Specialists Provide Nearly 40% of Primary Care Services

August 21, 2012 — Nearly 40% of primary care services are provided by specialists, according to a research letter published online August 20 in the Archives of Internal Medicine.

Investigators analyzed data from the 1999 and 2007 National Ambulatory Medical Care Surveys, which included 20,959 (n = 8730 from 1999 and n = 12,229 from 2007) primary care visits for adults requiring treatment either for common symptoms and diseases such as fever, nasal congestion, anemia, and asthma or for general preventive medical examinations.

The researchers, led by Minal S. Kale, MD, from the Division of General Internal Medicine, Mt. Sinai School of Medicine, New York City, found a disparity in the provision of primary care for common symptoms and ailments that remained stable during the 8-year period: only 60% of primary care was dispensed by primary care physicians (PCPs; 58.1% in 1999 and 57.2% in 2007; P = .79). The balance for these types of primary care visits was covered by internal medicine subspecialists (9.1% in 1999 and 9.6% in 2007; P = .82), obstetrician-gynecologists (3.4% in 1999 and 2.8% in 2007; P = .36), and other subspecialists (29.4% in 1999 and 30.4% in 2007; P = .73).

The proportion of general preventive exams performed by PCPs and internal medicine subspecialists increased slightly, but neither change was statistically significant (66.3% in 1999 and 71.2% in 2007 [P = .44] and 7.1% in 1999 and 11.9% in 2007 [P = .22], respectively).Commensurate decreases were observed among obstetrician-gynecologists and other specialist physicians (16.1% in 1999 and 10.0% in 2007 [P = .13] and 10.5% in 1999 and 6.8% in 2007 [P = .39], respectively), which were also not significant.

Rebalance Requires Education

"This study highlights the fact that the US healthcare system is out of balance. If you look at research into the quality and cost of other industrialized nations, you see that their systems are based on primary care. In the United States, our physician workforce is approximately 70% subspecialists and 30% primary care physicians. We must work to rectify this and rebalance our system on primary care," Douglas Henley, MD, executive vice president and chief executive officer, American Academy of Family Physicians, told Medscape Medical News.

"Good-quality healthcare stems from that comprehensive approach and ensuring smooth transitions from one health setting to another, which are 2 of the hallmarks of primary care," Dr. Henley added, noting that primary care physicians are the "front door" for the healthcare system, providing diagnoses and treatment for routine and complex/chronic illnesses and coordinating other healthcare team members.

According to the study authors, explanations for the large proportion of specialist visits may include patients' belief that specialists provide superior care for all ailments, as well as the well-documented shortage of PCPs in the United States.

Dr. Henley concurred: "It's possible that people who seek primary care from subspecialists don't understand that subspecialty physicians have a more focused practice and work with particular disease processes, rather than on comprehensive primary care," he said.

"Therefore, they don't provide whole-person care that prevents illness or complications from a chronic condition the subspecialist might be treating. This is at the core of why our healthcare system is fragmented, why we see so much duplication of tests and procedures, unnecessary hospitalizations and re-hospitalizations, and why we have lower-quality outcomes," he concluded.

According to Dr. Henley, implementation of the Affordable Care Act will help the educational and economic environment for primary care physicians, build the primary care physician workforce, and enable Americans to have access to the patient-centered medical home.

To this end, Dr. Henley explains, the act includes provisions for programs such as the National Health Service Corps, which provides financial aid for medical students choosing to practice primary care; implementation of the Primary Care Incentive Program, in which Medicare pays a 10% incentive for primary care services provided by a primary care physician; and the Comprehensive Primary Care Incentive, a patient-centered medical home demonstration in which Medicare, Medicaid, and private insurers pay a per patient, per month coordination fee.

"The Affordable Care Act is moving to reform our health delivery system so that the nation has a strong primary care physician workforce and so that patients understand the invaluable role of the primary care physician in providing comprehensive, coordinated care," Dr. Henley said.

