Dr. Bates called computerized prescribing the “single most powerful intervention for improving medication safety to date” and noted that errors could be reduced by more than 80% in some cases.

However, computerized prescribing will only work if the people using it follow all the rules, he continued. For example, at Brigham and Women's Hospital, researchers looked at more than 7,700 drug allergy alerts that were issued by the computer over a 3-month period in 2002 and found that the alerts were overridden 80% of the time. This may have been because only 6% of the alerts were triggered by an exact match between the drug ordered and a drug on the allergy list, Dr. Bates said.

In addition to drug allergies, a good computerized prescribing system should also alert physicians to drug-drug interactions, renal dosing issues, geriatric dosing issues, and dose ceilings, according to Dr. Bates. And it should have a way to alert physicians to potentially fatal interactions.

As to the future of computerized prescribing, Dr. Bates predicted a time when all physician drug orders would be sent electronically to the pharmacy, where the pharmacist would review them. Simple orders might be filled and dispensed from an ATM-like machine, he added.

In addition to safety issues, there is another reason physicians might want to consider electronic prescribing: More payers are starting to demand it, Dr. Bates said.

As an example, he cited the Leapfrog Group, an organization of 160 companies seeking to improve health care quality for their employees.

Leapfrog already uses computerized prescribing as a quality measure in the inpatient setting and is planning to include outpatient computerized prescribing in a new set of measures due out in 2006, Dr. Bates said.

A computerized prescribing system could warn physicians about drug interactions, drug allergies, and renal and geriatric dosing issues. Courtesy Dr. David Bates

WASHINGTON — Computerized prescribing could greatly reduce the number of medical errors, especially when it comes to adverse drug events, David Bates, M.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

In his own health care research at Brigham and Women's Hospital in Boston, where he is chief of general medicine, Dr. Bates and colleagues looked at more than 10,000 medication orders and found 530 errors, an average of 1.4 per hospital admission. Included among those were 35 potential adverse drug events and five preventable adverse drug events.

These data suggest that “about 1 in 100 medication errors results in an [adverse drug event], and 7 in 100 have the potential to do so,” said Dr. Bates, who also serves as medical director of clinical and quality analysis at Partners HealthCare, in Boston.

When do the errors occur? In another study, Dr. Bates and colleagues found that about half of prescribing errors (49%) occur at the ordering stage, followed by 26% at the administration stage, 14% at the dispensing stage, and 11% at the transcribing stage.

Although transcribing accounted for the smallest percentage of errors, it can still be a big problem. Dr. Bates showed a sample of a handwritten prescription for Avandia (rosiglitazone) that was mistakenly dispensed as Coumadin (warfarin). Such problems could be reduced or eliminated by the use of prescribing software, Dr. Bates said.

Ambulatory care settings are particularly ripe for prescribing errors, for several reasons, he said. “There is a long feedback loop, because often you don't hear from patients for a long time, and there are limited resources and redundancy,” he said. In addition, “the average primary care encounter is 12 minutes, and the average time to the first interruption is 18 seconds. And 75% of patients leave with unanswered questions.”

He cited a study by Tejal K. Gandhi, M.D., and colleagues showing that of 661 outpatients, 162 (25%) had adverse drug events, for a total of 181 events. Of those, 13% were serious and 11% were preventable (N. Engl. J. Med. 2003;348:1556-64).

Computerized prescribing can reduce errors in several ways, Dr. Bates said:

▸ Preventing errors from occurring in the first place.

▸ Catching them more quickly after they have occurred.

▸ Tracking the errors themselves.

▸ Providing feedback.

Dr. Bates called computerized prescribing the “single most powerful intervention for improving medication safety to date” and noted that errors could be reduced by more than 80% in some cases.

However, computerized prescribing will only work if the people using it follow all the rules, he continued. For example, at Brigham and Women's Hospital, researchers looked at more than 7,700 drug allergy alerts that were issued by the computer over a 3-month period in 2002 and found that the alerts were overridden 80% of the time. This may have been because only 6% of the alerts were triggered by an exact match between the drug ordered and a drug on the allergy list, Dr. Bates said.

