Jane Anderson

For the most part, the Centers for Medicare and Medicaid Services followed the advice of the American Medical Association’s Specialty Society Relative Value Scale Update Committee when the agency decided how to update work values for Medicare’s physician fee schedule, according to a study published in the May issue of Health Affairs.

This reliance on the RUC’s recommendations didn’t penalize primary care physicians, because the CMS was more likely to decrease recommended work values for medical specialty, surgical, and radiologic services relative to evaluation and management services, the study’s authors said (Health Affairs 2012;31:965-72).

"However, it does not explain why there has been no reduction in the income gap between primary care providers and specialists," the authors wrote.

The authors, led by Miriam J. Laugesen, Ph.D., of the department of health policy and management at Columbia University in New York, analyzed the CMS’s decisions on updating work values for physician services between 1994 and 2010.

The analysis found that the CMS agreed with 2,419 (87.4%) of the RUC’s 2,768 work value recommendations. The CMS decreased 298 work values (10.8% of the total), and increased 51 work values (1.8% of the total).

The rate of agreement between the CMS and the RUC in 1994-2010 has fluctuated, and the investigators noted that "some of the largest year-to-year differences have occurred in more recent years, such as the high of 99% in 2006 and the low of 62.2% in 2007."

On average, the RUC recommended significantly higher work values than those ultimately accepted by the CMS, and the average work value for new services also was significantly higher in the committee’s recommendations than in the decisions ultimately made by the CMS, the study found.

Surgical services saw the widest gap between RUC recommendations and CMS decisions, whereas pathology and laboratory services saw the smallest gaps. The CMS decreased the committee’s recommended work values for radiology services by 2.7% and those for medical specialty services by 4.7%.

Based on the available data, the authors weren’t able to determine why the CMS agreed or disagreed with the recommendations made by the RUC, the authors said.

"One major question is whether primary care physicians are penalized in the process of updating physician work values," the study said. "It is not easy to answer that question, given that the Medicare fee schedule includes services provided by many different kinds of physicians."

Nevertheless, the authors noted that the CMS could strengthen the review and calculation process through "long-term investment in the agency’s ability to undertake research and analysis of issues such as how the effort and time associated with different physician services is determined, and which specialties – if any – receive higher payments than others as a result."

American Academy of Family Physicians president Glen Stream said in an interview that it wasn’t surprising that the study found a high level agreement between the RUC’s recommendations and the CMS’s ultimate decisions on physician work values. "I do think they [the study’s authors] got it right," Dr. Stream said. "I wouldn’t say this is new news, but it’s a more thorough analysis."

Regardless, the RUC process does advantage procedure-driven specialties over cognitive services provided by primary care physicians, Dr. Stream said, adding, "then those biases are more often than not simply accepted by CMS."

The AAFP supported federal legislation last year that would have required the CMS to compare data from independent contractors vs. those in the RUC recommendations, but the legislation went nowhere, Dr. Stream said. Currently, the academy isn’t advocating specifically for either the CMS or independent contractors to provide recommendations on work values, he said, "but we need more [than the RUC]. Particularly for primary care services, we need a different voice – an alternative methodology."

Dr. Laugesen is supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.

For the most part, the Centers for Medicare and Medicaid Services followed the advice of the American Medical Association’s Specialty Society Relative Value Scale Update Committee when the agency decided how to update work values for Medicare’s physician fee schedule, according to a study published in the May issue of Health Affairs.

This reliance on the RUC’s recommendations didn’t penalize primary care physicians, because the CMS was more likely to decrease recommended work values for medical specialty, surgical, and radiologic services relative to evaluation and management services, the study’s authors said (Health Affairs 2012;31:965-72).

"However, it does not explain why there has been no reduction in the income gap between primary care providers and specialists," the authors wrote.

The authors, led by Miriam J. Laugesen, Ph.D., of the department of health policy and management at Columbia University in New York, analyzed the CMS’s decisions on updating work values for physician services between 1994 and 2010.

The analysis found that the CMS agreed with 2,419 (87.4%) of the RUC’s 2,768 work value recommendations. The CMS decreased 298 work values (10.8% of the total), and increased 51 work values (1.8% of the total).

The rate of agreement between the CMS and the RUC in 1994-2010 has fluctuated, and the investigators noted that "some of the largest year-to-year differences have occurred in more recent years, such as the high of 99% in 2006 and the low of 62.2% in 2007."

On average, the RUC recommended significantly higher work values than those ultimately accepted by the CMS, and the average work value for new services also was significantly higher in the committee’s recommendations than in the decisions ultimately made by the CMS, the study found.

Surgical services saw the widest gap between RUC recommendations and CMS decisions, whereas pathology and laboratory services saw the smallest gaps. The CMS decreased the committee’s recommended work values for radiology services by 2.7% and those for medical specialty services by 4.7%.

Based on the available data, the authors weren’t able to determine why the CMS agreed or disagreed with the recommendations made by the RUC, the authors said.

"One major question is whether primary care physicians are penalized in the process of updating physician work values," the study said. "It is not easy to answer that question, given that the Medicare fee schedule includes services provided by many different kinds of physicians."

Nevertheless, the authors noted that the CMS could strengthen the review and calculation process through "long-term investment in the agency’s ability to undertake research and analysis of issues such as how the effort and time associated with different physician services is determined, and which specialties – if any – receive higher payments than others as a result."

American Academy of Family Physicians president Glen Stream said in an interview that it wasn’t surprising that the study found a high level agreement between the RUC’s recommendations and the CMS’s ultimate decisions on physician work values. "I do think they [the study’s authors] got it right," Dr. Stream said. "I wouldn’t say this is new news, but it’s a more thorough analysis."

Regardless, the RUC process does advantage procedure-driven specialties over cognitive services provided by primary care physicians, Dr. Stream said, adding, "then those biases are more often than not simply accepted by CMS."

The AAFP supported federal legislation last year that would have required the CMS to compare data from independent contractors vs. those in the RUC recommendations, but the legislation went nowhere, Dr. Stream said. Currently, the academy isn’t advocating specifically for either the CMS or independent contractors to provide recommendations on work values, he said, "but we need more [than the RUC]. Particularly for primary care services, we need a different voice – an alternative methodology."

Dr. Laugesen is supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.

For the most part, the Centers for Medicare and Medicaid Services followed the advice of the American Medical Association’s Specialty Society Relative Value Scale Update Committee when the agency decided how to update work values for Medicare’s physician fee schedule, according to a study published in the May issue of Health Affairs.

This reliance on the RUC’s recommendations didn’t penalize primary care physicians, because the CMS was more likely to decrease recommended work values for medical specialty, surgical, and radiologic services relative to evaluation and management services, the study’s authors said (Health Affairs 2012;31:965-72).

"However, it does not explain why there has been no reduction in the income gap between primary care providers and specialists," the authors wrote.

The authors, led by Miriam J. Laugesen, Ph.D., of the department of health policy and management at Columbia University in New York, analyzed the CMS’s decisions on updating work values for physician services between 1994 and 2010.

The analysis found that the CMS agreed with 2,419 (87.4%) of the RUC’s 2,768 work value recommendations. The CMS decreased 298 work values (10.8% of the total), and increased 51 work values (1.8% of the total).

The rate of agreement between the CMS and the RUC in 1994-2010 has fluctuated, and the investigators noted that "some of the largest year-to-year differences have occurred in more recent years, such as the high of 99% in 2006 and the low of 62.2% in 2007."

On average, the RUC recommended significantly higher work values than those ultimately accepted by the CMS, and the average work value for new services also was significantly higher in the committee’s recommendations than in the decisions ultimately made by the CMS, the study found.

Surgical services saw the widest gap between RUC recommendations and CMS decisions, whereas pathology and laboratory services saw the smallest gaps. The CMS decreased the committee’s recommended work values for radiology services by 2.7% and those for medical specialty services by 4.7%.

Based on the available data, the authors weren’t able to determine why the CMS agreed or disagreed with the recommendations made by the RUC, the authors said.

"One major question is whether primary care physicians are penalized in the process of updating physician work values," the study said. "It is not easy to answer that question, given that the Medicare fee schedule includes services provided by many different kinds of physicians."

Nevertheless, the authors noted that the CMS could strengthen the review and calculation process through "long-term investment in the agency’s ability to undertake research and analysis of issues such as how the effort and time associated with different physician services is determined, and which specialties – if any – receive higher payments than others as a result."

American Academy of Family Physicians president Glen Stream said in an interview that it wasn’t surprising that the study found a high level agreement between the RUC’s recommendations and the CMS’s ultimate decisions on physician work values. "I do think they [the study’s authors] got it right," Dr. Stream said. "I wouldn’t say this is new news, but it’s a more thorough analysis."

Regardless, the RUC process does advantage procedure-driven specialties over cognitive services provided by primary care physicians, Dr. Stream said, adding, "then those biases are more often than not simply accepted by CMS."

The AAFP supported federal legislation last year that would have required the CMS to compare data from independent contractors vs. those in the RUC recommendations, but the legislation went nowhere, Dr. Stream said. Currently, the academy isn’t advocating specifically for either the CMS or independent contractors to provide recommendations on work values, he said, "but we need more [than the RUC]. Particularly for primary care services, we need a different voice – an alternative methodology."

Dr. Laugesen is supported by a Robert Wood Johnson Foundation Investigator Award in Health Policy Research.

Solo, independent medical practice is going the way of the horse and buggy: Few hospitals are seeking solo physicians to practice in their communities, and more than three out of five physician searches feature hospital employment, according to a report by a national recruiting company. However, the popularity of primary care physicians continues unabated.

Of the 2,710 nationwide physician recruiting assignments for hospitals, medical groups, and other health care organizations handled by the search firm Merritt Hawkins from April 1, 2011, to March 23, 2012, only 1% – a total of 28 – involved searches for solo physicians. In 2004, 22% of the firm’s recruiting assignments were for solo practitioners.

"The recruitment of physicians into solo practice settings has almost entirely abated," the study concluded. Meanwhile, searches involving hospital employment rose to 63%, compared with 56% in 2011 and only 11% in 2004, the study said.

In addition, salaries have almost entirely replaced the income guarantees traditionally used to recruit private practice physicians, Merritt Hawkins said. Only 7% of physician search assignments conducted in 2011 and 2012 featured income guarantees, down from 21% in 2006-2007 and 41% in 2003-2004, the firm said.