The study was not commercially supported. One author has received compensation as a board member for FAIR Health Inc Scientific and has received grants from Medtronic Inc and Pew Charitable Trusts, the National Institute on Aging, the American Federation of Aging Research through the Paul B Beeson Career Development Award Program, and the Centers for Medicare and Medicaid Services. The lead author is supported by the Mount Sinai Primary Care Research Fellowship, funded by the Health Resources and Services Administration through the Ruth K. Kirchstein National Research Service Award. Dr. Henley has disclosed no relevant financial relationships.

Arch Intern Med. Published online August 20, 2012. Abstract

Drug-Dispensing Physicians Charge More Than Pharmacies

August 21, 2012 — Physicians who dispense pain medications and other commonly used drugs to workers' compensation (WC) patients charge up to 3 times more than pharmacies in some states, according to a recent study from the not-for-profit Workers Compensation Research Institute (WCRI).

That kind of mark-up could explain why physician dispensing for WC patients has grown at a rapid clip in recent years, and why some states now limit how much clinicians can charge. However, a desire for profit may not be the only reason why physicians charge more than pharmacies. Another factor may be wholesale prices that physicians pay to obtain the drugs that they sell.

The WCRI study, published in July, compares 23 states, including 3 (Massachusetts, New York, and Texas) in which physician dispensing in general is prohibited. Author Dongchun Wang, a senior researcher at WCRI, examined WC claims for work-related injuries that were submitted and paid during 2 periods: from 2007 to 2008 and from 2010 to 2011. WC claims typically are processed by private insurers.

Illinois stood out as the epicenter for physician dispensing for WC patients. From 2007-2008 to 2010-2011, the percentage of all prescription drugs for WC patients that were dispensed by physicians rose from 26% to 43%, the fastest growth of any state in the study. More significantly, physician dispensing represented 63% of total spending on WC prescriptions in 2010-2011 compared with just 22% in 2007-2008.

In a trend repeated in other states, Illinois physicians raised prices for the drugs they dispensed — most of them generic versions — during this period, even as pharmacies were lowering theirs. For example, Illinois physicians in 2007-2008 charged 87 cents on average for a hydrocodone/acetaminophen (Vicodin, Abbott) pill compared with 54 cents charged by pharmacies.

By 2010-2010, the physician price for the analgesic had jumped 66%, to $1.44 per pill, whereas the pharmacy price had dropped to 53 cents. (Hydrocodone/acetaminophen was the most commonly dispensed drug that physicians and pharmacies alike dispensed to WC patients in 2010-2011, followed by ibuprofen, meloxicam, tramadol, and cyclobenzaprine).

Physicians also jacked up the price of over-the-counter drugs they handed to WC patients, charging as much as 15 times more than pharmacies.

In Florida, Georgia, Illinois, and Maryland, for example, WC patients paid physicians on average $4 to $7 for a pill of ranitidine (Zantac, Boehringer Ingelheim) when they could have bought it at Walgreens for from 33 to 42 cents, depending on the strength and quantity.

California Law Had Only Small Effect on Physician Dispensing

A number of states during the last 5 years have closed the gap between what pharmacies and physicians charge WC patients for medications, the WCRI study reports. These states generally limit physician reimbursement to the average wholesale price (AWP) that drug makers charge their customers, including pharmacies. In some states, physicians are allowed to tack on a dispensing fee.

Supporters of physician dispensing, writes Wang, have argued that reducing what physicians can charge will discourage them from dispensing, which in turn could hurt patient care. After all, one clinical rationale for physician dispensing is that it increases patient compliance with medication regimens, as patients given a prescription may not necessarily bother to fill it at a pharmacy. In addition, treatment starts much sooner.

Wang, however, did not find a major downturn in physician dispensing for WC patients when she analyzed the effects of a California regulation that equalized what physicians and pharmacies could charge, beginning in March 2007. In the first quarter of 2007, physicians dispensed 55% of medications ordered for WC patients (that percentage had topped 65% 12 months earlier). In the 2010-2011 claim period, dispensing physicians accounted for 53% of WC prescriptions, which is just a tad short of the mark set in early 2007.