In addition to drug allergies, a good computerized prescribing system should also alert physicians to drug-drug interactions, renal dosing issues, geriatric dosing issues, and dose ceilings, according to Dr. Bates. And it should have a way to alert physicians to potentially fatal interactions.

As to the future of computerized prescribing, Dr. Bates predicted a time when all physician drug orders would be sent electronically to the pharmacy, where the pharmacist would review them. Simple orders might be filled and dispensed from an ATM-like machine, he added.

In addition to safety issues, there is another reason physicians might want to consider electronic prescribing: More payers are starting to demand it, Dr. Bates said.

As an example, he cited the Leapfrog Group, an organization of 160 companies seeking to improve health care quality for their employees.

Leapfrog already uses computerized prescribing as a quality measure in the inpatient setting and is planning to include outpatient computerized prescribing in a new set of measures due out in 2006, Dr. Bates said.

A computerized prescribing system could warn physicians about drug interactions, drug allergies, and renal and geriatric dosing issues. Courtesy Dr. David Bates

WASHINGTON — Computerized prescribing could greatly reduce the number of medical errors, especially when it comes to adverse drug events, David Bates, M.D., said at a consensus conference sponsored by the American Association of Clinical Endocrinologists.

In his own health care research at Brigham and Women's Hospital in Boston, where he is chief of general medicine, Dr. Bates and colleagues looked at more than 10,000 medication orders and found 530 errors, an average of 1.4 per hospital admission. Included among those were 35 potential adverse drug events and five preventable adverse drug events.

These data suggest that “about 1 in 100 medication errors results in an [adverse drug event], and 7 in 100 have the potential to do so,” said Dr. Bates, who also serves as medical director of clinical and quality analysis at Partners HealthCare, in Boston.

When do the errors occur? In another study, Dr. Bates and colleagues found that about half of prescribing errors (49%) occur at the ordering stage, followed by 26% at the administration stage, 14% at the dispensing stage, and 11% at the transcribing stage.

Although transcribing accounted for the smallest percentage of errors, it can still be a big problem. Dr. Bates showed a sample of a handwritten prescription for Avandia (rosiglitazone) that was mistakenly dispensed as Coumadin (warfarin). Such problems could be reduced or eliminated by the use of prescribing software, Dr. Bates said.

Ambulatory care settings are particularly ripe for prescribing errors, for several reasons, he said. “There is a long feedback loop, because often you don't hear from patients for a long time, and there are limited resources and redundancy,” he said. In addition, “the average primary care encounter is 12 minutes, and the average time to the first interruption is 18 seconds. And 75% of patients leave with unanswered questions.”

He cited a study by Tejal K. Gandhi, M.D., and colleagues showing that of 661 outpatients, 162 (25%) had adverse drug events, for a total of 181 events. Of those, 13% were serious and 11% were preventable (N. Engl. J. Med. 2003;348:1556-64).

Computerized prescribing can reduce errors in several ways, Dr. Bates said:

▸ Preventing errors from occurring in the first place.

▸ Catching them more quickly after they have occurred.

▸ Tracking the errors themselves.

▸ Providing feedback.

Dr. Bates called computerized prescribing the “single most powerful intervention for improving medication safety to date” and noted that errors could be reduced by more than 80% in some cases.

However, computerized prescribing will only work if the people using it follow all the rules, he continued. For example, at Brigham and Women's Hospital, researchers looked at more than 7,700 drug allergy alerts that were issued by the computer over a 3-month period in 2002 and found that the alerts were overridden 80% of the time. This may have been because only 6% of the alerts were triggered by an exact match between the drug ordered and a drug on the allergy list, Dr. Bates said.

In addition to drug allergies, a good computerized prescribing system should also alert physicians to drug-drug interactions, renal dosing issues, geriatric dosing issues, and dose ceilings, according to Dr. Bates. And it should have a way to alert physicians to potentially fatal interactions.

