The American Board of Internal Medicine (ABIM) said it would offer a new form of maintenance of certification (MOC) exam that allows internists to answer a single question at a time and get immediate feedback on their answers, although no launch has yet been set.
The "longitudinal assessment option" for MOC is "part of our ongoing evolution at ABIM," Marianne Green, MD, chair of ABIM's board of directors, and Richard Baron, MD, ABIM president and CEO, wrote Tuesday in a blog post. "We recognize that some physicians may prefer a more continuous process that easily integrates into their lives and allows them to engage seamlessly at their preferred pace, while being able to access the resources they use in practice."
Under the new option, rather than taking an all-day test at a testing center or a 2- or 3-hour test at home, physicians could answer a single question at a time, accumulating a required number of questions within a given time period. "This would be something people don't do at a center; they would do it in a self-paced way one question at a time, accumulating their performance over time to make assessment decisions, rather than having everybody do everything at one point in time," Baron said in a phone interview.
In addition, "one of the things we have heard is that people want an assessment that has more educational value directly built into it, so when people answer a question [in this type of assessment], they'll [find out] what the correct answer is -- their answer will [also] be scored, and they'll get references and some discussion of why that's the right answer, and even in the process of doing the assessment, they'll have educational opportunities," he explained.
The timeline for launching the longitudinal assessment is still being worked out, Baron said. "There are a lot of operational issues, and we want to work those through in co-creation with the community rather than put it out there fully formed ... We expect a timeframe soon, but we need to work out operational details before we can commit to that."
As for the cost, "We expect there's going to be an annual fee and we need to develop a fee structure to support the program," he continued. "We don't expect that the overall cost over 10 years is going to be higher than what it is now."
This idea isn't completely new, Baron added. "Some other boards have done versions of this -- the first one was [the American Board of Anesthesiology], which released the MOCA Minute. It was a question a week," which was a little more frequent than ABIM diplomates seem to want, he said. "There is probably an expectation of a certain number of questions in a quarter that people can do weekly, monthly, or wait until the end of the period. These are the kind of questions we need to get feedback from people on how to do this." In addition, "we need to be sensitive [to the fact that] people get sick and people have life events, and how do you manage those sorts of things? We need to work through all of that."
In terms of developing specific test questions, internal medicine has special challenges because of the number of subspecialties involved, Baron said. "We're in the process of having conversations with a number of professional societies, so people could get content that was enriched for the kind of practice they do ... If a practice is focused on breast cancer, they will be able to do an assessment that has lots of breast cancer questions on it," although they will still also be tested on core internal medicine areas.
Initial reaction to the announcement has been positive -- at least in one corner. "ASH [American Society of Hematology] applauds ABIM's recognition that MOC can take many forms," ASH President Roy Silverstein, MD, said in a statement. "This new direction for MOC is a welcome change because it will better align with the needs of hematologists. For many years, the Society has advocated for assessment options that enhance medical knowledge through ongoing feedback outside of examination settings. We are thrilled to see this long-overdue reform being made."
Silverstein noted that "this change was recommended earlier this year by an independent 'Vision Commission' appointed by the American Board of Medical Specialties to improve MOC. These new assessments are expected to offer more interactive, less time-bound methods of assessment that allow physicians to continuously assess their knowledge, fill knowledge gaps, and demonstrate proficiency."
One group likely not happy about today's announcement, however, is the Practicing Physicians of America, a group of physicians that is currently supporting a lawsuit seeking to force ABIM to drop its MOC program entirely.
"Many of us believe Maintenance of Certification is not only discriminatory against younger, more economically vulnerable physicians who are increasingly comprised of females and physicians of color, but was fraudulently promoted to physicians, hospitals, insurance companies, medical corporations, health care employers, and the public to force working physicians to provide lifelong payments to the American Board of Medical Specialties member boards to serve personal, political, and promotional agendas," Westby Fisher, MD, a co-founder of the group, said Monday in a video opinion piecefor MedPage Today. Fisher did not respond to a request for comment on Wednesday's announcement by ABIM.
18% of patients younger than 65 say they can't afford to take meds as prescribed.
This article first appeared on Wednesday, August 21, 2019 in MedPage Today.
By Kristen Monaco, Staff Writer, MedPage Today.
Confirming widespread anecdotal reports, recent federal survey data indicate that high costs of diabetes drugs drive many patients to cut corners in their treatment regimens.
Findings from the 2017-2018 National Health Interview Survey show that nearly one-quarter of adults with type 1 or type 2 diabetes (including those on Medicare) asked his or her doctor for a lower-priced diabetes medication, according to a data brief from theCDC's National Center for Health Statistics (NCHS)released early Wednesday.
Even more alarming, 13% of adults of all ages diagnosed with diabetes reported they didn't take their medications as prescribed in order to cut costs, reported NCHS researchers Robin Cohen, PhD, and Amy Cha, PhD, MPH.
Specific tactics included skipping doses, splitting pills, and delaying prescription refills. Women were more likely than men (14.9% vs 11.6% of all individuals with diabetes) to report modifying their drug regimens because of cost.