The biggest change in California since 2007, writes Wang, was the location at which physicians obtained the drugs they dispensed. In early 2007, they bought them mostly from so-called repackagers, who buy them in bulk from manufacturers and repackage them in smaller, prescription-sized quantities. Repackaging companies, writes Wang, often sell their drugs at a much higher AWP than drug manufacturers. By 2010-2011, dispensing physicians had largely switched to buying generally less expensive non-repackaged drugs in bulk. Wang's study did not provide details on the difference in wholesale prices between repackaged drugs and bulk drugs and how that might affect what dispensing physicians charge.

The WCRI study undercuts another argument against limiting what physicians can charge — that if physician dispensing decreases or disappears, patients will pay higher prices at the pharmacy. The reasoning here is that physicians invariably dispense generic drugs, whereas pharmacies dispense both generic drugs and more costly brand-name versions.

However, Wang found that for the drugs most commonly dispensed by physicians, the generic version was almost always dispensed by physicians and pharmacies alike, meaning that patients did not face the prospect of paying for a brand-name drug at the pharmacy. Moreover, physicians invariably charged more than pharmacies for the generic drugs they handed to patients.

Ryan Says His Plan Keeps Obama's Health Savings

By Sam Youngman

NORTH CANTON, Ohio (Reuters) Aug 17 - Republican vice presidential candidate Paul Ryan acknowledged on Thursday that his proposed healthcare reforms rely on many of the same spending reductions for which he has criticized President Barack Obama, something that could undercut a central message of the Republican campaign.

Ryan and Republican presidential challenger Mitt Romney, charge that Obama's 2010 health law would weaken the popular Medicare health plan for the elderly by reducing its costs by $716 billion over the coming 10 years.

On Thursday, Ryan acknowledged that his own budget plan would keep the savings included in Obama's Affordable Care Act even as it would do away with the law itself.

"We voted to repeal Obamacare repeatedly, including those cuts," he told reporters at a hot dog stand in Ohio.

"When you repeal all of Obamacare what you end up doing is that repeals (those savings) as well. In our budget we've restored a lot of that," he said, referring to the savings.

Ryan's statement underlines the fact that his own budget plan, which passed the House of Representatives this spring, envisions spending $205 billion less on Medicare than Obama would during that time period.

Democratic Representative Chris Van Hollen, an Obama ally, told reporters Ryan would not use those savings to improve health coverage.

"While the Ryan plan took the savings, they did not plow any of the money back into strengthening Medicare benefits and in fact they used the money as part of their plan for additional tax cuts for the very wealthy," Van Hollen said on a conference call.

Medicare has moved front and center in the presidential race since Romney picked Ryan to be his running mate on Saturday.

Ryan has galvanized conservatives with his plan to gradually convert Medicare's fee-for-service approach into a system that relies on private insurers to keep costs down.

Under Ryan's plan, retirees would get a set amount of money each year to purchase health insurance on the private market or to pay for traditional Medicare.

The amount of the subsidy would grow at a slower rate than the projected rate of medical inflation. The nonpartisan Congressional Budget Office says that could force retirees to pay more out-of-pocket costs for their medical care.

The plan would only apply to people younger than 55.

Public reception of the plan has been mixed, with older voters most skeptical. Obama and his fellow Democrats charge that Ryan's approach would "end Medicare as we know it."

OBAMA PLAN UNPOPULAR TOO

Romney and Ryan are banking on the fact that voters, who go to the polls Nov. 6, are also unenthusiastic about Obama's health law.

Obama's planned health savings would come largely through reduced payments to hospitals and insurers, and patient benefits would not be affected. The savings would be used to expand health coverage to 30 million lower-income Americans.

Romney said that too much cost squeezing could prompt health care providers to drop out of the program, leaving Medicare recipients with fewer treatment options. His campaign said on Tuesday it would "restore the funding to Medicare."

"As the seniors in America understand what the President's plan is doing to Medicare, they're going to find it unacceptable," Romney told a news conference in Greer, South Carolina on Thursday.

As a congressman, Ryan was known for his detailed presentations about the merits of his plan and the perils of rising health costs. But the Romney campaign so far has avoided discussing details of the plan on the campaign trail.