As to the future of computerized prescribing, Dr. Bates predicted a time when all physician drug orders would be sent electronically to the pharmacy, where the pharmacist would review them. Simple orders might be filled and dispensed from an ATM-like machine, he added.

In addition to safety issues, there is another reason physicians might want to consider electronic prescribing: More payers are starting to demand it, Dr. Bates said.

As an example, he cited the Leapfrog Group, an organization of 160 companies seeking to improve health care quality for their employees.

Leapfrog already uses computerized prescribing as a quality measure in the inpatient setting and is planning to include outpatient computerized prescribing in a new set of measures due out in 2006, Dr. Bates said.

A computerized prescribing system could warn physicians about drug interactions, drug allergies, and renal and geriatric dosing issues. Courtesy Dr. David Bates

WASHINGTON — Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease (CHD), he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum; it doesn't start to even out until you get to the ninth decade of life. I'd be very concerned about these kinds of numbers.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery (CABG) has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in blacks, including the idea that blacks rarely had myocardial infarctions or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” Dr. Gavin noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter …that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

WASHINGTON — Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease (CHD), he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum; it doesn't start to even out until you get to the ninth decade of life. I'd be very concerned about these kinds of numbers.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery (CABG) has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in blacks, including the idea that blacks rarely had myocardial infarctions or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” Dr. Gavin noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter …that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

WASHINGTON — Health care disparities among ethnic groups should be considered a form of medical error, James Gavin, M.D., said at a consensus conference on patient safety and medical system errors in diabetes and endocrinology.

“When we see disparities, that really is a reflection of inadequate patient safety,” said Dr. Gavin, who is past president and professor of medicine at Morehouse School of Medicine, Atlanta. “It means that under the same or similar conditions of risk or exposure, the outcomes are sufficiently different that there is some disadvantage conferred on one of the other subject populations.”

One example is coronary heart disease (CHD), he said at the conference, sponsored by the American Association of Clinical Endocrinologists. “There is a real difference in CHD mortality in black males, compared with whites at every age stratum; it doesn't start to even out until you get to the ninth decade of life. I'd be very concerned about these kinds of numbers.”

Results like these are in part a reflection of how medical decisions are made for different patients, and, sometimes, the only way to get at that information is by looking at surrogates for decision making, such as utilization rates, Dr. Gavin said.

For instance, coronary artery bypass graft surgery (CABG) has proved to be of significant benefit in high-risk patients, and yet “CABG is significantly underutilized in blacks, compared with whites,” he said. On the other hand, data on amputation among patients with diabetes “suggest it is significantly more utilized in blacks, compared with whites. Something is driving these outcomes.”

Part of the problem may be bad information, he suggested. A report from a commission chartered in the 1980s by Health and Human Services Secretary Margaret Heckler found several myths about heart disease in blacks, including the idea that blacks rarely had myocardial infarctions or angina, or that they were immune to CHD.

“Because of flaws in the way data were interpreted, they were actually underreporting CHD as a cause of death, when … CHD was actually the leading cause of death in U.S. blacks then just as it is now,” Dr. Gavin noted.

Now that researchers are looking at disparities more systematically, they are finding that even when minorities have access to health care that is equivalent to that of white patients, there is still an inequity in the services they receive, he said.

“That part of the gap that is attributable to patient needs and patient preferences you have to back out [of the equation] because you can't blame a patient's choice,” he said. “But these other issues, the way the system operates, the way individual and group biases and prejudices [affect things], those issues are major drivers.”

Some of the disparities arise from the clinical encounter itself. “It's at that level we have to begin to pay more attention because it is only to the extent that we improve the quality of this encounter …that we will begin to influence this process,” Dr. Gavin said. “There will be less ambiguity, less misunderstanding, and we'll begin to mitigate the influence of prejudices, no matter who brings them to the table.”

