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    <recommendedItem id="20100101_19_377"
                     title="Advisory Panel Rates Genomic Cancer Tests"
                     score="0.009"
                     href="http://www.medpagetoday.com/PublicHealthPolicy/Medicare/tb/18269?impressionId=1265761309412"
                     
      &lt;p&gt;Some genomic tests aimed at identifying patients most likely to respond to cancer drugs won a thumbs-up from a Medicare advisory panel, but others didn&apos;t make the grade.&lt;/p&gt;
&lt;p&gt;As part of a national coverage determination under way at the Centers for Medicare and Medicaid Services, members of the Medicare Evidence Development &amp;amp; Coverage Advisory Committee (MEDCAC) last week rated the clinical value of several pharmacogenomic cancer tests now available.&lt;/p&gt;
&lt;p&gt;The tests would be used to select patients for treatment with drugs including tamoxifen, irinotecan (Camptosar), trastuzumab (Herceptin), and imatinib (Gleevec).&lt;/p&gt;
&lt;p&gt;CMS has not previously decided whether such tests should be reimbursed by Medicare, although testing is already routine for some of these treatments.&lt;/p&gt;
&lt;p&gt;The FDA-approved labeling for trastuzumab requires such testing. Imatinib&apos;s approvals include chronic myeloid leukemia featuring the BCR-ABL &quot;Philadelphia chromosome&quot; mutation, although the label doesn&apos;t explicitly mention testing.&lt;/p&gt;
&lt;p&gt;&quot;CMS is aware that the body of evidence on the role of pharmacogenomic testing in cancer continues to evolve,&quot; according to the agency&apos;s notice of the meeting.&lt;/p&gt;
&lt;p&gt;&quot;Recognizing the rapid accumulation of such evidence, CMS seeks guidance from the panel to inform future coverage determinations. We want to ensure that Medicare beneficiaries have access to any demonstrated improved health outcomes of pharmacogenomic testing, and are protected from inaccurate or inappropriate pharmacogenomic testing that could compromise therapy or increase the risks of adverse events during therapy.&quot;&lt;/p&gt;
&lt;p&gt;MEDCAC panelists were asked to rate their confidence in the clinical utility of five tests and in the scientific evidence available for review.&lt;/p&gt;
&lt;p&gt;The five tests cover: &lt;ul&gt; &lt;li&gt;Polymorphisms in the CYP2D6 drug-metabolizing enzyme for breast cancer patients who are candidates for tamoxifen&lt;/li&gt; &lt;li&gt;Polymorphisms in the UGT1A1 gene for colon cancer patients considered for irinotecan treatment&lt;/li&gt; &lt;li&gt;Presence of HER/neu epidermal growth factor receptor expression in patients with breast cancer, indicating suitability for trastuzumab&lt;/li&gt; &lt;li&gt;Presence of the BCR-ABL mutation in patients with chronic myeloid leukemia who would be candidates for imatinib&lt;/li&gt; &lt;li&gt;Mutations in the K-ras gene for metastatic colorectal cancer patients eligible for cetuximab (Erbitux) or panitumumab (Vectibix)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The 15 panel members assigned values of one to five, reflecting low to high confidence, to each test. A score of two reflected medium-low confidence, while a four meant medium-high confidence.&lt;/p&gt;
&lt;p&gt;Most of the panelists agreed that the evidence underlying the tests for CYP2D6 and UGT1A1 polymorphisms was still too scant for an assessment of their clinical value. Mean scores for these tests were 2.07 and 1.83, respectively, with nearly all votes either a one or two.&lt;/p&gt;
&lt;p&gt;But MEDCAC members were more confident that the usefulness of the other three tests for diagnostic and monitoring purposes could be evaluated. Mean scores for those tests were all well above four.&lt;/p&gt;
&lt;p&gt;For the HER/neu, BCR-ABL, and K-ras tests, since members believed the evidence was adequate for assessment, MEDCAC also voted on whether their use actually would improve health outcomes in cancer patients.&lt;/p&gt;
&lt;p&gt;A third ranking provided the committee&apos;s views on whether the conclusions could be generalized to the Medicare population and patients in the community.&lt;/p&gt;
&lt;p&gt;Mean scores for those rankings were all also above four, indicating the panel&apos;s support for these tests as clinically beneficial.&lt;/p&gt;
&lt;p&gt;On the other hand, when asked whether there was enough evidence to assess the utility of the BCR-ABL test in detecting treatment failure, panelists didn&apos;t think so. Most of those votes were twos, and the mean was 2.47.&lt;/p&gt;
&lt;p&gt;CMS has not given a time line for deciding whether to approve Medicare coverage for the tests.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_340"
                     title="Week 30: Obama Lashes Back at GOP Days After State of the Union"
                     score="0.006"
                     href="http://www.medpagetoday.com/Washington-Watch/Reform/tb/18223?impressionId=1265761309412"
                     