Meanwhile, nearly three-quarters of search assignments conducted in 2011-2012 featured a salary with production bonus, and the majority of those bonuses are based on a Relative Value Units (RVU) formula, according to the study. However, a fast-growing number of production formulas – 35% of searches in 2011-2012 – featured quality-based metrics as opposed to RVU-based formulas.

Signing bonuses, relocation, and continuing medical education allowances continue to be standard in most physician recruitment incentive packages, the study said. In addition, about 5% of health care organizations are offering housing allowances to assist physicians in relocating.

Family physicians and general internists were Merritt Hawkins’ two most requested physician search assignments. Psychiatrists were third on the "most requested" list, hospitalists were fourth, and general surgeons were fifth, the study found.

"Pediatrics, a recruiting afterthought for many years, has risen steadily up the list of the firm’s most requested search assignments and was the ninth most requested assignment this year," the researchers wrote. In 2005-2006, pediatrics was not in the top 20, the report added.

Family practitioners, pediatricians, and psychiatrists were offered average salaries of $189,000 in 2011-2012, internists were expected to earn $203,000, hospitalists’ average salary was $221,000, and general surgeons were offered $343,000, according to the study. Orthopedic surgeons and invasive cardiologists could expect to earn the highest average salaries: $519,000 and $512,000, respectively.

Solo, independent medical practice is going the way of the horse and buggy: Few hospitals are seeking solo physicians to practice in their communities, and more than three out of five physician searches feature hospital employment, according to a report by a national recruiting company. However, the popularity of primary care physicians continues unabated.

Of the 2,710 nationwide physician recruiting assignments for hospitals, medical groups, and other health care organizations handled by the search firm Merritt Hawkins from April 1, 2011, to March 23, 2012, only 1% – a total of 28 – involved searches for solo physicians. In 2004, 22% of the firm’s recruiting assignments were for solo practitioners.

"The recruitment of physicians into solo practice settings has almost entirely abated," the study concluded. Meanwhile, searches involving hospital employment rose to 63%, compared with 56% in 2011 and only 11% in 2004, the study said.

In addition, salaries have almost entirely replaced the income guarantees traditionally used to recruit private practice physicians, Merritt Hawkins said. Only 7% of physician search assignments conducted in 2011 and 2012 featured income guarantees, down from 21% in 2006-2007 and 41% in 2003-2004, the firm said.

Meanwhile, nearly three-quarters of search assignments conducted in 2011-2012 featured a salary with production bonus, and the majority of those bonuses are based on a Relative Value Units (RVU) formula, according to the study. However, a fast-growing number of production formulas – 35% of searches in 2011-2012 – featured quality-based metrics as opposed to RVU-based formulas.

Signing bonuses, relocation, and continuing medical education allowances continue to be standard in most physician recruitment incentive packages, the study said. In addition, about 5% of health care organizations are offering housing allowances to assist physicians in relocating.

Family physicians and general internists were Merritt Hawkins’ two most requested physician search assignments. Psychiatrists were third on the "most requested" list, hospitalists were fourth, and general surgeons were fifth, the study found.

"Pediatrics, a recruiting afterthought for many years, has risen steadily up the list of the firm’s most requested search assignments and was the ninth most requested assignment this year," the researchers wrote. In 2005-2006, pediatrics was not in the top 20, the report added.

Family practitioners, pediatricians, and psychiatrists were offered average salaries of $189,000 in 2011-2012, internists were expected to earn $203,000, hospitalists’ average salary was $221,000, and general surgeons were offered $343,000, according to the study. Orthopedic surgeons and invasive cardiologists could expect to earn the highest average salaries: $519,000 and $512,000, respectively.

Solo, independent medical practice is going the way of the horse and buggy: Few hospitals are seeking solo physicians to practice in their communities, and more than three out of five physician searches feature hospital employment, according to a report by a national recruiting company. However, the popularity of primary care physicians continues unabated.

Of the 2,710 nationwide physician recruiting assignments for hospitals, medical groups, and other health care organizations handled by the search firm Merritt Hawkins from April 1, 2011, to March 23, 2012, only 1% – a total of 28 – involved searches for solo physicians. In 2004, 22% of the firm’s recruiting assignments were for solo practitioners.

"The recruitment of physicians into solo practice settings has almost entirely abated," the study concluded. Meanwhile, searches involving hospital employment rose to 63%, compared with 56% in 2011 and only 11% in 2004, the study said.

In addition, salaries have almost entirely replaced the income guarantees traditionally used to recruit private practice physicians, Merritt Hawkins said. Only 7% of physician search assignments conducted in 2011 and 2012 featured income guarantees, down from 21% in 2006-2007 and 41% in 2003-2004, the firm said.

Meanwhile, nearly three-quarters of search assignments conducted in 2011-2012 featured a salary with production bonus, and the majority of those bonuses are based on a Relative Value Units (RVU) formula, according to the study. However, a fast-growing number of production formulas – 35% of searches in 2011-2012 – featured quality-based metrics as opposed to RVU-based formulas.

Signing bonuses, relocation, and continuing medical education allowances continue to be standard in most physician recruitment incentive packages, the study said. In addition, about 5% of health care organizations are offering housing allowances to assist physicians in relocating.

Family physicians and general internists were Merritt Hawkins’ two most requested physician search assignments. Psychiatrists were third on the "most requested" list, hospitalists were fourth, and general surgeons were fifth, the study found.

"Pediatrics, a recruiting afterthought for many years, has risen steadily up the list of the firm’s most requested search assignments and was the ninth most requested assignment this year," the researchers wrote. In 2005-2006, pediatrics was not in the top 20, the report added.

Family practitioners, pediatricians, and psychiatrists were offered average salaries of $189,000 in 2011-2012, internists were expected to earn $203,000, hospitalists’ average salary was $221,000, and general surgeons were offered $343,000, according to the study. Orthopedic surgeons and invasive cardiologists could expect to earn the highest average salaries: $519,000 and $512,000, respectively.

The incentives offered for early adopters of the various electronic health initiatives promulgated by the Centers for Medicare and Medicaid Services are expected to transition into penalties within the next 2-3 years.

Currently, the Electronic Prescribing, or eRx, program offers both incentives and penalties. However, the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) programs, which still offer incentives for participating, will transition to penalties by 2015.

The EHR incentive program authorized up to $27 billion for incentive payments to hospitals and physicians for "meaningful use" of a qualified electronic health record. Surgeons and other physicians qualifying for the first time last year and this year could receive up to $18,000 in the first year and annual payments through 2016 totaling $44,000.

During 2013 and 2014, there will be a reduced incentive for initial qualification, and beginning in 2015, failure to demonstrate meaningful use will lead to a penalty of 1% in Medicare reimbursement. That penalty increases to 2% in 2016 and to 3% for 2017 and beyond.

Dr. Margaret Tracci, a vascular surgeon at the University of Virginia Health System who has analyzed these programs and their potential effects on surgeons, projects that penalties for surgeons who don't meet the requirements for any of the programs could reach 5.5% in 2018.

The overall emphasis on primary care in the initial program rollouts may have made surgeons less attuned to the concept of electronic reporting and record-keeping, according to Dr. Don Detmer, medical director of the American College of Surgeons (ACS) Division of Advocacy and Health Policy. "It let some surgeons think they could put it off," he said in an interview. "We started out with some carrots, but the carrots are becoming sticks. Still, it's not like this hasn't been known from the beginning."

Ways to Participate

The ACS doesn't have a good sense of how many surgeons and which types of practices aren't prepared for these programs to transition to penalties. Nonetheless, EHR adoption may have outpaced adoption of the PQRS and eRx, because many surgeons are using some form of electronic health record, according to Dr. Tracci. There's less participation in electronic prescribing programs or in PQRS as of yet, she said.

PQRS, which began in 2007 as an incentive program for voluntary reporting of quality measures, will transition into penalties for nonparticipants beginning in 2015. Surgeons who don't report data for PQRS will be hit by a 1.5% Medicare reimbursement penalty in 2015 and a 2% penalty in 2016. Conversely, there's a 0.5% incentive available for Maintenance of Certification (MOC) for those who participate in PQRS through a qualified entity.

Surgeons and other "individual eligible professionals" may report selected measures by several mechanisms, including claims-based, registry-based, or EHR-based mechanisms. There's also a group practice reporting option, although the deadline already has passed for groups to select this option.

For PQRS, "there are three registries surgeons can use to participate now [but] we really are on our own collecting and submitting data," Dr. Tracci said. Several hundred institutions nationwide have formed their own registries, she added.

A 2009 CMS report indicated that surgeons are far more likely to report PQRS data when they participate in their own group's registry. However, there are no recent data indicating just how many surgeons are participating, according to the ACS.

The electronic prescribing, or eRx, incentive program provides an incentive to use a qualifying electronic health record to generate and transmit eligible prescriptions for Medicare beneficiaries. This program begins transitioning to its penalty phase this year.

To avoid penalties, individuals and groups must generate a set amount of e-prescriptions. "In practice, it has been much harder for surgeons to meet the requirements than primary care physicians," said Dr. Tracci.

Pay Now or Pay Later

EHR programs are admittedly expensive to implement, but the penalties for failing to do so can add up into the millions over the life of the program for a physician group of several hundred surgeons and other doctors, Dr. Tracci noted.

While her group at the University of Virginia is "in a position to do this" and maintains an EHR system that meets meaningful use requirements, she said, most practicing surgeons are in smaller groups, and will have a tougher time implementing EHR. And some practices have invested in EHR, only to find that the product they've chosen doesn't suit them and they need to switch. "That is incredibly costly, and also costly in terms of productivity," Dr. Tracci said.

Many enterprise-wide EHR products "are not well suited for subspecialty data requirements," noted Dr. Detmer. "When you get right down to it, when you put in an EHR, it's not about electronics, it's about changing the way you work. Once you make the transition -- and it usually takes a couple of months -- most folks would rather not go back."

The ACS is getting more engaged in an effort to help surgeons cope with the deadlines, he added. Surgeons who haven't started on any of these programs first should carefully analyze the reporting periods for all of the incentives and penalties when prioritizing which program to begin first, according to information provided by the ACS health policy division. "For example, this is the last year you can begin the stage 1 of the EHR incentive program to be eligible to receive the full incentive bonus of $44,000. The first 6 months of the year is also one of the reporting periods to avoid getting the 2013 eRx payment penalty," according to the ACS.

The time and money involved also should play a role in decision making. Keep in mind that the eRx and PQRS programs both have relatively low start-up costs, and do not take a long time to begin.