Stem Cell Dustup in Massachusetts

Massachusetts Gov. Mitt Romney (R) is sparring with Democratic state legislators over a possible ban on certain types of stem cell research now being conducted in the state.

In February, state senate president Robert Travaglini (D) introduced a bill to loosen restrictions on stem cell research; the measure allows for research involving “any human embryo whether formed by fertilization, somatic cell nuclear transfer, parthenogenesis, or other means.”

In response, the governor said that while he had no problem with stem cell research involving discarded fertility clinic embryos, “the law should prohibit all human cloning and the creation of new human embryos for the purpose of research. … I believe that the practice of cloning human embryos for research or reproduction crosses the boundary of ethics.”

Sen. Travaglini accused the governor of “raising fears and unfounded doubts” about the research. “We want to send the message that this kind of research is welcome in Massachusetts,” said a spokeswoman for Sen. Travaglini.

Assault on Salt?

Federal withholding of data on which the government has based its recommendation to reduce salt intake with the goal of lowering stroke risk is drawing fire from the salt industry.

The Salt Institute, which represents the interests of salt manufacturers, sued the Department of Health and Human Services, claiming that the department refused to release the studies that support its 2002 recommendation that Americans cut down on their salt intake as a way to avoid hypertension and stroke.

The failure to release that information was a violation of the federal Information Quality Act, the suit alleges. Under the act, parties who feel that the government is withholding information have the right to appeal to the agency in question; the Salt Institute, along with the U.S. Chamber of Commerce, did just that before the U.S. District Court for the Eastern District of Virginia, but the appeal was denied.

HHS says that the suit is not valid because there is no provision in the act for a judicial review of a denied appeal; the court agreed and dismissed the suit. The chamber and the institute have appealed.

HHS Budget Reviews Mixed

The president's 2006 budget request got mixed reviews from health care groups. While some groups objected to a lack of appropriate funding for health professions programs, others decried the $60 billion in proposed cuts to Medicaid over the next 10 years.

The Association of American Medical Colleges is opposed to cuts “that will further stretch the already taut health care safety net provided by teaching hospitals and medical school physicians,” Jordan Cohen, AAMC president said in a statement.

While pleased with a $300 million boost for community health centers, Daniel Hawkins of the National Association of Community Health Centers noted that proposed cuts to Medicaid and the National Health Service Corps presented a funding conflict. Not everyone was unhappy with the budget: the AMA praised the budget's efforts to fund tax credit initiatives and expand health savings accounts. The request includes $1.55 billion for the National Institute of Neurological Disorders and Stroke, a less than 1% increase from the institute's budget for fiscal year 2005.

The administration proposes to spend an additional $26 billion on the “Neuroscience Blueprint” project, a research collaboration involving 15 institutes within the National Institutes of Health.

Controversial Retiree Benefits Rule

AARP is rejoicing now that a federal judge has temporarily blocked a new rule from the Equal Employment Opportunity Commission (EEOC) regarding retiree health benefits, but some members of Congress are not happy about this latest development.

The rule, which the commission approved last April, exempts employers from age discrimination laws when it comes to designing retiree health benefits. The EEOC says the rule is designed to allow employers to better coordinate retiree benefits with Medicare.

However, AARP says the rule simply makes it easier for employers to reduce health benefits for older retirees or abandon them altogether.

EEOC chair Cari Dominguez said that “any delay in implementing the rule endangers vital protections for retirees.”

Rep. John Boehner (R-Ohio), chairman of the House Committee on Education and the Workforce, issued a statement saying that “if the AARP is successful with its lawsuit, it will surely cause more workers to lose their retiree health coverage.”

The judge's action prevents the rule from being implemented until early next month.

Stem Cell Dustup in Massachusetts

Massachusetts Gov. Mitt Romney (R) is sparring with Democratic state legislators over a possible ban on certain types of stem cell research now being conducted in the state.

In February, state senate president Robert Travaglini (D) introduced a bill to loosen restrictions on stem cell research; the measure allows for research involving “any human embryo whether formed by fertilization, somatic cell nuclear transfer, parthenogenesis, or other means.”