Patients 65 and older, presumably on Medicare, were less likely to report non-adherence for cost reasons than younger adults (7.2% vs 17.9%). Just over one-third of those ages 18-64 without insurance said they couldn't afford to take medications as prescribed.
"In 2018, medications to treat diabetes ranked sixth out of the top 20 therapeutic classes of dispensed prescriptions, accounting for 214 million prescriptions," Cohen and Cha explained. In 2017, "the annual per capita expense for outpatient medication for those with diagnosed diabetes was almost $5,000."
"Recently, there has been a shift towards lower-cost options as the first line of therapy for diabetes management," they wrote. "However, the burden associated with high prescription drug costs remains a public health concern for adults with diagnosed diabetes."
Asking for cheaper medications was most common among uninsured patients, 43% of whom said they had inquired with their provider. But it was not infrequent among those with private insurance or Medicaid (26% and 19%, respectively).
In the Medicare population, so-called dual eligibles -- those on Medicaid as well -- appeared to have the least trouble with drug costs. Only 13% of dual eligibles asked physicians for cheaper drugs, versus 23% or more of those with other insurance types. Not taking medications as prescribed was reported by 6% of dual eligibles and those with strictly private insurance, versus 9% for those using Medicare Advantage or standard Medicare.
WASHINGTON -- Fixing prior authorization is still a priority for the Trump administration, Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said Thursday.
Prior authorization and utilization management "have been shown to be a very effective method of assuring appropriate care, and [to assure] that you don't have inappropriate use of the program ... In the Medicare program, you see in some areas we have large profit margins and at the same time we have high improper payments," Verma said at a briefing with reporters. "So that kind of screams [that] there needs to be more oversight of utilization and that's where you use the prior authorization program. So the way that I'm looking at it is, we're going to have to have prior authorization. We're not going to do away with those types of programs."
"That being said, we've got to make them work in a way that doesn't interfere in the practice of medicine [so] that there are not delays, that patients can get access to the services they need in a timely manner," she continued. "So I'm looking at how do we make the process work to be less burdensome but also achieve the outcomes that it's intended to?"
Verma also discussed several other issues at the briefing, including:
The "public charge" proposed rule. Under a proposal from the Department of Homeland Security (DHS), legal U.S. residents who are applying for a green card will have it counted against them if they have used public programs such as Medicaid or food stamps. However, the rule has been modified from its original form, Verma told MedPage Today. "From their proposal to the finalization of the rule, [DHS] did make some changes." For example, "they did make exemptions for pregnant women, for children, for low-income seniors."
"At this point, it's very speculative to say what will happen and what won't happen," she added. "My understanding of the rule is this is one of many factors they're looking at when making decisions about somebody's legal status or about their path to citizenship, so I think right now it's premature to speculate what the impact would be."
Practice consolidation and competition. Verma bemoaned the fact that the number of independent practices has been decreasing each year because they are being bought out by hospitals. "What I worry about going forward is making sure that we always have an environment that creates competition ... When doctors are bought out by a particular hospital, you see the referrals to that hospital go up ... We're concerned about what that does for pricing in these markets."
That's one reason CMS is advancing "site-neutral" payment policies in Medicare, she continued. "I understand that there are differences in pricing between a hospital and maybe an outpatient center or a doctor's office, because [hospitals] do have more safety requirements." However, that argument doesn't really apply to a simple outpatient visit because there aren't any additional safety requirements for those, and it's not fair to patients who have to pay higher copays just because they happened to be at a hospital outpatient center rather than a physician's office, she said. "That's why we made these changes; it's about competition, but it's also about the patient."
The "two-midnight" rule. Under this rule, if a patient stays at a hospital through two midnights, Medicare generally will consider the patient as an inpatient and reimburse for the patient's care under the Medicare Part A program. Patients who stay for less than that amount of time are considered to be "observation" patients and will be covered as outpatients under Medicare Part B.
Verma said this rule was an example of rules that CMS would like to change but can't. "We have looked at this issue many times," she said. "[This is] an example of government policies that don't work, that don't make sense, that create problems ... I don't think that we have the authority to make the type of change that we would like to make." She did not specify what that change would be.
"We wrote a letter to [leaders on Capitol Hill] and we said, 'These are the issues [including this rule] that we don't have the authority [to change] but we wanted you to know' that there are problems with them," she said. "And that was something that we've already brought to their attention."
Medicare for All. Verma was asked what she thought of Democratic presidential candidate Kamala Harris's version of a Medicare for All healthcare plan, which builds on the Medicare Advantage program. "I like Medicare Advantage and I'm supportive of Medicare Advantage because it creates competition and there's choice, and that competition is around price and quality and people have the opportunity to pick what's going to work best for them," she said.
However, Medicare Advantage -- which contracts with private health insurance providers to provide services to Medicare patients -- is still a government-run program and still has all the problems that come with that, she continued. "We just added telehealth and supplemental benefits, and it took years to get them," she said. "So that's the example of, yes, these are private health plans, but they are governed by government policies and it kind of limits their ability to innovate."
