<?xml version="1.0" encoding="utf-8"?>
<recommendedContent xmlns="http://api.mspoke.com">
    <recommendedItem id="20100101_19_416"
                     title="For Diabetes, P4P Improves Patient Care, Outcomes (CME/CE)"
                     score="0.011"
                     href="http://www.medpagetoday.com/PracticeManagement/Reimbursement/tb/18328?impressionId=1265785162287"
                     
      &lt;p&gt;Measures of quality of care and clinical outcomes improved significantly when diabetic patients in a large private health plan were treated by physicians receiving pay-for-performance incentives, researchers said.&lt;/p&gt;
&lt;p&gt;The risk that diabetic patients would be hospitalized was 25% lower (incidence rate ratio 0.75, 95% CI 0.61 to 0.93) among those seen for three consecutive years by physicians who received extra pay for meeting quality-of-care targets, compared with the risk for patients whose physicians did not receive such incentives, reported Judy Ying Chen, MD, MSHS, of IMS Health in Woodland Hills, Calif., and colleagues.&lt;/p&gt;
&lt;p&gt;High-quality care  --  defined as receiving at least two tests for glycated hemoglobin (HbA1c) and one for LDL cholesterol during a given year  --  was delivered 16% more often by physicians in the pay-for-performance system (rate ratio 1.16, 95% CI 1.11 to 1.22), the researchers also reported online in the &lt;em&gt;American Journal of Managed Care&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;&quot;This study showed a robust, consistent, significant, and positive association between increased receipt of appropriate laboratory monitoring of A1c and LDL cholesterol levels and decreased hospitalization rates,&quot; Chen and colleagues declared.&lt;/p&gt;
&lt;p&gt;On the other hand, the researchers also found that quality of care diminished when patients saw multiple primary care physicians during a given year.&lt;/p&gt;
&lt;p&gt;&quot;This finding supports the hypothesis that patients have better outcomes when they have a medical home,&quot; Chen and colleagues indicated.&lt;/p&gt;
&lt;p&gt;The researchers examined records of diabetic patients enrolled with Hawaii Medical Services Association, a large preferred provider organization, from 1999 to 2006. The plan had about 19,600 such patients in 1999 and 32,365 in 2006.&lt;/p&gt;
&lt;p&gt;The plan offered physicians in the network the opportunity to earn bonuses of 1.5% to 7.5% of their base fees for meeting care-quality targets including HbA1c and LDL cholesterol testing of diabetic patients. Bonuses ranged from $10,000 to $16,000 annually. Starting in 2001, physicians could earn an extra $6,000 if their adherence to care-quality processes improved over the previous year.&lt;/p&gt;
&lt;p&gt;Bonuses were paid each year on the basis of administrative records for the previous year.&lt;/p&gt;
&lt;p&gt;The proportion of diabetic patients seen by physicians in the pay-for-performance plan increased from 78.7% in 1999 to 94.6% in 2006.&lt;/p&gt;
&lt;p&gt;As a result of the bonus structure, Chen and colleagues observed, improvements in care quality lagged implementation of these incentives by a year or two.&lt;/p&gt;
&lt;p&gt;The most substantial improvements in quality of care and patient outcomes were seen among patients seen continuously by a physician participating in the pay-for-performance system from 2004 to 2006.&lt;/p&gt;
&lt;p&gt;Compared with patients seen by physicians who chose not to participate in the system, those whose treatment was subject to the incentives were seen by primary care physicians and endocrinologists far more often: &lt;ul&gt; &lt;li&gt;Six to 10 outpatient visits in a year: odds ratio 2.16 (95% CI 2.00 to 2.33)&lt;/li&gt; &lt;li&gt;Eleven or more outpatient visits in a year: OR 2.35 (95% CI 2.14 to 2.57)&lt;/li&gt; &lt;li&gt;Visit to an endocrinologist: OR 1.56 (95% CI 1.38 to 1.75)&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;Among patients receiving quality care continuously from 2004 to 2006, the chance of being hospitalized in 2006 was reduced by 33% compared with patients whose care failed to meet the quality target at some point (rate ratio 0.67, 95% CI 0.61 to 0.75).&lt;/p&gt;
&lt;p&gt;But patients who saw more than two different primary care physicians in 2006 had a dramatically increased rate of hospitalizations (RR 6.13, 95% CI 5.33 to 7.04).&lt;/p&gt;
&lt;p&gt;Chen and colleagues noted several limitations to the study, including the fact that it was conducted in a PPO setting and might not be generalizable to health maintenance organizations or other frameworks.&lt;/p&gt;
&lt;p&gt;The researchers also had no data for years before the program started, leaving open the possibility that physicians participating in the pay-for-performance program were those who were already following treatment guidelines.&lt;/p&gt;
&lt;p&gt;The study also included only one clinical outcome; effects on others such as hypoglycemic episodes, cardiovascular events, and meeting HbA1c targets were not measured and might have been different.&lt;/p&gt;