More Information

The ACS provides information focused on each quality program -- eRx, HER, and PQRS -- where surgeons can find resources such as flow charts and step-by-step guides to help lead them through the process of implementation:

-- ACS Division of Advocacy and Health Policy: www.facs.org/ahp/index.html

-- EHR: www.facs.org/ahp/ehr/index.html

-- eRx: www.facs.org/ahp/erx.html; www.facs.org/ahp/erx-exemption.pdf

-- PQRS: www.facs.org/ahp/pqri/index.html

However, "if you get into this, you will need to have someone in your group really spend some time with it," Dr. Detmer cautioned. In addition, he noted that there can be long waits for installation of popular products, which surgeons need to keep in mind while considering when the EHRs need to be operational to avoid CMS penalties.

In general, institutions are much further ahead on EHRs than are surgeons practicing solo or in small groups, Dr. Detmer said. "Most people who are in an institution or large system are typically well into this at this point," he said. "If they haven't made the move to [electronic] order entry, they're doing it right now."

In institution-wide efforts involving multiple specialties, "surgeons don't necessarily have to lead, but surgeons will need a champion as part of the process," he added.

With the new subspecialty certification in medical informatics now available, "there really is a need for some young surgeons to decide they need to be part surgeon, part informatician," Dr. Detmer said. "We have some good surgeons involved in this, but not the numbers we need."

The incentives offered for early adopters of the various electronic health initiatives promulgated by the Centers for Medicare and Medicaid Services are expected to transition into penalties within the next 2-3 years.

Currently, the Electronic Prescribing, or eRx, program offers both incentives and penalties. However, the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) programs, which still offer incentives for participating, will transition to penalties by 2015.

The EHR incentive program authorized up to $27 billion for incentive payments to hospitals and physicians for "meaningful use" of a qualified electronic health record. Surgeons and other physicians qualifying for the first time last year and this year could receive up to $18,000 in the first year and annual payments through 2016 totaling $44,000.

During 2013 and 2014, there will be a reduced incentive for initial qualification, and beginning in 2015, failure to demonstrate meaningful use will lead to a penalty of 1% in Medicare reimbursement. That penalty increases to 2% in 2016 and to 3% for 2017 and beyond.

Dr. Margaret Tracci, a vascular surgeon at the University of Virginia Health System who has analyzed these programs and their potential effects on surgeons, projects that penalties for surgeons who don't meet the requirements for any of the programs could reach 5.5% in 2018.

The overall emphasis on primary care in the initial program rollouts may have made surgeons less attuned to the concept of electronic reporting and record-keeping, according to Dr. Don Detmer, medical director of the American College of Surgeons (ACS) Division of Advocacy and Health Policy. "It let some surgeons think they could put it off," he said in an interview. "We started out with some carrots, but the carrots are becoming sticks. Still, it's not like this hasn't been known from the beginning."

Ways to Participate

The ACS doesn't have a good sense of how many surgeons and which types of practices aren't prepared for these programs to transition to penalties. Nonetheless, EHR adoption may have outpaced adoption of the PQRS and eRx, because many surgeons are using some form of electronic health record, according to Dr. Tracci. There's less participation in electronic prescribing programs or in PQRS as of yet, she said.

PQRS, which began in 2007 as an incentive program for voluntary reporting of quality measures, will transition into penalties for nonparticipants beginning in 2015. Surgeons who don't report data for PQRS will be hit by a 1.5% Medicare reimbursement penalty in 2015 and a 2% penalty in 2016. Conversely, there's a 0.5% incentive available for Maintenance of Certification (MOC) for those who participate in PQRS through a qualified entity.

Surgeons and other "individual eligible professionals" may report selected measures by several mechanisms, including claims-based, registry-based, or EHR-based mechanisms. There's also a group practice reporting option, although the deadline already has passed for groups to select this option.

For PQRS, "there are three registries surgeons can use to participate now [but] we really are on our own collecting and submitting data," Dr. Tracci said. Several hundred institutions nationwide have formed their own registries, she added.

A 2009 CMS report indicated that surgeons are far more likely to report PQRS data when they participate in their own group's registry. However, there are no recent data indicating just how many surgeons are participating, according to the ACS.

The electronic prescribing, or eRx, incentive program provides an incentive to use a qualifying electronic health record to generate and transmit eligible prescriptions for Medicare beneficiaries. This program begins transitioning to its penalty phase this year.

To avoid penalties, individuals and groups must generate a set amount of e-prescriptions. "In practice, it has been much harder for surgeons to meet the requirements than primary care physicians," said Dr. Tracci.

Pay Now or Pay Later

EHR programs are admittedly expensive to implement, but the penalties for failing to do so can add up into the millions over the life of the program for a physician group of several hundred surgeons and other doctors, Dr. Tracci noted.

While her group at the University of Virginia is "in a position to do this" and maintains an EHR system that meets meaningful use requirements, she said, most practicing surgeons are in smaller groups, and will have a tougher time implementing EHR. And some practices have invested in EHR, only to find that the product they've chosen doesn't suit them and they need to switch. "That is incredibly costly, and also costly in terms of productivity," Dr. Tracci said.

Many enterprise-wide EHR products "are not well suited for subspecialty data requirements," noted Dr. Detmer. "When you get right down to it, when you put in an EHR, it's not about electronics, it's about changing the way you work. Once you make the transition -- and it usually takes a couple of months -- most folks would rather not go back."

The ACS is getting more engaged in an effort to help surgeons cope with the deadlines, he added. Surgeons who haven't started on any of these programs first should carefully analyze the reporting periods for all of the incentives and penalties when prioritizing which program to begin first, according to information provided by the ACS health policy division. "For example, this is the last year you can begin the stage 1 of the EHR incentive program to be eligible to receive the full incentive bonus of $44,000. The first 6 months of the year is also one of the reporting periods to avoid getting the 2013 eRx payment penalty," according to the ACS.

The time and money involved also should play a role in decision making. Keep in mind that the eRx and PQRS programs both have relatively low start-up costs, and do not take a long time to begin.

More Information

The ACS provides information focused on each quality program -- eRx, HER, and PQRS -- where surgeons can find resources such as flow charts and step-by-step guides to help lead them through the process of implementation:

-- ACS Division of Advocacy and Health Policy: www.facs.org/ahp/index.html

-- EHR: www.facs.org/ahp/ehr/index.html

-- eRx: www.facs.org/ahp/erx.html; www.facs.org/ahp/erx-exemption.pdf

-- PQRS: www.facs.org/ahp/pqri/index.html

However, "if you get into this, you will need to have someone in your group really spend some time with it," Dr. Detmer cautioned. In addition, he noted that there can be long waits for installation of popular products, which surgeons need to keep in mind while considering when the EHRs need to be operational to avoid CMS penalties.

In general, institutions are much further ahead on EHRs than are surgeons practicing solo or in small groups, Dr. Detmer said. "Most people who are in an institution or large system are typically well into this at this point," he said. "If they haven't made the move to [electronic] order entry, they're doing it right now."

In institution-wide efforts involving multiple specialties, "surgeons don't necessarily have to lead, but surgeons will need a champion as part of the process," he added.

With the new subspecialty certification in medical informatics now available, "there really is a need for some young surgeons to decide they need to be part surgeon, part informatician," Dr. Detmer said. "We have some good surgeons involved in this, but not the numbers we need."

The incentives offered for early adopters of the various electronic health initiatives promulgated by the Centers for Medicare and Medicaid Services are expected to transition into penalties within the next 2-3 years.

Currently, the Electronic Prescribing, or eRx, program offers both incentives and penalties. However, the Electronic Health Record (EHR) and Physician Quality Reporting System (PQRS) programs, which still offer incentives for participating, will transition to penalties by 2015.

The EHR incentive program authorized up to $27 billion for incentive payments to hospitals and physicians for "meaningful use" of a qualified electronic health record. Surgeons and other physicians qualifying for the first time last year and this year could receive up to $18,000 in the first year and annual payments through 2016 totaling $44,000.

During 2013 and 2014, there will be a reduced incentive for initial qualification, and beginning in 2015, failure to demonstrate meaningful use will lead to a penalty of 1% in Medicare reimbursement. That penalty increases to 2% in 2016 and to 3% for 2017 and beyond.

Dr. Margaret Tracci, a vascular surgeon at the University of Virginia Health System who has analyzed these programs and their potential effects on surgeons, projects that penalties for surgeons who don't meet the requirements for any of the programs could reach 5.5% in 2018.

The overall emphasis on primary care in the initial program rollouts may have made surgeons less attuned to the concept of electronic reporting and record-keeping, according to Dr. Don Detmer, medical director of the American College of Surgeons (ACS) Division of Advocacy and Health Policy. "It let some surgeons think they could put it off," he said in an interview. "We started out with some carrots, but the carrots are becoming sticks. Still, it's not like this hasn't been known from the beginning."

Ways to Participate

The ACS doesn't have a good sense of how many surgeons and which types of practices aren't prepared for these programs to transition to penalties. Nonetheless, EHR adoption may have outpaced adoption of the PQRS and eRx, because many surgeons are using some form of electronic health record, according to Dr. Tracci. There's less participation in electronic prescribing programs or in PQRS as of yet, she said.

PQRS, which began in 2007 as an incentive program for voluntary reporting of quality measures, will transition into penalties for nonparticipants beginning in 2015. Surgeons who don't report data for PQRS will be hit by a 1.5% Medicare reimbursement penalty in 2015 and a 2% penalty in 2016. Conversely, there's a 0.5% incentive available for Maintenance of Certification (MOC) for those who participate in PQRS through a qualified entity.

Surgeons and other "individual eligible professionals" may report selected measures by several mechanisms, including claims-based, registry-based, or EHR-based mechanisms. There's also a group practice reporting option, although the deadline already has passed for groups to select this option.

For PQRS, "there are three registries surgeons can use to participate now [but] we really are on our own collecting and submitting data," Dr. Tracci said. Several hundred institutions nationwide have formed their own registries, she added.

A 2009 CMS report indicated that surgeons are far more likely to report PQRS data when they participate in their own group's registry. However, there are no recent data indicating just how many surgeons are participating, according to the ACS.

The electronic prescribing, or eRx, incentive program provides an incentive to use a qualifying electronic health record to generate and transmit eligible prescriptions for Medicare beneficiaries. This program begins transitioning to its penalty phase this year.

To avoid penalties, individuals and groups must generate a set amount of e-prescriptions. "In practice, it has been much harder for surgeons to meet the requirements than primary care physicians," said Dr. Tracci.