In response, the governor said that while he had no problem with stem cell research involving discarded fertility clinic embryos, “the law should prohibit all human cloning and the creation of new human embryos for the purpose of research. … I believe that the practice of cloning human embryos for research or reproduction crosses the boundary of ethics.”

Sen. Travaglini accused the governor of “raising fears and unfounded doubts” about the research. “We want to send the message that this kind of research is welcome in Massachusetts,” said a spokeswoman for Sen. Travaglini.

Assault on Salt?

Federal withholding of data on which the government has based its recommendation to reduce salt intake with the goal of lowering stroke risk is drawing fire from the salt industry.

The Salt Institute, which represents the interests of salt manufacturers, sued the Department of Health and Human Services, claiming that the department refused to release the studies that support its 2002 recommendation that Americans cut down on their salt intake as a way to avoid hypertension and stroke.

The failure to release that information was a violation of the federal Information Quality Act, the suit alleges. Under the act, parties who feel that the government is withholding information have the right to appeal to the agency in question; the Salt Institute, along with the U.S. Chamber of Commerce, did just that before the U.S. District Court for the Eastern District of Virginia, but the appeal was denied.

HHS says that the suit is not valid because there is no provision in the act for a judicial review of a denied appeal; the court agreed and dismissed the suit. The chamber and the institute have appealed.

HHS Budget Reviews Mixed

The president's 2006 budget request got mixed reviews from health care groups. While some groups objected to a lack of appropriate funding for health professions programs, others decried the $60 billion in proposed cuts to Medicaid over the next 10 years.

The Association of American Medical Colleges is opposed to cuts “that will further stretch the already taut health care safety net provided by teaching hospitals and medical school physicians,” Jordan Cohen, AAMC president said in a statement.

While pleased with a $300 million boost for community health centers, Daniel Hawkins of the National Association of Community Health Centers noted that proposed cuts to Medicaid and the National Health Service Corps presented a funding conflict. Not everyone was unhappy with the budget: the AMA praised the budget's efforts to fund tax credit initiatives and expand health savings accounts. The request includes $1.55 billion for the National Institute of Neurological Disorders and Stroke, a less than 1% increase from the institute's budget for fiscal year 2005.

The administration proposes to spend an additional $26 billion on the “Neuroscience Blueprint” project, a research collaboration involving 15 institutes within the National Institutes of Health.

Controversial Retiree Benefits Rule

AARP is rejoicing now that a federal judge has temporarily blocked a new rule from the Equal Employment Opportunity Commission (EEOC) regarding retiree health benefits, but some members of Congress are not happy about this latest development.

The rule, which the commission approved last April, exempts employers from age discrimination laws when it comes to designing retiree health benefits. The EEOC says the rule is designed to allow employers to better coordinate retiree benefits with Medicare.

However, AARP says the rule simply makes it easier for employers to reduce health benefits for older retirees or abandon them altogether.

EEOC chair Cari Dominguez said that “any delay in implementing the rule endangers vital protections for retirees.”

Rep. John Boehner (R-Ohio), chairman of the House Committee on Education and the Workforce, issued a statement saying that “if the AARP is successful with its lawsuit, it will surely cause more workers to lose their retiree health coverage.”

The judge's action prevents the rule from being implemented until early next month.

Stem Cell Dustup in Massachusetts

Massachusetts Gov. Mitt Romney (R) is sparring with Democratic state legislators over a possible ban on certain types of stem cell research now being conducted in the state.

In February, state senate president Robert Travaglini (D) introduced a bill to loosen restrictions on stem cell research; the measure allows for research involving “any human embryo whether formed by fertilization, somatic cell nuclear transfer, parthenogenesis, or other means.”

In response, the governor said that while he had no problem with stem cell research involving discarded fertility clinic embryos, “the law should prohibit all human cloning and the creation of new human embryos for the purpose of research. … I believe that the practice of cloning human embryos for research or reproduction crosses the boundary of ethics.”