Deal with drug company will cap the states' treatment costs.
This article was first published on Monday, August 12, 2019 in MedPage Today.
By Joyce Frieden,News Editor, MedPage Today August 12, 2019
Is your state wondering how it can possibly afford to pay for expensive hepatitis C drugs for its Medicaid patients and its prisoners? Louisiana officials have a suggestion for you.
Rebekah Gee, MD, MPH, an obstetrician who is secretary of the Louisiana Department of Health in Baton Rouge, said that in her first month on the job nearly 4 years ago, she got a letter from the Centers for Medicare & Medicaid Services (CMS) saying that her state should be providing more hepatitis C treatment.
However, "a much higher 'spend' on it was simply not possible," Gee said last month at an event sponsored by the Brookings Institution, noting that the state at the time was facing a $2 billion deficit. On the other hand, she continued, "here we are with a disease that kills tens of thousands of people and through our research institutions we have a cure, and it's unacceptable that we can't provide it."
Nearly half of the state's hepatitis C population are either on Medicaid or in prison. Officials estimated at the time that it would cost $760 million to eliminate hepatitis C just for Medicaid alone, "and that that would be more than our K-12 budget, our prisoner budget, and all administrative functions of government combined," said Gee. Neither the state itself -- which funds healthcare for prisoners -- nor the Medicaid program would ever have enough money to treat all hepatitis C patients, "so why not this win-win where pharmaceutical companies could have this guaranteed revenue, and yet a state could solve a public health challenge?"
"We were agnostic to the solution as long as we were able to provide individuals with access," Gee said, noting that because programs such as Medicaid also involve a federal component, "we can't just write a check to a pharmaceutical company." In addition, the federal "best price" law meant that any big price discount that a state like Louisiana negotiated with a drug company would need to be offered to everyone else as well. "We knew no pharmaceutical company would give a deal to a state with 4.6 million people that would affect their entire national price."
So the state negotiated a 5-year deal with Asegua Therapeutics -- a division of Gilead -- which makes a generic form of Epclusa (sofosbuvir/velpatasvir), to pay the regular price of the drug up to a cap, and then any prescriptions after that are free. With unlimited access to the drug, "we will be able to eliminate this infectious disease and focus on more difficult challenges," she said. The agreement involves a supplemental rebate arrangement that is exempt from the "best price" law.
The state started the program in mid-July and is really excited about it, Gee said, adding that being able to extend the program to the prison system is very important. "We think about 30% of people with Hep C will pass through a prison during their lifetime. About 95% will get out, and if we aim to eliminate this disease, we can't ignore then. And so we're really, really proud to be the first state to be able to offer this unlimited access to individuals who are incarcerated."
Getting the agreement done took about 3 years -- and a lot of convincing, she said. "We were told 'No' at least 50 times from a variety of people; whether it was the industry, or policymakers, or individuals at the CDC ... because it had never been done before. Now it looks like it was an easy thing." It helped that the market for hepatitis C cures became more competitive during that time, she added. "Then it became an economic impetus to enter into this kind of agreement."
"Part of the consideration here was, how do we provide predictable expenditure for the state and spread the budget impact over time?" said Rekha Ramesh, MPP, executive director for public policy at Gilead. "And that's kind of where we started with this ... while still providing an incentive for the state to want to continue finding patients and curing patients over a 5-year period."
"It took considerable effort to get here and to implement this model," she added. "I think this is the first of its kind ... We believe in what Louisiana is doing, and this does pose a bit of risk on behalf of the company."
This type of payment model -- which experts call a "modified subscription model," could be applied not only to drugs paid for by the state, but also those reimbursed by private insurers, said Neeraj Sood, PhD, professor of public policy at the University of Southern California in Los Angeles. However, he added, for it to work well, three conditions must apply:
There must be a large access problem. "That's why hep C was such a great example, because we solved the access problem for hep C," he said.
Cutting the price doesn't lead to inappropriate use. "There could be other drugs where you make the copay equal zero, and maybe it leads to overprescribing of say antipsychotics that we don't want," said Sood. "So we've got to make sure that we limit it to drugs where even if the price is zero, only people who actually need the drug are getting it."
There must be competition in the drug class. "If there is no competition, the upfront payment that you will pay for a breakthrough therapy is still going to cost you billions and billions of dollars ... because you have a monopoly and there is no other competition," he said. "If there is no competition ... it will solve the access problem, but not the affordability problem."
But Rena Conti, PhD, associate professor of markets, public policy, and law at Boston University, didn't agree that competition was absolutely necessary. "Instead, what is the binding criteria is a willingness by the pharmaceutical companies to want to engage and to really care about access here," she said. "I think that there are many innovator companies that are particularly innovating for these type of conditions for which restraining access is going to be untenable."
This article was first published on Tuesday, August 6, 2019 in MedPage Today.
By Ashley Lyles, Staff Writer, MedPage Today
Selfies taken with a smartphone with transdermal optical imaging (TOI) may soon be a way to conveniently measure blood pressure, a study found.