      &lt;p&gt;WASHINGTON  --  President Barack Obama chided Republicans on Friday for portraying healthcare reform as a &quot;Bolshevik plot&quot; in which the president is &quot;doing all kinds of crazy stuff that&apos;s going to destroy America.&quot;&lt;/p&gt;
&lt;p&gt;The accusation came when Obama addressed House Republicans at their annual policy retreat, where he urged the GOP to back away from hyperbolic rhetoric on healthcare.&lt;/p&gt;
&lt;p&gt;&quot;All I&apos;m saying is we&apos;ve got to close the gap a little bit between the rhetoric and the reality,&quot; he said during a question-and-answer session following his speech.&lt;/p&gt;
&lt;p&gt;&quot;I&apos;m not suggesting that we&apos;re going to agree on everything, whether it&apos;s on healthcare or energy or what have you, but if the way these issues are being presented by the Republicans is that this is some wild-eyed plot to impose huge government in every aspect of our lives, what happens is you guys then don&apos;t have a lot of room to negotiate with me.&quot;&lt;/p&gt;
&lt;p&gt;&quot;You&apos;ve given yourselves very little room to work in a bipartisan fashion because what you&apos;ve been telling your constituents is, &apos;This guy&apos;s doing all kinds of crazy stuff that&apos;s going to destroy America.&apos;&quot;&lt;/p&gt;
&lt;p&gt;But he appreciates opposition, Obama told the crowd.&lt;/p&gt;
&lt;p&gt;&quot;I&apos;m a big believer not just in the loyalty of opposition but in its necessity,&quot; Obama said. &quot;It&apos;s only through the process of disagreement and debate that bad ideas get tossed out and good ideas get refined and made better.&quot;&lt;/p&gt;
&lt;p&gt;He told the Republicans that his healthcare reform plan incorporates a number of GOP ideas, including allowing people to purchase insurance across state lines.&lt;/p&gt;
&lt;p&gt;House Republican Leader John Boehner (R-Ohio) presented Obama with a binder of their party&apos;s solutions to the nation&apos;s problems.&lt;/p&gt;
&lt;p&gt;&quot;I&apos;ve read your legislation,&quot; Obama said. &quot;I take a look at this stuff. And the good ideas we take.&quot; But, he said, &quot;It can&apos;t be all or nothing, one way or the other.&quot;&lt;/p&gt;
&lt;p&gt;Following the address and the question-and-answer period, House Republicans held a press conference, in which they thanked the president for agreeing to hold a conversation with them on their turf.&lt;/p&gt;
&lt;p&gt;&quot;Let me say, House Republican leaders are grateful for the president of the United States&apos; willingness to come in a freewheeling and open environment and have a frank and honest conversation about the future of this country, said Rep. Mike Pence (R-Ind.).&lt;/p&gt;
&lt;p&gt;But, as Boehner pointed out, willingness to engage does not equate to bi-partisan lawmaking.&lt;/p&gt;
&lt;p&gt;&quot;The president has always been willing to work a little more closely with us, but, really, it&apos;s never translated into real action on the Hill,&quot; he told reporters.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;State of the Union &lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;The GOP retreat came just two days after Obama addressed the nation in his first &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/18182&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/18182&quot; target=&quot;_blank&quot; title=&quot;&apos;Do&amp;#8200;Not&amp;#8200;Walk&amp;#8200;Away&amp;#8200;from&amp;#8200;Reform,&apos;&amp;#8200;Obama&amp;#8200;Urges&amp;#8200;Congress&quot;&gt;State of the Union address.&lt;/a&gt; The address was short on healthcare specifics and lacked a blueprint for jump starting the stalled healthcare reform legislation.&lt;/p&gt;
&lt;p&gt;&quot;Here&apos;s what I ask of Congress, though: Do not walk away from reform,&quot; the president said Wednesday night.&lt;/p&gt;
&lt;p&gt;&quot;Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people,&quot; he said, to a standing ovation from both Democrats and Republicans.&lt;/p&gt;
&lt;p&gt;The Jan. 19 &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Reform/18053&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Reform/18053&quot; target=&quot;_blank&quot; title=&quot;GOP&amp;#8200;Scores&amp;#8200;Win&amp;#8200;in&amp;#8200;Massachusetts&amp;#8200;Senate&amp;#8200;Race&quot;&gt;election&lt;/a&gt; of Massachusetts Republican Scott Brown to the U.S. Senate significantly altered the trajectory of healthcare reform. Now Democrats are regrouping, working on a strategy to pass reform legislation without a 60-vote majority in the Senate, and denying that there is any timeline for melding the measures passed by the &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/17679&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Washington-Watch/17679&quot; target=&quot;_blank&quot; title=&quot;Senate&amp;#8200;Passes&amp;#8200;Healthcare&amp;#8200;Reform&quot;&gt;Senate&lt;/a&gt; and the &lt;a href=&quot;http://www.medpagetoday.com/Washington-Watch/Reform/16847&quot; mce_href=&quot;http://www.medpagetoday.com/Washington-Watch/Reform/16847&quot; target=&quot;_blank&quot; title=&quot;House&amp;#8200;Passes&amp;#8200;Healthcare&amp;#8200;Reform&quot;&gt;House&lt;/a&gt;.&lt;/p&gt;