Sen. Travaglini accused the governor of “raising fears and unfounded doubts” about the research. “We want to send the message that this kind of research is welcome in Massachusetts,” said a spokeswoman for Sen. Travaglini.

Assault on Salt?

Federal withholding of data on which the government has based its recommendation to reduce salt intake with the goal of lowering stroke risk is drawing fire from the salt industry.

The Salt Institute, which represents the interests of salt manufacturers, sued the Department of Health and Human Services, claiming that the department refused to release the studies that support its 2002 recommendation that Americans cut down on their salt intake as a way to avoid hypertension and stroke.

The failure to release that information was a violation of the federal Information Quality Act, the suit alleges. Under the act, parties who feel that the government is withholding information have the right to appeal to the agency in question; the Salt Institute, along with the U.S. Chamber of Commerce, did just that before the U.S. District Court for the Eastern District of Virginia, but the appeal was denied.

HHS says that the suit is not valid because there is no provision in the act for a judicial review of a denied appeal; the court agreed and dismissed the suit. The chamber and the institute have appealed.

HHS Budget Reviews Mixed

The president's 2006 budget request got mixed reviews from health care groups. While some groups objected to a lack of appropriate funding for health professions programs, others decried the $60 billion in proposed cuts to Medicaid over the next 10 years.

The Association of American Medical Colleges is opposed to cuts “that will further stretch the already taut health care safety net provided by teaching hospitals and medical school physicians,” Jordan Cohen, AAMC president said in a statement.

While pleased with a $300 million boost for community health centers, Daniel Hawkins of the National Association of Community Health Centers noted that proposed cuts to Medicaid and the National Health Service Corps presented a funding conflict. Not everyone was unhappy with the budget: the AMA praised the budget's efforts to fund tax credit initiatives and expand health savings accounts. The request includes $1.55 billion for the National Institute of Neurological Disorders and Stroke, a less than 1% increase from the institute's budget for fiscal year 2005.

The administration proposes to spend an additional $26 billion on the “Neuroscience Blueprint” project, a research collaboration involving 15 institutes within the National Institutes of Health.

Controversial Retiree Benefits Rule

AARP is rejoicing now that a federal judge has temporarily blocked a new rule from the Equal Employment Opportunity Commission (EEOC) regarding retiree health benefits, but some members of Congress are not happy about this latest development.

The rule, which the commission approved last April, exempts employers from age discrimination laws when it comes to designing retiree health benefits. The EEOC says the rule is designed to allow employers to better coordinate retiree benefits with Medicare.

However, AARP says the rule simply makes it easier for employers to reduce health benefits for older retirees or abandon them altogether.

EEOC chair Cari Dominguez said that “any delay in implementing the rule endangers vital protections for retirees.”

Rep. John Boehner (R-Ohio), chairman of the House Committee on Education and the Workforce, issued a statement saying that “if the AARP is successful with its lawsuit, it will surely cause more workers to lose their retiree health coverage.”

The judge's action prevents the rule from being implemented until early next month.

WASHINGTON — Medicare's proposal to require a face-to-face visit before a physician can prescribe a wheelchair or other durable medical equipment to a patient is annoying and inconvenient, several physicians said at a meeting of the program's Practicing Physicians Advisory Council.

“How is a face-to-face visit a step forward?” said Laura Powers, M.D., a Knoxville, Tenn., neurologist and member of the council, which advises Medicare on issues of interest to physicians. “If I take care of stroke patients in the hospital and they leave with a walker, then progress to a cane, do they have to come back for a face-to-face visit before I can prescribe a cane?”

Herb Kuhn, director of the Center for Medicare Management at the Centers for Medicare and Medicaid Services, said that the idea behind the regulation was to deter durable medical equipment (DME) supplier fraud in the wake of the recent scandal in the power wheelchair industry.

“We're looking for continuity of care,” Mr. Kuhn said.