TOI "processes imperceptible facial blood flow changes from videos captured with a smartphone camera and uses advanced machine learning to determine blood pressure from the captured signal," explained Kang Lee, PhD, of the University of Toronto, and colleagues.
Their smartphone software model predicted BP measures with an average accuracy of 95.8% for pulse pressure, 95.7% for diastolic BP, and 94.8% for systolic BP in normotensive adults, they wrote inCirculation: Cardiovascular Imaging.
The average prediction biases were 0.52 mm Hg for pulse pressure, 0.39 mm Hg for systolic BP, and −0.20 mm Hg for diastolic BP, the investigators found.
Monitoring BP is key in the managment and prevention of hypertension, noted Lee, but "The current cuff-based methods are not convenient and uncomfortable for regularly and repeated measurement."
"The present study shows the new method may make convenient and comfortable monitoring of blood pressure a reality," Lee told MedPage Today.
Co-author Zhong-Ping Feng MD, PhD, also of the University of Toronto, added that "This convenient contactless tool provides the option for individuals regularly monitoring and recording their blood pressure over time, allowing for better detection of early onset of blood pressure changes and time-lapse- based blood pressure monitoring by the increased population of smartphone users, and thus permits early prevention and management of high blood pressure of the general [public] at none or little cost of health care funds."
These findings point to the promise of obtaining BP measurement with a video camera, noted Ramakrishna Mukkamala, PhD, of Michigan State University in East Lansing, in an accompanying editorial.
Although privacy concerns would have to be addressed, "such rich information in facial video may render this video camera approach to be more promising for BP measurement than a contact measurement of the finger [photo-plethysmography] waveform," Mukkamala stated.
Future studies should include heterogeneous participants, and focus on gathering possible BP-related data from facial video, such as facial expressions and head ballistocardiography, he added.
The researchers evaluated 1,328 normotensive Chinese and Canadian adults using a smartphone with TOI to record BP. Recordings were 2-minutes long. The participants were recruited from the Toronto institution and the Physical Examination Center of the Affiliated Hospital of Hangzhou Normal University in Hangzhou, China.
To create computational models that predicted reference pulse pressure, diastolic and systolic BPs from facial blood flow information, the investigators used an advanced machine learning algorithm. They used 15% of the cohort to test these models, 70% to train them, and 15% of the sample to validate the models' performance.
Study limitations included the focus on individuals with a diastolic BP range of ≥60 to <90 mm Hg and a normotensive systolic BP range of ≥100 to <140 mm Hg. The study did not have a cohort with hypotensive and hypertensive BPs. Also, the cohort was racially homogeneous as the majority was of East Asian descent, but "our participants displayed a reasonable degree of skin tone variation and this factor did not impact model prediction accuracy," the authors pointed out.
"Future work will determine whether these models meet the clinically accepted accuracy threshold of 5±8 mm Hg when tested on a full range of blood pressures according to international accuracy standards," they stated.
(The study was supported by the Canadian Institutes of Health Research, the Natural Sciences and Engineering Research Council of Canada, and the National Science Foundation of China.
Lee and a co-author disclosed relevant relationships with Transdermal Optical Imaging. Feng disclosed no relevant relationships with industry.
Mukkamala disclosed support from the NIH, patents for cuffless BP measurements, and a relevant relationship with Digitouch Health.)
One-quarter got general payments of 'significant financial interest.'
This article first appeared on Monday, August 5, 2019 in MedPage Today.
By Ian Ingram, Deputy Managing Editor, MedPage Today.
Roughly half of physician directors (49%) for National Cancer Institute (NCI)-designated cancer centers received general or research payments from industry in 2017, a new study found.
And among the 53 physicians holding these top positions, 23% received over $5,000 in general payments, which is defined by the NCI as being of "significant financial interest," reported David Carr, MD, of the University of California San Diego, and H. Gilbert Welch, MD, MPH, formerly of the Dartmouth Institute for Health Policy and Clinical Practicein Lebanon, New Hampshire.
Industry payments that year totalled $4.42 million and consisted of $2.53 million for general payments (consulting, lectures, travel, other) and $1.89 million for research payments, they wrote in JAMA Internal Medicine.
"We were actually pleasantly surprised to find that only about half of directors received payments," Carr told MedPage Today. "This is a lower percentage than has been reported in some of the other cohorts that have been studied."
Past research on payments to authors of National Comprehensive Cancer Network guidelines, for example, found that about 84% received general payments and 47% received payments for research.
"These are the most prestigious cancer centers that exist in the whole country," said Carr. "I think that's a really promising finding."
The authors were particularly interested in the group receiving payments of over $5,000. Twelve of the 53 directors received general payments (23%) while 19 received payments for research (36%) that exceeded this amount. Overall, the median value of industry payments was higher for research versus general payments ($37,036 vs $5,828).