Pay Now or Pay Later

EHR programs are admittedly expensive to implement, but the penalties for failing to do so can add up into the millions over the life of the program for a physician group of several hundred surgeons and other doctors, Dr. Tracci noted.

While her group at the University of Virginia is "in a position to do this" and maintains an EHR system that meets meaningful use requirements, she said, most practicing surgeons are in smaller groups, and will have a tougher time implementing EHR. And some practices have invested in EHR, only to find that the product they've chosen doesn't suit them and they need to switch. "That is incredibly costly, and also costly in terms of productivity," Dr. Tracci said.

Many enterprise-wide EHR products "are not well suited for subspecialty data requirements," noted Dr. Detmer. "When you get right down to it, when you put in an EHR, it's not about electronics, it's about changing the way you work. Once you make the transition -- and it usually takes a couple of months -- most folks would rather not go back."

The ACS is getting more engaged in an effort to help surgeons cope with the deadlines, he added. Surgeons who haven't started on any of these programs first should carefully analyze the reporting periods for all of the incentives and penalties when prioritizing which program to begin first, according to information provided by the ACS health policy division. "For example, this is the last year you can begin the stage 1 of the EHR incentive program to be eligible to receive the full incentive bonus of $44,000. The first 6 months of the year is also one of the reporting periods to avoid getting the 2013 eRx payment penalty," according to the ACS.

The time and money involved also should play a role in decision making. Keep in mind that the eRx and PQRS programs both have relatively low start-up costs, and do not take a long time to begin.

More Information

The ACS provides information focused on each quality program -- eRx, HER, and PQRS -- where surgeons can find resources such as flow charts and step-by-step guides to help lead them through the process of implementation:

-- ACS Division of Advocacy and Health Policy: www.facs.org/ahp/index.html

-- EHR: www.facs.org/ahp/ehr/index.html

-- eRx: www.facs.org/ahp/erx.html; www.facs.org/ahp/erx-exemption.pdf

-- PQRS: www.facs.org/ahp/pqri/index.html

However, "if you get into this, you will need to have someone in your group really spend some time with it," Dr. Detmer cautioned. In addition, he noted that there can be long waits for installation of popular products, which surgeons need to keep in mind while considering when the EHRs need to be operational to avoid CMS penalties.

In general, institutions are much further ahead on EHRs than are surgeons practicing solo or in small groups, Dr. Detmer said. "Most people who are in an institution or large system are typically well into this at this point," he said. "If they haven't made the move to [electronic] order entry, they're doing it right now."

In institution-wide efforts involving multiple specialties, "surgeons don't necessarily have to lead, but surgeons will need a champion as part of the process," he added.

With the new subspecialty certification in medical informatics now available, "there really is a need for some young surgeons to decide they need to be part surgeon, part informatician," Dr. Detmer said. "We have some good surgeons involved in this, but not the numbers we need."

Primary care providers and the public health system need to better coordinate their efforts to prevent disease and injury, promote health and well-being and provide timely, effective health care, according to an Institute of Medicine-appointed committee that wrote a blueprint for public-provider partnership.

The current lack of integration between primary care and public health "is a big problem," according to the committee’s leader, Dr. Paul Wallace, an internist and senior vice president at The Lewin Group. "But it also may be at the core of how we look at health care moving forward."

At the heart of the blueprint are five principles that the committee said are essential for successful integration of primary care and public health efforts: a shared goal of population health improvement; community engagement in defining and addressing population health needs; aligned leadership across disciplines, programs, and jurisdictions that works towards changes in the system; sustainability, including a shared infrastructure between primary care and public health; and the sharing and collaborative use of data and analysis.

The Committee on Integrating Primary Care and Public Health identified a number of examples of successful integration efforts, and found they had several common elements. For example, many targeted a specific health issue that was identified as a community area of concern, such as chronic disease, or the health needs of a specific population.

None of these successful initiatives took place on the federal level, instead, they were concentrated on state and local levels, Dr. Wallace noted. Successful initiatives "have a strategic view from the beginning," along with a plan to "get beyond pilot funding" and make the funding stream sustainable, he said.

One example cited was an effort by the Michigan Department of Community Health, which formed six independent regional networks that partner with and support providers, business and community groups to improve diabetes care. The program, which according to the IOM has demonstrated improved health outcomes for Michigan residents with diabetes, has created public awareness campaigns and developed systems for medical practices to use to promote adherence to established care guidelines.

The committee also laid out a detailed blueprint for more coordinated efforts among federal agencies, including the Health Resources and Services Administration (HRSA), Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services.

Specifically, HRSA-supported public health departments could integrate efforts in three specific areas: the Maternal, Infant, and Early Childhood Home Visiting Program; cardiovascular disease prevention; and colorectal cancer screening.

It noted that HRSA and CDC have very different organizational structures, a problem that creates logistical barriers to partnerships. Nonetheless, it recommended that the two agencies develop joint projects to enhance public health; evaluate existing projects and develop new initiatives involving integrated primary care and public health.

The agencies were also advised to work with CMS to identify regulatory options for graduate medical education funding that give priority to provide training in primary care and public health settings. Furthermore, they were advised to work together to develop training grants and teaching tools to prepare the next generation of health professionals for more integrated clinical and public health functions in practice.

The current lack of integration between primary care and public health "is a big problem," said Dr. Wallace. "But it also may be at the core of how we look at health care moving forward."

The 17-member committee was convened in early 2011 at the request of HRSA and the CDC.

Funding for the effort was provided by HRSA, CDC, and the UnitedHealth Foundation.

Primary care providers and the public health system need to better coordinate their efforts to prevent disease and injury, promote health and well-being and provide timely, effective health care, according to an Institute of Medicine-appointed committee that wrote a blueprint for public-provider partnership.

The current lack of integration between primary care and public health "is a big problem," according to the committee’s leader, Dr. Paul Wallace, an internist and senior vice president at The Lewin Group. "But it also may be at the core of how we look at health care moving forward."

At the heart of the blueprint are five principles that the committee said are essential for successful integration of primary care and public health efforts: a shared goal of population health improvement; community engagement in defining and addressing population health needs; aligned leadership across disciplines, programs, and jurisdictions that works towards changes in the system; sustainability, including a shared infrastructure between primary care and public health; and the sharing and collaborative use of data and analysis.

The Committee on Integrating Primary Care and Public Health identified a number of examples of successful integration efforts, and found they had several common elements. For example, many targeted a specific health issue that was identified as a community area of concern, such as chronic disease, or the health needs of a specific population.

None of these successful initiatives took place on the federal level, instead, they were concentrated on state and local levels, Dr. Wallace noted. Successful initiatives "have a strategic view from the beginning," along with a plan to "get beyond pilot funding" and make the funding stream sustainable, he said.

One example cited was an effort by the Michigan Department of Community Health, which formed six independent regional networks that partner with and support providers, business and community groups to improve diabetes care. The program, which according to the IOM has demonstrated improved health outcomes for Michigan residents with diabetes, has created public awareness campaigns and developed systems for medical practices to use to promote adherence to established care guidelines.

The committee also laid out a detailed blueprint for more coordinated efforts among federal agencies, including the Health Resources and Services Administration (HRSA), Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services.

Specifically, HRSA-supported public health departments could integrate efforts in three specific areas: the Maternal, Infant, and Early Childhood Home Visiting Program; cardiovascular disease prevention; and colorectal cancer screening.

It noted that HRSA and CDC have very different organizational structures, a problem that creates logistical barriers to partnerships. Nonetheless, it recommended that the two agencies develop joint projects to enhance public health; evaluate existing projects and develop new initiatives involving integrated primary care and public health.

The agencies were also advised to work with CMS to identify regulatory options for graduate medical education funding that give priority to provide training in primary care and public health settings. Furthermore, they were advised to work together to develop training grants and teaching tools to prepare the next generation of health professionals for more integrated clinical and public health functions in practice.

The current lack of integration between primary care and public health "is a big problem," said Dr. Wallace. "But it also may be at the core of how we look at health care moving forward."

The 17-member committee was convened in early 2011 at the request of HRSA and the CDC.

Funding for the effort was provided by HRSA, CDC, and the UnitedHealth Foundation.

Primary care providers and the public health system need to better coordinate their efforts to prevent disease and injury, promote health and well-being and provide timely, effective health care, according to an Institute of Medicine-appointed committee that wrote a blueprint for public-provider partnership.

The current lack of integration between primary care and public health "is a big problem," according to the committee’s leader, Dr. Paul Wallace, an internist and senior vice president at The Lewin Group. "But it also may be at the core of how we look at health care moving forward."

At the heart of the blueprint are five principles that the committee said are essential for successful integration of primary care and public health efforts: a shared goal of population health improvement; community engagement in defining and addressing population health needs; aligned leadership across disciplines, programs, and jurisdictions that works towards changes in the system; sustainability, including a shared infrastructure between primary care and public health; and the sharing and collaborative use of data and analysis.

The Committee on Integrating Primary Care and Public Health identified a number of examples of successful integration efforts, and found they had several common elements. For example, many targeted a specific health issue that was identified as a community area of concern, such as chronic disease, or the health needs of a specific population.

None of these successful initiatives took place on the federal level, instead, they were concentrated on state and local levels, Dr. Wallace noted. Successful initiatives "have a strategic view from the beginning," along with a plan to "get beyond pilot funding" and make the funding stream sustainable, he said.

One example cited was an effort by the Michigan Department of Community Health, which formed six independent regional networks that partner with and support providers, business and community groups to improve diabetes care. The program, which according to the IOM has demonstrated improved health outcomes for Michigan residents with diabetes, has created public awareness campaigns and developed systems for medical practices to use to promote adherence to established care guidelines.

The committee also laid out a detailed blueprint for more coordinated efforts among federal agencies, including the Health Resources and Services Administration (HRSA), Centers for Disease Control and Prevention (CDC), and the Centers for Medicare and Medicaid Services.

Specifically, HRSA-supported public health departments could integrate efforts in three specific areas: the Maternal, Infant, and Early Childhood Home Visiting Program; cardiovascular disease prevention; and colorectal cancer screening.

It noted that HRSA and CDC have very different organizational structures, a problem that creates logistical barriers to partnerships. Nonetheless, it recommended that the two agencies develop joint projects to enhance public health; evaluate existing projects and develop new initiatives involving integrated primary care and public health.

The agencies were also advised to work with CMS to identify regulatory options for graduate medical education funding that give priority to provide training in primary care and public health settings. Furthermore, they were advised to work together to develop training grants and teaching tools to prepare the next generation of health professionals for more integrated clinical and public health functions in practice.