“If a person had a relationship with a physician and had seen that physician over a period of time and the physician knew they were ultimately going to need a power wheelchair, they could make that prescription before then. We wanted to try to avoid a situation where people are popping in for one time, getting a wheelchair, and moving on.”

Council chair Michael Rapp, M.D., said he could understand why the agency was concerned about wheelchair fraud. “Power wheelchairs are one thing,” said Dr. Rapp, an emergency physician. “But [other] DME—I don't even know what it all includes, but a lot of stuff could be involved here.”

Under the proposed rule, a face-to-face examination would be required “to determine the medical necessity of durable medical equipment, orthotics, and prosthetics.”

However, the exam must be “for the purpose of evaluating and treating the patient's medical condition and not for the sole purpose of obtaining the prescribing physician's or practitioner's order for the [equipment].”

Don Thompson, director of the division of ambulatory services at CMS, told the council members that the agency “doesn't want to create an unnecessary burden for physicians,” even as it is trying to combat DME fraud.

Dr. Rapp expressed concern that Medicare would not pay for evaluations performed solely to determine whether the patient needed a power wheelchair, despite the fact that “that might be an extensive evaluation.” Mr. Kuhn responded that he did not think the agency would want to get out of paying for such an extended visit, “but it perhaps requires some clarification and comment,” he added.

Although wheelchair fraud is at the heart of the agency's fraud concerns, the CMS Physician Regulatory Issues Team (PRIT) is looking at expanding the categories of specialists permitted to prescribe power wheelchairs.

Currently only physiatrists, orthopedic surgeons, neurologists, or rheumatologists can prescribe power wheelchairs, and primary care physicians and other specialists can prescribe them only if one of those specialists is not readily available—that is, if they are located more than a day's round trip from the beneficiary's home—or if the patient is too sick to travel to a specialist.

“I think we're coming to a good resolution on this with our proposal to allow physicians of any specialty to prescribe them, and that's in the final approval process now,” said William Rogers, M.D., director of PRIT. “It really wasn't the best time to be broadening the number of specialties that can do it, but it is the right thing to do.

WASHINGTON — Medicare's proposal to require a face-to-face visit before a physician can prescribe a wheelchair or other durable medical equipment to a patient is annoying and inconvenient, several physicians said at a meeting of the program's Practicing Physicians Advisory Council.

“How is a face-to-face visit a step forward?” said Laura Powers, M.D., a Knoxville, Tenn., neurologist and member of the council, which advises Medicare on issues of interest to physicians. “If I take care of stroke patients in the hospital and they leave with a walker, then progress to a cane, do they have to come back for a face-to-face visit before I can prescribe a cane?”

Herb Kuhn, director of the Center for Medicare Management at the Centers for Medicare and Medicaid Services, said that the idea behind the regulation was to deter durable medical equipment (DME) supplier fraud in the wake of the recent scandal in the power wheelchair industry.

“We're looking for continuity of care,” Mr. Kuhn said.

“If a person had a relationship with a physician and had seen that physician over a period of time and the physician knew they were ultimately going to need a power wheelchair, they could make that prescription before then. We wanted to try to avoid a situation where people are popping in for one time, getting a wheelchair, and moving on.”

Council chair Michael Rapp, M.D., said he could understand why the agency was concerned about wheelchair fraud. “Power wheelchairs are one thing,” said Dr. Rapp, an emergency physician. “But [other] DME—I don't even know what it all includes, but a lot of stuff could be involved here.”

Under the proposed rule, a face-to-face examination would be required “to determine the medical necessity of durable medical equipment, orthotics, and prosthetics.”

However, the exam must be “for the purpose of evaluating and treating the patient's medical condition and not for the sole purpose of obtaining the prescribing physician's or practitioner's order for the [equipment].”

Don Thompson, director of the division of ambulatory services at CMS, told the council members that the agency “doesn't want to create an unnecessary burden for physicians,” even as it is trying to combat DME fraud.