Two directors had general payments greater than $50,000 in 2017. Though not named in the article, these were:
$2.27 million to Laurie Glimcher, MD, of Dana-Farber/Harvard Cancer Center in Boston, the bulk of which came from Bristol-Myers Squibb (BMS) as "compensation for services other than consulting, including serving as faculty or as a speaker at a venue other than a continuing education program"; in 2018, Glimcher again received over $2 million in general payments, again largely from BMS.
$65,514 toRichard Fisher, MD, of Fox Chase Cancer Center in Philadelphia, mostly from consulting fees from Genentech, Bayer, and Sandoz; in 2018, Fisher received $16,513 from AstraZeneca and Bayer.
Last year, the New York Times and ProPublica investigation into José Baselga, MD, PhD, then the Chief Medical Officer of Memorial Sloan Kettering Cancer Center, shined a spotlight on industry involvement and conflicts of interest among top physicians at cancer centers. (The fallout from the investigation ultimately led to Baselga's resignation.)
Carr said the news broke while he and Welch were conducting the exploratory data collection for their study and it spurred them on to continue. "It seemed to be a pretty important issue," he said.
Some experts have argued that any type of industry payment can be problematic, but the NCI's conflict of interest policy is "silent" on the research funding, they noted. In the study, four directors received general payments greater than $50,000 in 2017.
To conduct their research, the authors used Open Payments to examine industry payments from 2015 to 2017 to the 53 physician directors at the 70 NCI-designated cancer centers. All medical device and pharmaceutical companies are required by law to report research and general payments made to U.S. physicians to the database, which is run by the Centers for Medicare & Medicaid Services. As such, any payments to the 16 non-physician directors were not available.
Among the 53 physician NCI cancer center directors in 2017, general payments were made to 22 while research payments were made to 12 (some received both). No payments for that year were listed in Open Payments as being under dispute.
Carr and Welch disclosed no relevant relationships with industry.
They're using the momentum of #ThisIsOurLane, along with partnerships with organized medicine, to crowdsource dollars for investigating gun violence.
"We founded Affirm Research because we tried working through traditional channels for many years but got frustrated by the lack of movement. Meanwhile, we watched patients coming into our emergency departments or die on the streets," co-founder Megan Ranney, MD, MPH, an emergency physician at Rhode Island Hospital in Providence and associate professor at Brown University, told MedPage Today. "We said it's time to do something, so we created Affirm with the goal of making gun violence about health, rather than a political debate."
Ranney and co-founder Chris Barsotti, MD -- who is a gun owner himself -- launched Affirm in 2017, after the Las Vegas mass shooting, though it's recently been propelled into the spotlight by the #ThisIsOurLane movement. The hashtag came as a response to a National Rifle Association tweet in November 2018 telling "self-important, anti-gun doctors to stay in their lane" when it comes to gun regulation. Physicians responded by flooding social media with examples of why gun violence should be considered a public health issue, including images of blood-stained scrubs and hospital rooms where families are informed that they've lost a loved one.
This weekend's mass shootings in El Paso, Texas and Dayton, Ohio, have once again reignited that debate, though many organizations -- including the American Medical Association (AMA), the American College of Physicians (ACP), and the American College of Emergency Physicians (ACEP) -- have firmly labeled gun violence a public health issue that deserves the same research treatment as seat belt safety, tobacco, obesity, and HIV.
The challenge has been paying for that kind of research, Ranney said. Federal funding has been lacking due to a 1996 rider to an omnibus spending bill known as the Dickey Amendment. It prohibited use of CDC funds for "advocacy" or "promotion" of gun control.
Although the amendment didn't explicitly ban federal funding for firearm research, Congress still has not allocated any money to the CDC to study gun violence. In 2018, as part of yet another omnibus spending resolution, Congress included language from HHS Secretary Alex Azar clarifying that CDC can conduct research on gun violence but can't use government funds specifically to advocate for gun control; but no effects are yet apparent.
"I was told early in my career as an injury prevention researcher that I couldn't talk about gun violence as a public health problem, because it's too political," Ranney said. That only began to shift after the 2012 mass shooting at Sandy Hook elementary school in Connecticut, she said, with leadership of organized medicine beginning to talk about it as a public health issue so that members of those organizations "felt comfortable doing so as well."
Affirm's goal is to support work that will ultimately "stop the shooters before they shoot." A major effort will be to create guidelines for physicians on how to identify and counsel those patients who pose a risk to themselves or others, Ranney said.
She declined to say how much Affirm has raised to date, but said the organization is "well on its way" to its $2.5-million funding goal, with the majority of its donations coming from "individual donors from all walks of life," including healthcare professionals. She said the organization currently uses funds to support community health programs, and awarded its first research grants in June, in partnership with the Emergency Medicine Foundation.
One of those grants was a two-year, $150,000 career development grant to Kristen Mueller, MD, of Washington University in St. Louis, to assess the characteristics of patients with firearm injuries who are treated at level-1 trauma hospitals. Mueller's team is also identifying patients at the highest risk of repeat injury.
Also, Henry Schwimmer, a medical student at Emory University, received $5,000 for a trial aimed at developing and expanding screening tools and tailored interventions to reduce firearm injury risk among patients in rural emergency departments.