The current lack of integration between primary care and public health "is a big problem," said Dr. Wallace. "But it also may be at the core of how we look at health care moving forward."

The 17-member committee was convened in early 2011 at the request of HRSA and the CDC.

Funding for the effort was provided by HRSA, CDC, and the UnitedHealth Foundation.

Seven new nonprofit health insurance cooperatives, including four with a strong focus on patient-centered medical homes and primary care, will receive approximately $639 million in seed money to create what the Centers for Medicare and Medicaid Services calls "more affordable, consumer-friendly and high quality health insurance options," the agency announced Feb. 21.

This new type of health insurance plan, known as a Consumer Oriented and Operated Plan (CO-OP), was created by the Affordable Care Act. The newly approved CO-OPs are expected to operate in eight states beginning Jan. 1, 2014, through the new health insurance exchanges; however, the CO-OPs also will be allowed to offer health plans outside the exchanges, according to CMS officials.

The CO-OP program offers low-interest federal loans to nonprofit groups to help them set up and maintain health insurance programs.

"Each awardee receives start-up loans and solvency loans," said Tim Hill, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at CMS. The loans carry interest rates of less than 1%, Mr. Hill said during a telephone briefing.

The seven CO-OPs approved by CMS represent what should be only the first round of such approvals, said Barbara Smith, director of the CO-OP program at CMS.

Even though the CO-OPs are sponsored by community organizations and coalitions, "they’re designed to be completely separate organizations. They have to be consumer governed, and they will have separate CEOs and boards," Ms. Smith said in the teleconference.

The first round of CO-OPs includes three sponsored by the Freelancers Union, a union made up of independent workers. Those CO-OPs are partnering with physicians and other health care providers in three states – New Jersey, New York, and Oregon – to create models based on patient-centered medical homes, according to CMS; they received a total of more than $341 million in loans from CMS.

Another CO-OP, New Mexico Health Connections, is sponsored by a coalition of health care providers, community groups, and business leaders that plan to work with their provider community to improve health outcomes, according to CMS. New Mexico Health Connections, which is slated to start in 11 counties and expand statewide within 2 years, received more than $70 million in loans through CMS.

Through a rigorous selection process, the agency selected only CO-OPs that officials believe have a strong chance of success, Ms. Smith said.

The agency will closely monitor the organizations to ensure that they are meeting program milestones and will release funds incrementally as those milestones are met. CO-OPs also will submit quarterly financial statements including cash flow and enrollment data, be subject to site visits, and undergo annual external audits.

CMS officials continue to review more CO-OP applications and will accept more through the end of this year, said Ms. Smith, who added that awards will be announced "on a rolling basis."

Seven new nonprofit health insurance cooperatives, including four with a strong focus on patient-centered medical homes and primary care, will receive approximately $639 million in seed money to create what the Centers for Medicare and Medicaid Services calls "more affordable, consumer-friendly and high quality health insurance options," the agency announced Feb. 21.

This new type of health insurance plan, known as a Consumer Oriented and Operated Plan (CO-OP), was created by the Affordable Care Act. The newly approved CO-OPs are expected to operate in eight states beginning Jan. 1, 2014, through the new health insurance exchanges; however, the CO-OPs also will be allowed to offer health plans outside the exchanges, according to CMS officials.

The CO-OP program offers low-interest federal loans to nonprofit groups to help them set up and maintain health insurance programs.

"Each awardee receives start-up loans and solvency loans," said Tim Hill, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at CMS. The loans carry interest rates of less than 1%, Mr. Hill said during a telephone briefing.

The seven CO-OPs approved by CMS represent what should be only the first round of such approvals, said Barbara Smith, director of the CO-OP program at CMS.

Even though the CO-OPs are sponsored by community organizations and coalitions, "they’re designed to be completely separate organizations. They have to be consumer governed, and they will have separate CEOs and boards," Ms. Smith said in the teleconference.

The first round of CO-OPs includes three sponsored by the Freelancers Union, a union made up of independent workers. Those CO-OPs are partnering with physicians and other health care providers in three states – New Jersey, New York, and Oregon – to create models based on patient-centered medical homes, according to CMS; they received a total of more than $341 million in loans from CMS.

Another CO-OP, New Mexico Health Connections, is sponsored by a coalition of health care providers, community groups, and business leaders that plan to work with their provider community to improve health outcomes, according to CMS. New Mexico Health Connections, which is slated to start in 11 counties and expand statewide within 2 years, received more than $70 million in loans through CMS.

Through a rigorous selection process, the agency selected only CO-OPs that officials believe have a strong chance of success, Ms. Smith said.

The agency will closely monitor the organizations to ensure that they are meeting program milestones and will release funds incrementally as those milestones are met. CO-OPs also will submit quarterly financial statements including cash flow and enrollment data, be subject to site visits, and undergo annual external audits.

CMS officials continue to review more CO-OP applications and will accept more through the end of this year, said Ms. Smith, who added that awards will be announced "on a rolling basis."

Seven new nonprofit health insurance cooperatives, including four with a strong focus on patient-centered medical homes and primary care, will receive approximately $639 million in seed money to create what the Centers for Medicare and Medicaid Services calls "more affordable, consumer-friendly and high quality health insurance options," the agency announced Feb. 21.

This new type of health insurance plan, known as a Consumer Oriented and Operated Plan (CO-OP), was created by the Affordable Care Act. The newly approved CO-OPs are expected to operate in eight states beginning Jan. 1, 2014, through the new health insurance exchanges; however, the CO-OPs also will be allowed to offer health plans outside the exchanges, according to CMS officials.

The CO-OP program offers low-interest federal loans to nonprofit groups to help them set up and maintain health insurance programs.

"Each awardee receives start-up loans and solvency loans," said Tim Hill, deputy administrator and director of the Center for Consumer Information and Insurance Oversight at CMS. The loans carry interest rates of less than 1%, Mr. Hill said during a telephone briefing.

The seven CO-OPs approved by CMS represent what should be only the first round of such approvals, said Barbara Smith, director of the CO-OP program at CMS.

Even though the CO-OPs are sponsored by community organizations and coalitions, "they’re designed to be completely separate organizations. They have to be consumer governed, and they will have separate CEOs and boards," Ms. Smith said in the teleconference.

The first round of CO-OPs includes three sponsored by the Freelancers Union, a union made up of independent workers. Those CO-OPs are partnering with physicians and other health care providers in three states – New Jersey, New York, and Oregon – to create models based on patient-centered medical homes, according to CMS; they received a total of more than $341 million in loans from CMS.

Another CO-OP, New Mexico Health Connections, is sponsored by a coalition of health care providers, community groups, and business leaders that plan to work with their provider community to improve health outcomes, according to CMS. New Mexico Health Connections, which is slated to start in 11 counties and expand statewide within 2 years, received more than $70 million in loans through CMS.

Through a rigorous selection process, the agency selected only CO-OPs that officials believe have a strong chance of success, Ms. Smith said.

The agency will closely monitor the organizations to ensure that they are meeting program milestones and will release funds incrementally as those milestones are met. CO-OPs also will submit quarterly financial statements including cash flow and enrollment data, be subject to site visits, and undergo annual external audits.

CMS officials continue to review more CO-OP applications and will accept more through the end of this year, said Ms. Smith, who added that awards will be announced "on a rolling basis."

Many physicians report not always being completely honest with their patients and more than 10% say they’ve told a patient something untrue in the past year, despite professional charters and standards that call for openness and honesty in all communications with patients, according to a study published in Health Affairs.

In addition, one-fifth of physicians said they did not fully disclose medical mistakes to patients because of fears of lawsuits.

"Despite widespread acceptance of communication principles and commitments by professional organizations, substantial percentages of U.S. physicians did not completely endorse these precepts, and many reported behaving in ways that deviated from these norms," wrote Dr. Lisa I. Iezzoni, director of the Mongan Institute for Health Policy at Massachusetts General Hospital, Boston, and her colleagues.

The study authors surveyed 1,891 practicing physicians, asking them questions about attitudes and behavior related to physician-patient communication. Because respondents probably tended to answer questions in a way that others would view favorably, the authors said the survey may underestimate communication failures between doctors and patients.

Most respondents agreed that physicians should fully inform patients about the risks and benefits of interventions (89% agreed), never tell a patient something that is not true (83% agreed), and never disclose confidential information to unauthorized persons (91% agreed), according to the survey (Health Affairs 2012;31[doi:10.1377/hlthaff.2010.1137]).

However, the study found that approximately one-third of physicians did not completely agree with the need to disclose serious medical errors to patients, about 17% did not completely agree that physicians should never tell a patient something untrue, and more than 35% did not completely agree that they should disclose their financial relationships with drug and device companies to patients, the study reported.

When asked about their own behavior in the past year, more than 10% said they had told an adult patient or child’s guardian something that was not true, and almost one-fifth said they had not fully disclosed mistakes to patients for fear of being sued, the study said. In addition, more than one-quarter reported revealing unauthorized health information about a patient, and more than half said they had described a prognosis more positively than the facts warranted, the study found.

Women physicians were more likely than men were to provide responses consistent with professional charter principles on four questions: those concerning never telling patients something untrue, fully describing benefits and risks, disclosing financial relationships, and never having told an untruth in the prior year, the study found.

Physicians from underrepresented minority groups – that is, minority groups other than Asian – were more likely than were white or Asian respondents to report attitudes consistent with professional charter commitments, the investigators found. In addition, physicians who had graduated from medical schools outside the United States were more likely to say they never tell untruths and never disclose confidential patient information.

General surgeons and pediatricians were most likely to completely agree about needing to disclose all serious medical errors to patients, while cardiologists and psychiatrists were least likely to report this attitude. However, the questions involving self-reported actual behavior in disclosing errors found no significant differences by specialty, the study said.

Anesthesiologists, general surgeons and pediatricians were most likely to report never having described patients’ prognoses in more positive terms than warranted, while internists and psychiatrists were least likely to report this, the study said. Cardiologists and general surgeons were most likely to report never having told patients an untruth in the previous year, while pediatricians and psychiatrists were least likely to report never having told untruths, according to the study.

The results suggest that many physicians do not completely support physician charter requirements dealing with doctor-patient communications, the authors wrote. However, "an alternative interpretation is that treating support for the charter precepts as ‘black or white’ – physicians either do or do not completely endorse and adhere to these principles – fails to recognize complexities of patient-physician communication in everyday practice," they said.