&lt;p&gt;The researchers also acknowledged that the claims data underlying the study might not have been totally accurate, and they noted that it did not include other factors known to affect hospitalizations such as cardiovascular risk factors.&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;The study was funded by the Hawaii Medical Service Association, the health plan that was the focus of the work.&lt;/p&gt;&lt;p&gt;IMS Health is a healthcare consulting firm that, among other services, advises health insurers on performance and quality programs.&lt;/p&gt;&lt;p&gt;Several co-authors were employees of the Hawaii Medical Service Association, and officials of the group reviewed the manuscript before submission. But the authors declared that the association had no influence on the study design, analysis, or results reported. No other potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_19_3419"
                     title="AAO: CMS Payment Cuts for Eye Drug Called Counterproductive"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/AAO/tb/16639?impressionId=1265785162287"
                     
      &lt;p&gt;SAN FRANCISCO  --  The recent cut in Medicare reimbursement for intravitreal bevacizumab (Avastin) will hurt both patients and taxpayers by forcing a shift to more expensive options, according to American Academy of Ophthalmology officials.&lt;/p&gt;
&lt;p&gt;The rule change that went into effect on Oct. 1 created a code to account for the tiny doses used in ophthalmology, requiring practices to bill in 0.25 mg increments at $1.25 each.&lt;/p&gt;
&lt;p&gt;That dropped reimbursement for the standard 1.25-mg intravitreal dose from about $50 to $6.25.&lt;/p&gt;
&lt;p&gt;Reimbursement for its competitor ranibizumab (Lucentis)  --  a closely related molecule generally considered to have equal efficacy  --  remained unchanged at a whopping $2,039.&lt;/p&gt;
&lt;p&gt;Since ranibizumab costs under $2,000 for a single dose, ophthalmologists usually make around $120 with each injection.&lt;/p&gt;
&lt;p&gt;But even at the prior reimbursement level, they usually didn&apos;t profit from choosing bevacizumab.&lt;/p&gt;
&lt;p&gt;One vial of bevacizumab  --  originally developed for cancer treatment  --  contains more than one intravitreal dose, but drawing multiple doses from the same container almost doubles the risk of infection.&lt;/p&gt;
&lt;p&gt;So, compounding pharmacies divide up the drug into individual doses, repackage, and sterilize them  --  but at a price that typically pulled even with reimbursement before the Oct. 1 cut.&lt;/p&gt;
&lt;p&gt;So the new rule actually creates a disincentive for using the drug that has been estimated to save Medicare $1.5 billion each year in treating macular degeneration alone, said William Rich, MD, the medical director for health policy at the AAO.&lt;/p&gt;
&lt;p&gt;The AAO and other ophthalmology organizations immediately started negotiating for a change that would reflect compounding charges, he said.&lt;/p&gt;
&lt;p&gt;One argument for the new rule is that CMS cannot legally pay for pharmacist costs, but that&apos;s not true, according to Rich, who said it is allowed for some asthma and pain management treatments.&lt;/p&gt;
&lt;p&gt;Early talks were positive but led nowhere except to a Congressional inquiry, according to George Williams, MD, of William Beaumont Hospital in Royal Oak, Mich., and a member of the AAO Health Policy Committee.&lt;/p&gt;
&lt;p&gt;&quot;We thought we had a solution,&quot; he told retinal surgeons at the AAO meeting here. After daily talks with CMS, &quot;we were told two weeks ago it would be fixed. Two weeks have passed, and it is still not fixed.&quot;&lt;/p&gt;
&lt;p&gt;Sen. Herb Kohl, D-Wis., who chairs the Senate Committee on Aging, has demanded an explanation for the change and questioned the role of Genentech, which manufactures both drugs and would stand to gain financially from greater use of its more expensive product.&lt;/p&gt;
&lt;p&gt;The company has denied any part in the CMS decision, according to media reports. But Kohl has reportedly asked for a copy of all communication between CMS and Genentech.&lt;/p&gt; 
&lt;p&gt;CMS officials met with the Senate Committee on Aging today and said there were plans to rectify the situation with new coding rules expected to come out later this week.&lt;/p&gt;
&lt;p&gt;However, exactly what the changes would be and when they would occur remained unclear, according to Kohl&apos;s committee staff.&lt;/p&gt;
&lt;p&gt;However, Rich was skeptical that CMS would have a remedy in place soon.&lt;/p&gt;
&lt;p&gt;&quot;If the current policy is left in place, physicians lose, patients lose, and taxpayers lose,&quot; he said.&lt;/p&gt;
&lt;p&gt;He has already heard reports of some ophthalmologists switching to the more expensive drug in order to avoid losing money. Because most patients with conditions treated off-label with bevacizumab are on Medicare, their 20% copays have increased dramatically.&lt;/p&gt;