Dr. Rapp expressed concern that Medicare would not pay for evaluations performed solely to determine whether the patient needed a power wheelchair, despite the fact that “that might be an extensive evaluation.” Mr. Kuhn responded that he did not think the agency would want to get out of paying for such an extended visit, “but it perhaps requires some clarification and comment,” he added.

Although wheelchair fraud is at the heart of the agency's fraud concerns, the CMS Physician Regulatory Issues Team (PRIT) is looking at expanding the categories of specialists permitted to prescribe power wheelchairs.

Currently only physiatrists, orthopedic surgeons, neurologists, or rheumatologists can prescribe power wheelchairs, and primary care physicians and other specialists can prescribe them only if one of those specialists is not readily available—that is, if they are located more than a day's round trip from the beneficiary's home—or if the patient is too sick to travel to a specialist.

“I think we're coming to a good resolution on this with our proposal to allow physicians of any specialty to prescribe them, and that's in the final approval process now,” said William Rogers, M.D., director of PRIT. “It really wasn't the best time to be broadening the number of specialties that can do it, but it is the right thing to do.

WASHINGTON — Medicare's proposal to require a face-to-face visit before a physician can prescribe a wheelchair or other durable medical equipment to a patient is annoying and inconvenient, several physicians said at a meeting of the program's Practicing Physicians Advisory Council.

“How is a face-to-face visit a step forward?” said Laura Powers, M.D., a Knoxville, Tenn., neurologist and member of the council, which advises Medicare on issues of interest to physicians. “If I take care of stroke patients in the hospital and they leave with a walker, then progress to a cane, do they have to come back for a face-to-face visit before I can prescribe a cane?”

Herb Kuhn, director of the Center for Medicare Management at the Centers for Medicare and Medicaid Services, said that the idea behind the regulation was to deter durable medical equipment (DME) supplier fraud in the wake of the recent scandal in the power wheelchair industry.

“We're looking for continuity of care,” Mr. Kuhn said.

“If a person had a relationship with a physician and had seen that physician over a period of time and the physician knew they were ultimately going to need a power wheelchair, they could make that prescription before then. We wanted to try to avoid a situation where people are popping in for one time, getting a wheelchair, and moving on.”

Council chair Michael Rapp, M.D., said he could understand why the agency was concerned about wheelchair fraud. “Power wheelchairs are one thing,” said Dr. Rapp, an emergency physician. “But [other] DME—I don't even know what it all includes, but a lot of stuff could be involved here.”

Under the proposed rule, a face-to-face examination would be required “to determine the medical necessity of durable medical equipment, orthotics, and prosthetics.”

However, the exam must be “for the purpose of evaluating and treating the patient's medical condition and not for the sole purpose of obtaining the prescribing physician's or practitioner's order for the [equipment].”

Don Thompson, director of the division of ambulatory services at CMS, told the council members that the agency “doesn't want to create an unnecessary burden for physicians,” even as it is trying to combat DME fraud.

Dr. Rapp expressed concern that Medicare would not pay for evaluations performed solely to determine whether the patient needed a power wheelchair, despite the fact that “that might be an extensive evaluation.” Mr. Kuhn responded that he did not think the agency would want to get out of paying for such an extended visit, “but it perhaps requires some clarification and comment,” he added.

Although wheelchair fraud is at the heart of the agency's fraud concerns, the CMS Physician Regulatory Issues Team (PRIT) is looking at expanding the categories of specialists permitted to prescribe power wheelchairs.

Currently only physiatrists, orthopedic surgeons, neurologists, or rheumatologists can prescribe power wheelchairs, and primary care physicians and other specialists can prescribe them only if one of those specialists is not readily available—that is, if they are located more than a day's round trip from the beneficiary's home—or if the patient is too sick to travel to a specialist.

“I think we're coming to a good resolution on this with our proposal to allow physicians of any specialty to prescribe them, and that's in the final approval process now,” said William Rogers, M.D., director of PRIT. “It really wasn't the best time to be broadening the number of specialties that can do it, but it is the right thing to do.