External financial support for the survey was provided by the Center on Medicine as a Profession at Columbia University, New York.

Many physicians report not always being completely honest with their patients and more than 10% say they’ve told a patient something untrue in the past year, despite professional charters and standards that call for openness and honesty in all communications with patients, according to a study published in Health Affairs.

In addition, one-fifth of physicians said they did not fully disclose medical mistakes to patients because of fears of lawsuits.

"Despite widespread acceptance of communication principles and commitments by professional organizations, substantial percentages of U.S. physicians did not completely endorse these precepts, and many reported behaving in ways that deviated from these norms," wrote Dr. Lisa I. Iezzoni, director of the Mongan Institute for Health Policy at Massachusetts General Hospital, Boston, and her colleagues.

The study authors surveyed 1,891 practicing physicians, asking them questions about attitudes and behavior related to physician-patient communication. Because respondents probably tended to answer questions in a way that others would view favorably, the authors said the survey may underestimate communication failures between doctors and patients.

Most respondents agreed that physicians should fully inform patients about the risks and benefits of interventions (89% agreed), never tell a patient something that is not true (83% agreed), and never disclose confidential information to unauthorized persons (91% agreed), according to the survey (Health Affairs 2012;31[doi:10.1377/hlthaff.2010.1137]).

However, the study found that approximately one-third of physicians did not completely agree with the need to disclose serious medical errors to patients, about 17% did not completely agree that physicians should never tell a patient something untrue, and more than 35% did not completely agree that they should disclose their financial relationships with drug and device companies to patients, the study reported.

When asked about their own behavior in the past year, more than 10% said they had told an adult patient or child’s guardian something that was not true, and almost one-fifth said they had not fully disclosed mistakes to patients for fear of being sued, the study said. In addition, more than one-quarter reported revealing unauthorized health information about a patient, and more than half said they had described a prognosis more positively than the facts warranted, the study found.

Women physicians were more likely than men were to provide responses consistent with professional charter principles on four questions: those concerning never telling patients something untrue, fully describing benefits and risks, disclosing financial relationships, and never having told an untruth in the prior year, the study found.

Physicians from underrepresented minority groups – that is, minority groups other than Asian – were more likely than were white or Asian respondents to report attitudes consistent with professional charter commitments, the investigators found. In addition, physicians who had graduated from medical schools outside the United States were more likely to say they never tell untruths and never disclose confidential patient information.

General surgeons and pediatricians were most likely to completely agree about needing to disclose all serious medical errors to patients, while cardiologists and psychiatrists were least likely to report this attitude. However, the questions involving self-reported actual behavior in disclosing errors found no significant differences by specialty, the study said.

Anesthesiologists, general surgeons and pediatricians were most likely to report never having described patients’ prognoses in more positive terms than warranted, while internists and psychiatrists were least likely to report this, the study said. Cardiologists and general surgeons were most likely to report never having told patients an untruth in the previous year, while pediatricians and psychiatrists were least likely to report never having told untruths, according to the study.

The results suggest that many physicians do not completely support physician charter requirements dealing with doctor-patient communications, the authors wrote. However, "an alternative interpretation is that treating support for the charter precepts as ‘black or white’ – physicians either do or do not completely endorse and adhere to these principles – fails to recognize complexities of patient-physician communication in everyday practice," they said.

External financial support for the survey was provided by the Center on Medicine as a Profession at Columbia University, New York.

Many physicians report not always being completely honest with their patients and more than 10% say they’ve told a patient something untrue in the past year, despite professional charters and standards that call for openness and honesty in all communications with patients, according to a study published in Health Affairs.

In addition, one-fifth of physicians said they did not fully disclose medical mistakes to patients because of fears of lawsuits.

"Despite widespread acceptance of communication principles and commitments by professional organizations, substantial percentages of U.S. physicians did not completely endorse these precepts, and many reported behaving in ways that deviated from these norms," wrote Dr. Lisa I. Iezzoni, director of the Mongan Institute for Health Policy at Massachusetts General Hospital, Boston, and her colleagues.

The study authors surveyed 1,891 practicing physicians, asking them questions about attitudes and behavior related to physician-patient communication. Because respondents probably tended to answer questions in a way that others would view favorably, the authors said the survey may underestimate communication failures between doctors and patients.

Most respondents agreed that physicians should fully inform patients about the risks and benefits of interventions (89% agreed), never tell a patient something that is not true (83% agreed), and never disclose confidential information to unauthorized persons (91% agreed), according to the survey (Health Affairs 2012;31[doi:10.1377/hlthaff.2010.1137]).

However, the study found that approximately one-third of physicians did not completely agree with the need to disclose serious medical errors to patients, about 17% did not completely agree that physicians should never tell a patient something untrue, and more than 35% did not completely agree that they should disclose their financial relationships with drug and device companies to patients, the study reported.

When asked about their own behavior in the past year, more than 10% said they had told an adult patient or child’s guardian something that was not true, and almost one-fifth said they had not fully disclosed mistakes to patients for fear of being sued, the study said. In addition, more than one-quarter reported revealing unauthorized health information about a patient, and more than half said they had described a prognosis more positively than the facts warranted, the study found.

Women physicians were more likely than men were to provide responses consistent with professional charter principles on four questions: those concerning never telling patients something untrue, fully describing benefits and risks, disclosing financial relationships, and never having told an untruth in the prior year, the study found.

Physicians from underrepresented minority groups – that is, minority groups other than Asian – were more likely than were white or Asian respondents to report attitudes consistent with professional charter commitments, the investigators found. In addition, physicians who had graduated from medical schools outside the United States were more likely to say they never tell untruths and never disclose confidential patient information.

General surgeons and pediatricians were most likely to completely agree about needing to disclose all serious medical errors to patients, while cardiologists and psychiatrists were least likely to report this attitude. However, the questions involving self-reported actual behavior in disclosing errors found no significant differences by specialty, the study said.

Anesthesiologists, general surgeons and pediatricians were most likely to report never having described patients’ prognoses in more positive terms than warranted, while internists and psychiatrists were least likely to report this, the study said. Cardiologists and general surgeons were most likely to report never having told patients an untruth in the previous year, while pediatricians and psychiatrists were least likely to report never having told untruths, according to the study.

The results suggest that many physicians do not completely support physician charter requirements dealing with doctor-patient communications, the authors wrote. However, "an alternative interpretation is that treating support for the charter precepts as ‘black or white’ – physicians either do or do not completely endorse and adhere to these principles – fails to recognize complexities of patient-physician communication in everyday practice," they said.

External financial support for the survey was provided by the Center on Medicine as a Profession at Columbia University, New York.

Physicians in eight countries agree that health information technology has the potential to improve clinical data and care coordination while reducing medical errors, according to a new survey.

However, physicians in the United States and doctors older than 50 voiced considerably more skepticism than did their younger and international colleagues about the technology's ability to improve care.

The survey, conducted by global consulting firm Accenture, exposed generational and geographic divides among physicians when it comes to their views on the benefits of health information technology (HIT). Physicians who haven't used the technology are most skeptical, but once they start to use HIT, they begin to see those benefits, said Frances Dare, a senior executive with Accenture Health.

“The value indicators from those [physicians] who have used the technology are very strong,” meaning they think the technology can improve care and reduce costs, Ms. Dare said in an interview.

“It's not that physicians try it and don't like it and stop. We really do need to focus on physicians who haven't used these technologies; it's really getting across that first adoption hurdle,” she explained.

Accenture surveyed 500 doctors per country in Australia, Canada, England, France, Germany, Spain, and the United States, along with 200 doctors in Singapore, in August and September 2011.

The researchers measured physicians' attitudes toward HIT, including whether they thought it would bring access to better-quality data, improved coordination, reductions in medical errors, and improved diagnostic decisions.

The survey found that nearly 71% of physicians in the eight countries surveyed think that HIT will improve data for clinical research, and 69% think it will improve coordination of care. About two-thirds think it will lead to a reduction in medical errors, and about 65% think it will lead to better health care decisions.

However, fewer than 50% of physicians think it will lead to less litigation, and fewer than 50% think it will lead to fewer unnecessary procedures or increased speed of access to health services for patients. Because HIT is frequently touted with promises of improved access and better coordination of care, this finding shows that physicians haven't fully bought into those promises, according to Accenture.

Finally, fewer than 40% of physicians in the eight countries are not certain that HIT will lead to improved patient outcomes.

Ms. Dare said that policy makers and companies involved in the HIT field have tended to focus on how the technology can reduce costs and unnecessary care, whereas this survey shows that physicians care more about how HIT can improve access to care and care coordination for patients. However, using HIT to improve care – which physicians want – ultimately will address cost issues as well, she said.

“If we say to physicians, 'This technology will allow you to better coordinate care' – if we speak to the benefits physicians care about – then we will get the benefits policy makers and industry care about, which are utilization and cost,” Ms. Dare said.

Physicians who use HIT most frequently have the highest opinions of it, according to the survey.

For example, more than 72% of physicians younger than age 50 say that electronic medical records and health information exchanges will improve care coordination, the survey found, whereas 73% think those technologies will offer better access to quality data for clinical research. Among older physicians, only 65% think research data will improve, and 68% think care coordination will improve, according to the survey.

Meanwhile, negative opinions about HIT are most pronounced among physicians in the United States, according to Accenture.

Fewer than half of all U.S. physicians surveyed said they believed that HIT would improve health care overall, compared with 59% of physicians in all eight countries.

In addition, only 45% of U.S. physicians believe that health information technology will improve diagnostic decisions, compared with 61% of all physicians surveyed, and just 47% of American physicians say that technology already has improved the quality of treatment decisions, compared with an average of 61% of physicians in all eight countries.

Only 45% of U.S. physicians believe that health information technology leads to improved outcomes, compared with 59% of all physicians.

The United States “is behind,” Ms. Dare said. “We're … a decade late [in having] a national agenda to drive adoption and having a unified approach to drive adoption” of HIT. Still, Ms. Dare said she believes the United States can catch up quickly if more physicians begin to use HIT and see the benefits from it.

Physicians in eight countries agree that health information technology has the potential to improve clinical data and care coordination while reducing medical errors, according to a new survey.

However, physicians in the United States and doctors older than 50 voiced considerably more skepticism than did their younger and international colleagues about the technology's ability to improve care.

The survey, conducted by global consulting firm Accenture, exposed generational and geographic divides among physicians when it comes to their views on the benefits of health information technology (HIT). Physicians who haven't used the technology are most skeptical, but once they start to use HIT, they begin to see those benefits, said Frances Dare, a senior executive with Accenture Health.