&lt;p&gt;&quot;Physicians who changed are getting tremendous pushback from patients,&quot; Rich said.&lt;/p&gt;
&lt;p&gt;He urged a quick solution to avoid the shift in practice patterns from becoming set. As of 2007, bevacizumab held about 60% of the market share.&lt;/p&gt;
&lt;p&gt;&quot;We&apos;re not interested in assigning blame, we just want to get it fixed&quot; Rich said.&lt;/p&gt;

    </recommendedItem>
    <recommendedItem id="20090101_19_3443"
                     title="AAO: Poor Clinic Management Tops Causes of Missed Glaucoma Visits (CME/CE)"
                     score="-0.005"
                     href="http://www.medpagetoday.com/MeetingCoverage/AAO/tb/16672?impressionId=1265785162287"
                     
      &lt;p&gt;SAN FRANCISCO  --  Long waits and other clinic management problems, and not finances, may underlie the majority of missed follow-up appointments for glaucoma in safety-net hospitals.&lt;/p&gt;
&lt;p&gt;Some 75% of patients at one county hospital said sitting too long in the waiting room  --  an average 2.3 hours  --  was the reason for missing visits, investigators reported here at the American Academy of Ophthalmology meeting.&lt;/p&gt;
&lt;p&gt;Only 12% cited cost as an issue, which was surprising, given the current economy and relatively needy population treated at the hospital, said Yohko Murakami, a medical student at Stanford University, who presented the results.&lt;/p&gt;
&lt;p&gt;These findings run counter to common assumptions among eye care providers &quot;that the primary reasons for poor follow-up are financial costs, insurance issues, or other personal or health issues that patients feel take precedence over their glaucoma care,&quot; the researchers said.&lt;/p&gt;
&lt;p&gt;One explanation might be that many patients were covered by a county outreach program that provided financial support, Murakami said.&lt;/p&gt;
&lt;p&gt;But even for other populations, finances might not be a major stumbling block because most glaucoma patients are covered by Medicare, said Steven Safran, MD, an eye surgeon in private practice in Lawrenceville, N.J., who was not involved in the study.&lt;/p&gt;
&lt;p&gt;Since glaucoma follow-up is often worse in medically underserved settings and critical to preventing blindness, the researchers conducted in-person interviews with patients at San Francisco General Hospital to see what their experience was.&lt;/p&gt;
&lt;p&gt;The 152 participants had established glaucoma treated at the center for at least one year and were matched by good versus poor follow-up.&lt;/p&gt;
&lt;p&gt;The reasons they cited as significant barriers to follow-up were: &lt;ul&gt; &lt;li&gt;Long waiting times in the clinic for 75%&lt;/li&gt; &lt;li&gt;Appointment scheduling difficulties for 38%&lt;/li&gt; &lt;li&gt;Medical comorbidities or other physical conditions for 29%&lt;/li&gt; &lt;li&gt;Issues with interpreters for 23%&lt;/li&gt; &lt;li&gt;Forgetting appointments for 16%&lt;/li&gt; &lt;li&gt;Financial costs for 12%&lt;/li&gt; &lt;li&gt;Inability to leave work responsibilities for 11%&lt;/li&gt; &lt;li&gt;Lack of escort for 10%&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;About half of the interviewed patients were proficient in English; the majority were non-Caucasian (22.4% black, 37.5% Latino, 27.0% Asian).&lt;/p&gt;
&lt;p&gt;Problems getting an interpreter were most common for Latinos (37%) and Asians (32%) but rare for blacks (3%) and Caucasians (0%), making race and ethnicity a significant factor (&lt;em&gt;P&lt;/em&gt;&lt;em&gt;&lt;/em&gt;=0.0001).&lt;/p&gt;
&lt;p&gt;This was notable given that San Francisco General regularly incorporates professional interpreters for its diverse population, Murakami said.&lt;/p&gt;
&lt;p&gt;Financial costs also tended to be disproportionately reported by Asian patients (22%) compared with the other ethnic and racial groups (&lt;em&gt;P&lt;/em&gt;=0.09).&lt;/p&gt;
&lt;p&gt;Murakami cautioned that the study&apos;s generalizability to private practices may be limited, and for other county hospitals, results would depend on the population and safety-net programs available locally.&lt;/p&gt;
&lt;p&gt;No matter what local circumstances are, listening to patients will go a long way toward addressing glaucoma follow-up problems, Murakami said. &quot;There are healthcare delivery issues that could be modifiable,&quot; she declared.&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;The study was supported by a fellowship from Stanford University School of Medicine and a National Eye Institute grant to the University of California San Francisco.&lt;/p&gt;&lt;p&gt;Murakami reported no conflicts of interest.&lt;/p&gt;&lt;p&gt;Safran provided no information on conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_3_288"
                     title="USPSYCH: From the Couch to the Laptop: The Age of Psychiatrist-Patient Email"
                     score="-0.006"
                     href="