The AMA, ACP, ACEP, the American Psychiatric Association, the American Academy of Pediatrics, the American Association of Family Physicians, and the American College of Obstetricians and Gynecologists are just some of the 20 medical organizations that have partnered with Affirm to fund research on gun violence.
In a statement, ACEP says it is actively participating in Affirm and its mission to "end the epidemic of gun violence through research, innovation, and evidence-based practice."
"Firearm injuries -- accidental or otherwise -- should be addressed as a public health epidemic, with investments in research and a sweeping commitment to change that matches or exceeds the level of a number of diseases, outbreaks or disorders that capture the public conscience but have exacted far less of a human toll in recent years," the statement said.
It remains to be seen whether Affirm and its collaborators will have an impact on firearm injury research, let alone eventual policy change. Ranney says the $2.5-million goal is "enough to jump start this field," which hasn't really progressed since the 1990s.
Garen Wintemute, MD, MPH, of the University of California Davis, who has famously spent more than $1 million of his own money to fund his firearms research, told CBS News that gun violence prevention measures can become more effective if the research happens.
Between #ThisIsOurLane and partnerships with physician, nursing, and public health groups, Ranney is hopeful that the time is right for the message that "gun violence is a public health epidemic, and we can solve it using public health tools."
"We want to create evidence using the collective will of medicine to create real change," she said.
This article was first published on Tuesday, July 30, 2019 in MedPage Today.
By Shannon Firth, Washington Correspondent, MedPage Today.
WASHINGTON -- The proposed rule for 2020 Medicare payment rates for U.S. physicians garnered mixed reactions from stakeholders.
Taking into account certain budget neutrality adjustments in relative value units (RVUs) as required by law, the 2020 Medicare Physician Fee Schedule released Monday establishes a conversion factor of $36.09, up $0.05 from 2019, for an overall increase of 0.14%.
The proposed rule aims to give clinicians' more time with their patients by scrapping unnecessary measures and shrinking their paperwork burden, explained Seema Verma, administrator for the Centers for Medicare & Medicaid Services (CMS), in a press release.
"Clinicians are drowning in paperwork and reporting requirements caused by cumbersome government rules and regulations. These administrative costs add to the total cost of delivering healthcare," she said, noting that practices often hire additional staff to keep up with requirements.
CMS would for the first time pay clinicians for care managment services for patients with a "high-risk chronic condition," such as diabetes or high blood pressure, according to the agency. It would also pay clinicians more for managing the care of a patient with multiple conditions.
Anders Gilberg, vice president for the Medical Group Management Association (MGMA), described the rule overall as "mostly status quo."
That the conversion factor has "remained flat" for several years and increased only a nickel from 2019 is a frustration for MGMA members who feel the fee schedule isn't keeping up with the cost of practice inflation, he stated.
While the changes to chronic care management, which recognize the work clinicians do outside of a traditional office visit, appear positive, Gilberg said the complexity around billing for these codes has often left MGMA members frustrated.
Having to jump through hoops -- for instance, paying a claims processing fee of $7 to retrieve a $2 coinsurance, and requiring physicians themselves to obtain patient consent for such bills -- it's often not worth the effort for members to bill the code, he said. MGMA supports legislation in Congress to waive the coinsurance for Medicare beneficiaries for these services.
Gilberg said he's not sure whether the proposal addresses these underlying concerns, but that's a question he'll be discussing with MGMA members before the group submits its comment letter.
The American Medical Group Association (AMGA) was critical of the rule, stating that proposed changes to the Merit-based Incentive Payment System (MIPS) "do not reflect congressional intent" or adequately reimburse its members.
Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), providers were supposed to be able to earn as much as a 9% bump on their Medicare payments in 2022, based on 2020 performance, but the proposed rule sets an overall payment adjustment of 1.4%, according to AMGA.
"By proposing an overly cautious approach, CMS is not rewarding those organizations that made the necessary investments in and championed value-based care as envisioned by congressional leaders," Jerry Penso, MD, MBA, AMGA president and CEO, said in a press statement.
CMS appears to have reversed course on a proposal to overhaul evaluation and management (E/M) codes that would have paid physicians the same amount for an office visit with a complex patient as a healthy one. The proposal was initially met with intense backlash from medical groups.
"Consistent with our goals of burden reduction, we are proposing to align our E/M coding with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits," said an updated CMS fact sheet.
"The CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the code definitions. The CPT changes also revise the times and medical decision making process for all of the codes, and requires performance of history and exam only as medically appropriate. The CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision making or time," according to the CMS.
Kavita Patel, MD, a primary care internist and vice president at Johns Hopkins Medicine in Baltimore, told MedPage Today she was relieved to see the changes in E/M coding.
Patel was "incredibly worried" that non-procedural specialties -- including primary care, rheumatology, medical oncology -- would be penalized under the previous approach to E/M codes, but it appears "[CMS] made some changes for the better."