“The value indicators from those [physicians] who have used the technology are very strong,” meaning they think the technology can improve care and reduce costs, Ms. Dare said in an interview.

“It's not that physicians try it and don't like it and stop. We really do need to focus on physicians who haven't used these technologies; it's really getting across that first adoption hurdle,” she explained.

Accenture surveyed 500 doctors per country in Australia, Canada, England, France, Germany, Spain, and the United States, along with 200 doctors in Singapore, in August and September 2011.

The researchers measured physicians' attitudes toward HIT, including whether they thought it would bring access to better-quality data, improved coordination, reductions in medical errors, and improved diagnostic decisions.

The survey found that nearly 71% of physicians in the eight countries surveyed think that HIT will improve data for clinical research, and 69% think it will improve coordination of care. About two-thirds think it will lead to a reduction in medical errors, and about 65% think it will lead to better health care decisions.

However, fewer than 50% of physicians think it will lead to less litigation, and fewer than 50% think it will lead to fewer unnecessary procedures or increased speed of access to health services for patients. Because HIT is frequently touted with promises of improved access and better coordination of care, this finding shows that physicians haven't fully bought into those promises, according to Accenture.

Finally, fewer than 40% of physicians in the eight countries are not certain that HIT will lead to improved patient outcomes.

Ms. Dare said that policy makers and companies involved in the HIT field have tended to focus on how the technology can reduce costs and unnecessary care, whereas this survey shows that physicians care more about how HIT can improve access to care and care coordination for patients. However, using HIT to improve care – which physicians want – ultimately will address cost issues as well, she said.

“If we say to physicians, 'This technology will allow you to better coordinate care' – if we speak to the benefits physicians care about – then we will get the benefits policy makers and industry care about, which are utilization and cost,” Ms. Dare said.

Physicians who use HIT most frequently have the highest opinions of it, according to the survey.

For example, more than 72% of physicians younger than age 50 say that electronic medical records and health information exchanges will improve care coordination, the survey found, whereas 73% think those technologies will offer better access to quality data for clinical research. Among older physicians, only 65% think research data will improve, and 68% think care coordination will improve, according to the survey.

Meanwhile, negative opinions about HIT are most pronounced among physicians in the United States, according to Accenture.

Fewer than half of all U.S. physicians surveyed said they believed that HIT would improve health care overall, compared with 59% of physicians in all eight countries.

In addition, only 45% of U.S. physicians believe that health information technology will improve diagnostic decisions, compared with 61% of all physicians surveyed, and just 47% of American physicians say that technology already has improved the quality of treatment decisions, compared with an average of 61% of physicians in all eight countries.

Only 45% of U.S. physicians believe that health information technology leads to improved outcomes, compared with 59% of all physicians.

The United States “is behind,” Ms. Dare said. “We're … a decade late [in having] a national agenda to drive adoption and having a unified approach to drive adoption” of HIT. Still, Ms. Dare said she believes the United States can catch up quickly if more physicians begin to use HIT and see the benefits from it.

Physicians in eight countries agree that health information technology has the potential to improve clinical data and care coordination while reducing medical errors, according to a new survey.

However, physicians in the United States and doctors older than 50 voiced considerably more skepticism than did their younger and international colleagues about the technology's ability to improve care.

The survey, conducted by global consulting firm Accenture, exposed generational and geographic divides among physicians when it comes to their views on the benefits of health information technology (HIT). Physicians who haven't used the technology are most skeptical, but once they start to use HIT, they begin to see those benefits, said Frances Dare, a senior executive with Accenture Health.

“The value indicators from those [physicians] who have used the technology are very strong,” meaning they think the technology can improve care and reduce costs, Ms. Dare said in an interview.

“It's not that physicians try it and don't like it and stop. We really do need to focus on physicians who haven't used these technologies; it's really getting across that first adoption hurdle,” she explained.

Accenture surveyed 500 doctors per country in Australia, Canada, England, France, Germany, Spain, and the United States, along with 200 doctors in Singapore, in August and September 2011.

The researchers measured physicians' attitudes toward HIT, including whether they thought it would bring access to better-quality data, improved coordination, reductions in medical errors, and improved diagnostic decisions.

The survey found that nearly 71% of physicians in the eight countries surveyed think that HIT will improve data for clinical research, and 69% think it will improve coordination of care. About two-thirds think it will lead to a reduction in medical errors, and about 65% think it will lead to better health care decisions.

However, fewer than 50% of physicians think it will lead to less litigation, and fewer than 50% think it will lead to fewer unnecessary procedures or increased speed of access to health services for patients. Because HIT is frequently touted with promises of improved access and better coordination of care, this finding shows that physicians haven't fully bought into those promises, according to Accenture.

Finally, fewer than 40% of physicians in the eight countries are not certain that HIT will lead to improved patient outcomes.

Ms. Dare said that policy makers and companies involved in the HIT field have tended to focus on how the technology can reduce costs and unnecessary care, whereas this survey shows that physicians care more about how HIT can improve access to care and care coordination for patients. However, using HIT to improve care – which physicians want – ultimately will address cost issues as well, she said.

“If we say to physicians, 'This technology will allow you to better coordinate care' – if we speak to the benefits physicians care about – then we will get the benefits policy makers and industry care about, which are utilization and cost,” Ms. Dare said.

Physicians who use HIT most frequently have the highest opinions of it, according to the survey.

For example, more than 72% of physicians younger than age 50 say that electronic medical records and health information exchanges will improve care coordination, the survey found, whereas 73% think those technologies will offer better access to quality data for clinical research. Among older physicians, only 65% think research data will improve, and 68% think care coordination will improve, according to the survey.

Meanwhile, negative opinions about HIT are most pronounced among physicians in the United States, according to Accenture.

Fewer than half of all U.S. physicians surveyed said they believed that HIT would improve health care overall, compared with 59% of physicians in all eight countries.

In addition, only 45% of U.S. physicians believe that health information technology will improve diagnostic decisions, compared with 61% of all physicians surveyed, and just 47% of American physicians say that technology already has improved the quality of treatment decisions, compared with an average of 61% of physicians in all eight countries.

Only 45% of U.S. physicians believe that health information technology leads to improved outcomes, compared with 59% of all physicians.

The United States “is behind,” Ms. Dare said. “We're … a decade late [in having] a national agenda to drive adoption and having a unified approach to drive adoption” of HIT. Still, Ms. Dare said she believes the United States can catch up quickly if more physicians begin to use HIT and see the benefits from it.

The odds that a patient visiting a physician would be referred to another physician – usually a specialist – rose by 94% between 1999 and 2009, while the absolute number of physician visits that resulted in a referral increased 159% during the same time frame, reflecting the rise in overall ambulatory visits during that decade.

The biggest increases were noted in referral rates from primary care physicians for patients with the following types of symptoms: cardiovascular (a referral rate of 8.5% in 1999-2002, increasing to 14.9% in 2006-2009), gastrointestinal (12.3% to 17.7%), orthopedic (12.4% to 16.5%), dermatologic (10.1% to 15.4%), and ear/nose/throat (4.5% to 8.5%), according to a study published Jan. 23 in the Archives of Internal Medicine.

Only physicians with ownership interests in their practices or those who obtained most of their income from managed care contracts had slower growth in referral rates.

The authors analyzed nearly 850,000 ambulatory patient visits in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, focusing on the decade 1999-2009.

It’s not entirely clear why referral rates are rising, according to Dr. Michael L. Barnett and his colleagues from Harvard Medical School, Boston.

"One possibility is that care is becoming increasingly complex, thereby requiring ever more care by specialized physicians," Dr. Barnett said. Evidence for this theory includes the fact that physicians increased referrals for patients with cardiovascular or dermatologic symptoms, but not for those who presented with more general symptoms, such as those associated with viral illnesses.

"Likewise, chief concerns outside the traditional spectrum of primary care, such as ocular or gynecologic/breast symptoms, had a consistently high likelihood of referral from [primary care physicians] but had no significant change in referral rate," they said (Arch. Intern. Med. 2012;172:163-170). "This suggests that some areas, such as cardiovascular and ear/nose/throat symptoms, may be increasingly outside the expertise or clinical portfolio of PCPs [primary care physicians] to manage alone. Other areas, such as gastrointestinal and orthopedic symptoms, had consistently increasing referral rates for PCPs and specialists, which may reflect increasing influence of those specialties in health care markets."

Another possibility is that PCPs simply have too much to accomplish during limited visits, with increasing screening and preventive recommendations, the authors noted.

While appointment duration has not changed significantly in more than 20 years, "patients require more medications and frequently have one or more chronic medical conditions," they said. "As a result... physicians, and in particular PCPs, may not have enough time to address each patient issue, resulting in increased rates of referrals."

Finally, growing numbers of specialists – plus better availability of specialist physicians in many parts of the country – may influence referral rates, the authors said.

It’s not clear whether the increase in referrals overall reflects any kind of an increase in inappropriate referrals, Dr. Barnett said, adding that little literature exists on how to define appropriate referrals. "The complexity of referral appropriateness is compounded by the multiple roles that specialists can play in the care of a patient, ranging from consultative to procedural to co-managing a complex condition."

The increase in referrals between 1999 and 2009 has implications for health care policy and health care spending in the United States, Dr. Barnett and his colleagues noted. "As federal and state policy makers consider policies for reforming the health care system, developing methods to measure referral appropriateness and using these to promote appropriate referrals may be an important strategy for controlling growth in health care spending."

The authors reported they had no conflicts of interest. Dr. Barnett reported no conflicts of interest.

The odds that a patient visiting a physician would be referred to another physician – usually a specialist – rose by 94% between 1999 and 2009, while the absolute number of physician visits that resulted in a referral increased 159% during the same time frame, reflecting the rise in overall ambulatory visits during that decade.

The biggest increases were noted in referral rates from primary care physicians for patients with the following types of symptoms: cardiovascular (a referral rate of 8.5% in 1999-2002, increasing to 14.9% in 2006-2009), gastrointestinal (12.3% to 17.7%), orthopedic (12.4% to 16.5%), dermatologic (10.1% to 15.4%), and ear/nose/throat (4.5% to 8.5%), according to a study published Jan. 23 in the Archives of Internal Medicine.

Only physicians with ownership interests in their practices or those who obtained most of their income from managed care contracts had slower growth in referral rates.

The authors analyzed nearly 850,000 ambulatory patient visits in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, focusing on the decade 1999-2009.