&lt;p&gt;&lt;strong&gt;Budget Due&lt;/p&gt;
&lt;p&gt;&lt;/strong&gt;&lt;/p&gt;
&lt;p&gt;Although healthcare reform may be in flux, the president is looking ahead, and will release on Monday his proposed 2011 budget, in which he will outline proposed allocations for the Department of Health and Human Services, including the Food and Drug Administration, the Centers for Medicare and Medicaid Services, and the National Institutes of Health.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20100101_19_309"
                     title="Increasing Copays: Penny-Wise but Pound-Foolish? (CME/CE)"
                     score="0.003"
                     href="http://www.medpagetoday.com/Geriatrics/GeneralGeriatrics/tb/18173?impressionId=1265761309412"
                     
      &lt;p&gt;Raising seniors&apos; copayments for ambulatory care to offset increasing healthcare costs may backfire on insurers, researchers asserted.&lt;/p&gt;
&lt;p&gt;Seniors enrolled in Medicare plans that increased copayments had significantly fewer outpatient visits but spent more time in the hospital than patients in plans that left copayments untouched, according to Amal Trivedi, MD, MPH, of Brown University in Providence, R.I., and colleagues.&lt;/p&gt;
&lt;p&gt;Assuming an average reimbursement of $60 for an outpatient visit, seven annual visits per enrollee, and an average copay increase of $8.50 per visit, a plan should save $7,150 for every 100 enrollees, they noted in the Jan. 28 &lt;em&gt;New England Journal of Medicine&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;But, assuming an average cost of $11,065 per hospitalization of a person 65 to 84, the researchers estimated that the costs for inpatient care would actually increase by $24,000 for every 100 enrollees in the year after copays are increased.&lt;/p&gt;
&lt;p&gt;Even using more conservative criteria, the increased costs for inpatient care would nearly double any savings from increasing copays, they argued.&lt;/p&gt;
&lt;p&gt;&quot;Cost-sharing has generally been thought to reduce total healthcare spending without harming health for the average person,&quot; the researchers wrote, but these results suggest increasing copays in Medicare beneficiaries &quot;may be a particularly ill-advised cost-containment strategy.&quot;&lt;/p&gt;
&lt;p&gt;Increasing copayments may be particularly harmful to older patients, they said, because they have lower incomes and are more likely to have poor health and greater out-of-pocket healthcare expenses than younger patients.&lt;/p&gt;
&lt;p&gt;To explore the issue in a Medicare population, Trivedi and colleagues compared the use of outpatient and inpatient care between enrollees in 18 plans that increased copays for ambulatory care and 18 that did not. The study included 899,060 patients.&lt;/p&gt;
&lt;p&gt;According to data from the Medicare Healthcare Effectiveness Data and Information Set from the Centers for Medicare and Medicaid Services, mean copays increased during the study period for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05) in the case plans.&lt;/p&gt;
&lt;p&gt;Mean copays remained stable at $8.33 and $11.38 for primary and specialty care, respectively, in the control plans.&lt;/p&gt;
&lt;p&gt;In both groups, there were increases in the number of ambulatory visits over time, but the increase was smaller in the plans that raised copays.&lt;/p&gt;
&lt;p&gt;There was also a rise in the number of hospitalizations, the proportion of patients who were hospitalized, and the length of time spent in the hospital in both groups, but there were larger increases in the plans that increased copays.&lt;/p&gt;
&lt;p&gt;Compared with the control plans, in the year after the increase in copays, case plans had: &lt;ul&gt; &lt;li&gt;19.8 fewer annual outpatient visits per 100 enrollees (95% CI 16.6 to 23.1)&lt;/li&gt; &lt;li&gt;2.2 additional annual hospital admissions per 100 enrollees (95% CI 1.8 to 2.6)&lt;/li&gt; &lt;li&gt;13.4 more annual inpatient days per 100 enrollees (95% CI 10.2 to 16.6)&lt;/li&gt; &lt;li&gt;A 0.7% increase in the proportion of enrollees who were hospitalized (95% CI 0.51% to 0.95%)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;The findings were amplified among enrollees living in areas of lower income and education, black patients, and those who had hypertension, diabetes, or a history of myocardial infarction.&lt;/p&gt;
&lt;p&gt;Trivedi and colleagues noted some limitations of the analysis: it was not randomized, and unmeasured differences could have influenced the results.&lt;/p&gt;
&lt;p&gt;Also, the case and control plans could not be matched in a geographic area smaller than census region because of the small number of Medicare plans, and data were lacking on diagnoses, procedures, and costs associated with hospital admissions and outpatient visits.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Trivedi is the recipient of a Pfizer Health Policy Scholars Award and a career development award from the Veterans Affairs Health Services Research and Development Services.&lt;/p&gt;&lt;p&gt;The authors reported no relevant conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_304"