While she said she's concerned that stakeholders could conflate these E/M changes with a path towards value on the fee schedule, to achieve that goal would require correcting mis-valued services. "But I think it's a step in the right direction," she said.
The American Medical Association (AMA) said it was pleased to see the changes CMS proposed around documenting and coding for E/M services. AMA President Patrice Harris, MD, noted in a press release that the AMA and other medical groups helped CMS develop the new proposal.
"The proposed changes to documenting and coding for office visits will streamline reporting requirements, reduce note bloat, improve workflow, and contribute to a better environment for health care professionals and their Medicare patients," Harris said, highlighting an AMA website that offers background on the new approach to E/M documentation.
Ted Okon, executive director for the Community Oncology Alliance, also applauded the E/M changes.
"Instead of simply collapsing or reducing reimbursement for evaluation and management ... services as proposed in past years, CMS has realized that the complexity of cancer care is valuable, as is the expertise and time of the community oncologists who treat patients with complex cancers," he said in a press statement.
The changes to E/M coding were "in many ways ... what we were looking for," he told MedPage Today during a phone interview at which a press representative was present. However, "in reality CMS is more or less walking back a number of its own proposals," he added.
New primary care payment models are a good start, says Azar.
This story was first published on Tuesday, July 23, 2019, in MedPage Today.
ByJoyce Frieden,News Editor, MedPage Today July 23, 2019
WASHINGTON -- The way physicians are paid needs to become more "patient-centered," Health and Human Services Secretary Alex Azar said Tuesday.
"Sometimes 'patient-centered' can sound like a cliché, especially here in Washington," Azar said in a speech during a meeting of the Better Medicare Alliance, a trade group for Medicare Advantage plans. "But the way we pay physicians today truly is not patient-centered. Instead, it's procedure-centered, oriented around the Medicare physician fee schedule."
"In such a system, physicians aren't incentivized to help you stay healthy -- they're driven to order more procedures," said Azar. He recounted a story told by Marty Makary, MD, a surgeon at Johns Hopkins in Baltimore, who saw a strange practice at some health fairs he attended.
"Health professionals were meeting with older patients, doing tests, and asking them if they had any leg pain -- and who doesn't?" said Azar. "If they had leg pain, the doctor would suggest this might be a symptom of narrowing of the arteries -- and that can be easily fixed, they were told, with a stent or balloon. Makary was shocked to see this, because these surgeries aren't necessary as a preventive measure -- clinical best practices generally don't even recommend screening for the condition they address."
The patients were then signing up for these unnecessary procedures, "costing Medicare, and sometimes their own pocketbooks, thousands and thousands of dollars," he said. "There's a better way -- a system where the profitable path for physicians isn't more procedures, but better health for their patients." Azar was referring to the new Medicare primary care payment models that the Centers for Medicare & Medicaid Services rolled out in April; the models require doctors to assume varying levels of risks for their patients' healthcare costs.
The Trump administration also is working on improving coordination of care, he added. "One of the downsides to this Balkanized health IT [information technology] system is how time-consuming it can be to go from doctor to doctor. But the barriers to effective coordination among providers are much steeper than just excessive paperwork."
"In many cases, it doesn't matter how much paperwork doctors are willing to put up with," said Azar. "Coordinating care and sharing risk for outcomes among providers simply isn't allowed under the current interpretations of some statutes. Addressing these regulations that impede care coordination are part of a much broader regulatory reform effort at HHS. ... Last year, I had [HHS] Deputy Secretary Eric Hargan launch a regulatory sprint on examining barriers to coordinated care, which is getting very close to proposing new rules that will free up opportunities for information sharing, care coordination, and value creation."
Azar also continued the administration's attack on some Democrats' proposals for implementing a Medicare for All system. Currently, he said, 60 million people are enrolled in either Medicare or Medicare Advantage, 180 million people are in employer-sponsored private health plans, 70 million are enrolled in Medicaid, 10 million are in plans from the Affordable Care Act (ACA) heath insurance exchanges, and about 29 million are uninsured.
Azar hovered over the 10 million in the ACA exchange plans, which he pointed out represents only 3% of the healthcare system. "Many of them have suffered greatly, and we need to improve their experience -- but healthcare is much more than just Obamacare," he said. "The world is bigger than the debate over the Affordable Care Act."
Although most people are happy with their health insurance coverage, they see problems with it, and the Trump administration is working to fix them, Azar said. He emphasized that the administration "will always protect Americans with preexisting conditions -- a guarantee we will maintain at the federal level." He then discussed the administration's "new, affordable options" for people who buy individual insurance, including short-term, limited-duration plans; those plans are not required to include all the areas of coverage mandated by the ACA, such as mental health or maternity care benefits.
"We look forward to a day when Congress is willing to work with us to replace Obamacare for good, with affordability, options and control, and quality as the guiding principles," Azar said. In April, President Trump said the Republicans would become the "party of healthcare" and that congressional Republicans were developing a plan to replace the ACA; no such plan has yet been forthcoming.