It’s not entirely clear why referral rates are rising, according to Dr. Michael L. Barnett and his colleagues from Harvard Medical School, Boston.

"One possibility is that care is becoming increasingly complex, thereby requiring ever more care by specialized physicians," Dr. Barnett said. Evidence for this theory includes the fact that physicians increased referrals for patients with cardiovascular or dermatologic symptoms, but not for those who presented with more general symptoms, such as those associated with viral illnesses.

"Likewise, chief concerns outside the traditional spectrum of primary care, such as ocular or gynecologic/breast symptoms, had a consistently high likelihood of referral from [primary care physicians] but had no significant change in referral rate," they said (Arch. Intern. Med. 2012;172:163-170). "This suggests that some areas, such as cardiovascular and ear/nose/throat symptoms, may be increasingly outside the expertise or clinical portfolio of PCPs [primary care physicians] to manage alone. Other areas, such as gastrointestinal and orthopedic symptoms, had consistently increasing referral rates for PCPs and specialists, which may reflect increasing influence of those specialties in health care markets."

Another possibility is that PCPs simply have too much to accomplish during limited visits, with increasing screening and preventive recommendations, the authors noted.

While appointment duration has not changed significantly in more than 20 years, "patients require more medications and frequently have one or more chronic medical conditions," they said. "As a result... physicians, and in particular PCPs, may not have enough time to address each patient issue, resulting in increased rates of referrals."

Finally, growing numbers of specialists – plus better availability of specialist physicians in many parts of the country – may influence referral rates, the authors said.

It’s not clear whether the increase in referrals overall reflects any kind of an increase in inappropriate referrals, Dr. Barnett said, adding that little literature exists on how to define appropriate referrals. "The complexity of referral appropriateness is compounded by the multiple roles that specialists can play in the care of a patient, ranging from consultative to procedural to co-managing a complex condition."

The increase in referrals between 1999 and 2009 has implications for health care policy and health care spending in the United States, Dr. Barnett and his colleagues noted. "As federal and state policy makers consider policies for reforming the health care system, developing methods to measure referral appropriateness and using these to promote appropriate referrals may be an important strategy for controlling growth in health care spending."

The authors reported they had no conflicts of interest. Dr. Barnett reported no conflicts of interest.

The odds that a patient visiting a physician would be referred to another physician – usually a specialist – rose by 94% between 1999 and 2009, while the absolute number of physician visits that resulted in a referral increased 159% during the same time frame, reflecting the rise in overall ambulatory visits during that decade.

The biggest increases were noted in referral rates from primary care physicians for patients with the following types of symptoms: cardiovascular (a referral rate of 8.5% in 1999-2002, increasing to 14.9% in 2006-2009), gastrointestinal (12.3% to 17.7%), orthopedic (12.4% to 16.5%), dermatologic (10.1% to 15.4%), and ear/nose/throat (4.5% to 8.5%), according to a study published Jan. 23 in the Archives of Internal Medicine.

Only physicians with ownership interests in their practices or those who obtained most of their income from managed care contracts had slower growth in referral rates.

The authors analyzed nearly 850,000 ambulatory patient visits in the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, focusing on the decade 1999-2009.

It’s not entirely clear why referral rates are rising, according to Dr. Michael L. Barnett and his colleagues from Harvard Medical School, Boston.

"One possibility is that care is becoming increasingly complex, thereby requiring ever more care by specialized physicians," Dr. Barnett said. Evidence for this theory includes the fact that physicians increased referrals for patients with cardiovascular or dermatologic symptoms, but not for those who presented with more general symptoms, such as those associated with viral illnesses.

"Likewise, chief concerns outside the traditional spectrum of primary care, such as ocular or gynecologic/breast symptoms, had a consistently high likelihood of referral from [primary care physicians] but had no significant change in referral rate," they said (Arch. Intern. Med. 2012;172:163-170). "This suggests that some areas, such as cardiovascular and ear/nose/throat symptoms, may be increasingly outside the expertise or clinical portfolio of PCPs [primary care physicians] to manage alone. Other areas, such as gastrointestinal and orthopedic symptoms, had consistently increasing referral rates for PCPs and specialists, which may reflect increasing influence of those specialties in health care markets."

Another possibility is that PCPs simply have too much to accomplish during limited visits, with increasing screening and preventive recommendations, the authors noted.

While appointment duration has not changed significantly in more than 20 years, "patients require more medications and frequently have one or more chronic medical conditions," they said. "As a result... physicians, and in particular PCPs, may not have enough time to address each patient issue, resulting in increased rates of referrals."

Finally, growing numbers of specialists – plus better availability of specialist physicians in many parts of the country – may influence referral rates, the authors said.

It’s not clear whether the increase in referrals overall reflects any kind of an increase in inappropriate referrals, Dr. Barnett said, adding that little literature exists on how to define appropriate referrals. "The complexity of referral appropriateness is compounded by the multiple roles that specialists can play in the care of a patient, ranging from consultative to procedural to co-managing a complex condition."

The increase in referrals between 1999 and 2009 has implications for health care policy and health care spending in the United States, Dr. Barnett and his colleagues noted. "As federal and state policy makers consider policies for reforming the health care system, developing methods to measure referral appropriateness and using these to promote appropriate referrals may be an important strategy for controlling growth in health care spending."

The authors reported they had no conflicts of interest. Dr. Barnett reported no conflicts of interest.

House Democrats have called on the Drug Enforcement Administration and two manufacturers of drugs to treat attention-deficit/hyperactivity disorder to explain shortages of medicines to treat the disorder, especially generic versions of the drugs.

The request comes amid reports that the drug makers may be manipulating the market to force consumers to purchase brand-name products.

Rep. Henry Waxman (D-Calif.), ranking member of the House Energy and Commerce Committee, joined Reps. Diana DeGette (D-Colo.), Frank Pallone, Jr. (D-N.J.), and Chris Van Hollen (D-Md.) to question the DEA as well as Shire Pharmaceuticals and Novartis regarding recent reports of shortages of generic ADHD drugs.

The FDA is reporting current shortages of three drugs that are prescribed to treat ADHD: amphetamine mixed salts immediate-release tablets, dextroamphetamine tablets, and methylphenidate HCI tablets.

"Reports indicate that drug manufacturers may be manipulating the market to create an artificial shortage of the generic ADD drugs and force patients to purchase the more expensive brand-name drugs," the lawmakers said in a statement. "Reports have also indicated that DEA policies regarding ADD drug quotas may be exacerbating these shortages."

In a letter dated Jan. 17, the lawmakers asked the DEA for details on how the agency sets the quotas for the drugs involved and how it develops quotas for drugs with rapidly increasing sales, such as amphetamine mixed salts immediate-release tablets. They also asked the DEA to describe any changes in the process it plans to make to address the reported shortages.

Meanwhile, the lawmakers sent separate letters asking Novartis, which produces both branded and generic methylphenidate (Ritalin), and Shire Pharmaceuticals, which makes both branded and generic amphetamine mixed salts immediate-release tablets (Adderall), to provide details on their production of both brand name and generic versions of their ADHD drugs.

House Democrats have called on the Drug Enforcement Administration and two manufacturers of drugs to treat attention-deficit/hyperactivity disorder to explain shortages of medicines to treat the disorder, especially generic versions of the drugs.

The request comes amid reports that the drug makers may be manipulating the market to force consumers to purchase brand-name products.

Rep. Henry Waxman (D-Calif.), ranking member of the House Energy and Commerce Committee, joined Reps. Diana DeGette (D-Colo.), Frank Pallone, Jr. (D-N.J.), and Chris Van Hollen (D-Md.) to question the DEA as well as Shire Pharmaceuticals and Novartis regarding recent reports of shortages of generic ADHD drugs.

The FDA is reporting current shortages of three drugs that are prescribed to treat ADHD: amphetamine mixed salts immediate-release tablets, dextroamphetamine tablets, and methylphenidate HCI tablets.

"Reports indicate that drug manufacturers may be manipulating the market to create an artificial shortage of the generic ADD drugs and force patients to purchase the more expensive brand-name drugs," the lawmakers said in a statement. "Reports have also indicated that DEA policies regarding ADD drug quotas may be exacerbating these shortages."

In a letter dated Jan. 17, the lawmakers asked the DEA for details on how the agency sets the quotas for the drugs involved and how it develops quotas for drugs with rapidly increasing sales, such as amphetamine mixed salts immediate-release tablets. They also asked the DEA to describe any changes in the process it plans to make to address the reported shortages.

Meanwhile, the lawmakers sent separate letters asking Novartis, which produces both branded and generic methylphenidate (Ritalin), and Shire Pharmaceuticals, which makes both branded and generic amphetamine mixed salts immediate-release tablets (Adderall), to provide details on their production of both brand name and generic versions of their ADHD drugs.

House Democrats have called on the Drug Enforcement Administration and two manufacturers of drugs to treat attention-deficit/hyperactivity disorder to explain shortages of medicines to treat the disorder, especially generic versions of the drugs.

The request comes amid reports that the drug makers may be manipulating the market to force consumers to purchase brand-name products.

Rep. Henry Waxman (D-Calif.), ranking member of the House Energy and Commerce Committee, joined Reps. Diana DeGette (D-Colo.), Frank Pallone, Jr. (D-N.J.), and Chris Van Hollen (D-Md.) to question the DEA as well as Shire Pharmaceuticals and Novartis regarding recent reports of shortages of generic ADHD drugs.

The FDA is reporting current shortages of three drugs that are prescribed to treat ADHD: amphetamine mixed salts immediate-release tablets, dextroamphetamine tablets, and methylphenidate HCI tablets.

"Reports indicate that drug manufacturers may be manipulating the market to create an artificial shortage of the generic ADD drugs and force patients to purchase the more expensive brand-name drugs," the lawmakers said in a statement. "Reports have also indicated that DEA policies regarding ADD drug quotas may be exacerbating these shortages."

In a letter dated Jan. 17, the lawmakers asked the DEA for details on how the agency sets the quotas for the drugs involved and how it develops quotas for drugs with rapidly increasing sales, such as amphetamine mixed salts immediate-release tablets. They also asked the DEA to describe any changes in the process it plans to make to address the reported shortages.

Meanwhile, the lawmakers sent separate letters asking Novartis, which produces both branded and generic methylphenidate (Ritalin), and Shire Pharmaceuticals, which makes both branded and generic amphetamine mixed salts immediate-release tablets (Adderall), to provide details on their production of both brand name and generic versions of their ADHD drugs.