                     title="&apos;Virtual&apos; Colon Scans Effective in Seniors (CME/CE)"
                     score="0.003"
                     href="http://www.medpagetoday.com/HematologyOncology/ColonCancer/tb/18164?impressionId=1265761309412"
                     
      Patients 65 and older are as suitable as younger individuals for CT colonography, said researchers conducting a large retrospective study.&lt;br&gt;
&lt;br&gt;Advanced neoplasias were detected with CT colonography  --  often called &quot;virtual colonoscopy&quot;  --  in older patients at more than double the rate in the general screening population, reported David H. Kim, MD, of the University of Wisconsin in Madison, Wis., and colleagues in the February issue of &lt;em&gt;Radiology&lt;/em&gt;.&lt;br&gt;
&lt;br&gt;They found that 7.6% of older patients had advanced neoplasias, compared with 3.2% of all patients screened in the university&apos;s clinic (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;On the basis of this and other findings in 577 individuals 65 and older versus the entire group of 3,120 patients undergoing the procedure, Kim and colleagues concluded that &quot;CT colonography performance is maintained in an older cohort.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Overall, the observations from this clinical experience confirm that CT colonography may be a valuable screening modality in the older population,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;On the other hand, the study did not address several objections raised by the Centers for Medicare and Medicaid Services (CMS) in its decision last year to deny Medicare coverage for the procedure. (See &lt;a href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/Medicare/14186&quot; mce_href=&quot;http://www.medpagetoday.com/PublicHealthPolicy/Medicare/14186&quot; target=&quot;_blank&quot;&gt;Medicare Finalizes Denial of Virtual Colonoscopy Coverage&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;CMS had pointed to relatively low sensitivity of CT colonography compared with optical colonoscopy in prospective trials, especially for small lesions.&lt;/p&gt;
&lt;p&gt;The agency also determined that CT colonography increased the costs of positive findings, since abnormalities in the CT scans must be confirmed with optical colonoscopy. In addition, CMS said there was no evidence to support claims that the less invasive imaging procedure would be more acceptable to patients and therefore would raise screening rates.&lt;/p&gt;
&lt;p&gt;The data analyzed by Kim and colleagues did not allow for calculations of false-negative rates or predictive values of positive or negative findings. Nor did the researchers report cost information.&lt;/p&gt;
&lt;p&gt;Mean age of their older cohort was 69.2 (SD 3.8). The oldest was 79.&lt;/p&gt;
&lt;p&gt;The researchers reported that 15.3% of the older patients were referred for optical colonoscopy on the basis of the CT results, compared with 7.9% of the overall screening group.&lt;/p&gt;
&lt;p&gt;Less than 4% of positive findings were determined to be false with the optical procedure (3.6% for polyps 6 to 10 mm in diameter, 2.1% for larger lesions).&lt;/p&gt;
&lt;p&gt;Of the 59 advanced neoplasias identified in the older patients, all but three were at least 10 mm in size.&lt;/p&gt;
&lt;p&gt;The scans also suggested abnormalities outside the colon in 89 (15.4%) patients. Of these, 45 received a full workup, which revealed substantial and previously unsuspected diagnoses in 21 cases  -- 18 were vascular aneurysms. The other three included one lung tumor, a femoral hernia, and a malrotation.&lt;/p&gt;
&lt;p&gt;Kim and colleagues reported that no &quot;substantial complications&quot; such as perforations or major hemorrhage occurred in the older patients, either with the CT scan or follow-up colonoscopy.&lt;/p&gt;
&lt;p&gt;They also indicated that the ratio of large to small neoplasias was similar in the older patients compared with their CT screening group as a whole. Histologic and morphologic findings were similar as well.&lt;/p&gt;
&lt;p&gt;The researchers cited the observational nature of the study, in which negative findings were not corroborated with optical colonoscopy, and its restriction to a single center as its main limitations.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;No external funding for the study was reported.&lt;/p&gt;&lt;p&gt;Kim and one co-author reported relationships with Viatronix and Medicsight and are co-founders of a company called VirtuoCTC, which produces educational materials on CT colonography.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_5_592"
                     title="McCain&apos;s Positions Put Him at Odds with Physician Readers"
                     score="-0.006"
                     href="