Azar noted that the number of seniors choosing Medicare Advantage plans instead of traditional Medicare has been increasing, "yet some are proposing to expand the traditional Medicare program to cover all Americans, no matter their age, income, or circumstances. This is not only ignoring the lessons of our programs as they stand today -- it is also a path to undermining Medicare's promise and delivering fiscal ruin, doubling Americans' tax bills and increasing the size of the federal government by more than half."
"No American should ever lose his or her house because of their healthcare bills," he said. "But we have to provide that protection in a fiscally sustainable way."
Cigarette smoking is a greater risk factor for peripheral artery disease (PAD) than for coronary heart disease (CHD) and stroke, and that risk persists far longer than for the other atherosclerotic diseases after smoking cessation, researchers reported.
Current smokers in the prospective cohort study with a ≥35 pack-year cigarette history had more than double the adjusted risk for developing PAD compared with the other two diseases (adjusted hazard ratios of 5.56, 2.30, and 1.91 for PAD, CHD, and stroke, respectively), according to Kunihiro Matsushita, MD, PhD, of Johns Hopkins Bloomberg School of Public Health in Baltimore, and colleagues.
The analysis of data on more than 13,000 participants, with a median of 26 years of follow-up, in the Atherosclerosis Risk in Communities (ARIC) study is among the first to show the long-term impact of cigarette smoking and smoking cessation on each of the three major atherosclerotic diseases, they wrote in the Journal of the American College of Cardiology.
Quitting smoking was associated with the greatest reduction in risk for PAD, with an 80% lower risk seen ≥30 following cessation.
But smoking-related risk also remained elevated following cessation for a longer period -- roughly 3 decades versus 2 decades following cessation for CHD and 5 to 20 years for stroke, the authors reported.
Matsushita told MedPage Today that while the very strong association between smoking and PAD has long been recognized within the field of atherosclerotic medicine, it is not as well recognized outside the field.
"To my knowledge, this is the first study to prospectively quantify this risk in a single study population," he said. "Policy statements addressing smoking have mainly focused on the risk of coronary heart disease and stroke. The recognition that the impact of smoking is largest for peripheral artery disease should definitely be part of the conversation moving forward."
Matsushita added that younger smokers need to be made aware that their risk for PAD and the other atherosclerotic diseases can remain elevated for decades after they give up cigarettes.
"The impact of smoking on major artery disease may last up to 30 years," he said.
In an accompanying editorial, Nancy Rigotti, MD of Massachusetts General Hospital/Harvard Medical School in Boston, and Mary McDermott, MD, of Northwestern University Feinberg School of Medicine in Chicago, stated that "Overall, [the findings] reinforce the existing public health message for smokers: it is never too early or too late to benefit from quitting."
"It is never too late because of the relatively rapid reversal of cardiovascular disease risk after smoking cessation and never too early because complete risk reversal requires decades -- even longer for PAD than for myocardial infarction or stroke, as this report demonstrates," they wrote.
The study included 13,355 ARIC participants without PAD, CHD, or stroke at enrollment (from 1987 to 1989). Researchers evaluated the associations of pack years of smoking, duration of smoking, smoking intensity, and smoking cessation with incident PAD, contrasted with CHD and stroke via Cox modelling.
During a median follow-up of 26 years, a total of 492 PAD cases, 1,798 CHD cases, and 1,106 stroke cases were identified and a dose-response relationship was seen between pack-years of smoking and the three atherosclerotic diseases.
The authors reported that compared with never-smokers, people who smoked for ≥40 pack-years had approximately four-fold increased risk for PAD, 2.1-fold increased risk for CHD, and 1.8-fold increased risk for stroke.
Current smokers with ≥35 years of smoking duration showed hazard ratios of 5.56 (95% CI 4.26-7.26) for PAD, 2.30 (95% CI 1.98-2.66) for CHD, and 1.91 (95% CI 1.57-2.31) for stroke compared with never smokers.
Current smokers of ≥1 pack/day (higher intensity) had HRs of 5.36 (95% CI 4.1-6.91) for PAD, 2.38 (95% CI 2.08-2.73) for CHD, and 1.88 (95% CI 1.57-2.26) for stroke.
"There is a perception that (atherosclerotic) leg disease is less serious than heart or brain disease, but several recent studies have shown the prognostic impact of peripheral artery disease to be similar to CHD and stroke in terms of mortality and quality of life," Matsushita told MedPage Today.
Study limitations included the self-reporting to smoking status, and the possibility that mild PAD cases were missed because the ascertainment of PAD was based on hospitalization with PAD diagnosis or leg revascularization, according to the authors.
The ARIC study was funded by the National Heart, Lung, and Blood Institute (NHLBI) and the Department of Health and Human Services.
Matsushita disclosed support from the NHLBI and relevant relationships with Fukuda Denshi. Rigotti disclosed relevant relationships with Achieve Life Sciences and Pfizer. McDermott disclosed relevant relationships with Regeneron, the NHLBI, the National Institute on Aging, the American Heart Association, ChromaDex, Reserveage, Hershey, and ViroMed.