"Romney wants Ryan to be the Coke Zero of his campaign: All the bold taste, but none of the calories of a detailed policy discussion of entitlements," said Dante Scala, a political analyst at the University of New Hampshire.

One Republican strategist with knowledge of the campaign's thinking said that its cautious approach was less due to Ryan's abilities than a desire to avoid a repeat of the disastrous reception of the party's 2008 vice presidential candidate, Sarah Palin.

"I think it's smart that he gains his footing, his traction and his comfort level," the strategist said. "Frankly, I'm pleased that they're erring on the side of caution as they tell the country who he is."

Reduction in Depression Treatment Linked to EMR Use

Patients with multiple chronic conditions are significantly less likely to receive treatment for depression at primary care practices that use electronic medical records (EMRs) compared with practices that do not use EMRs, new research shows.

Researchers at the University of Florida hypothesized that practices using EMRs would be particularly beneficial for complex patients with chronic conditions who are in need of depression treatment, offering greater efficiency in information sharing and delivery of care than those not using EMRs.

But the study of 3467 primary care practice visits by patients aged 18 years and older who were identified as having depression, which used data from the 2006 to 2008 National Ambulatory Medical Care Surveys, showed an opposite effect.

Although the use of EMRs did not affect depression treatment, defined as antidepressant prescription, referral to counselling, or both, in patients with 2 or fewer chronic conditions, the odds of receiving the treatment were significantly lower among patients with 3 or more chronic conditions (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.36 - 0.70; P > .001).

"We had been doing some research on the effect of health information technology on the delivery of care, and we expected use of EMRs would improve depression care by perhaps sending reminders of screening or treatment or help coordinate care," lead investigator Jeffrey S. Harman, PhD, at the University of Florida's College of Public Health and Health Professions, in Gainesville, told Medscape Medical News.

"We thought EMRs would be even more beneficial for patients who were complex with multiple conditions, but when we ran the analysis, we found the opposite of that."

The study is published in the August issue of the Journal of General Internal Medicine.

Learning Curve

The authors speculated that several factors could explain why a system designed to improve care could paradoxically be associated with as much as a 50% reduction in treatment.

For one thing, some research suggests that EMRs tend to have a heavier focus on biomedical information, as opposed to mental health issues. Other studies suggest that the use of EMRs can have the effect of interfering with psychosocial exchange, with the doctor spending more time interacting with the computer than the patient.

"We thought those 2 things might explain why we saw what we did, but to be clear, we have no way to know what caused the results we found, based on this data."

Psychiatrist Gabrielle Beaubrun, MD, whose work at Kaiser Permanente South Bay Medical Center, in Harbor City, California, focuses on integrating depression care into primary care, speculated that a diminished psychosocial exchange related to EMR use may have indeed factored into the findings, but that may have reflected the fact that the data came from the period 2006 to 2008, when many practices were only beginning to transition to EMRs.

"It's important to remember that back then, as psychiatrists, we were initially devastated by the idea of the electronic record," she told Medscape Medical News.

"We felt we were going to lose eye contact with the patient, and at first you do, but you have to get it back. You have to learn to let the patient interact with the machine."

"In our department, we demanded that our computers be set up on wheels so we could easily spin the screen around to show the patient what we're doing and to see what their graph looks like."

Patients, as well as physicians, have also been subject to a learning curve in the new age of EMRs, Dr. Beaubrun noted, "particularly the psychiatric patient, who is a bit wary of all of this stuff going into a computer, but they are gradually gaining comfort with it."

Time a Factor?

Whether or not EMRs are used, the idea of biomedical issues taking priority over mental health issues in primary care is an ongoing concern, but the fact that the patients in the study were diagnosed with depression indicates that clinicians at least got as far as spotting the problem.

The failure to take the next steps and offer treatment, particularly when there are 3 or more chronic conditions to address, may simply come down to a matter of time, Dr. Beaubrun noted.

"Primary care physicians, especially if they are contending with various other conditions, tend to view depression treatment as somewhat of a Pandora's box," she said.

"They may feel like, 'Oh no, I can't get into that whole antidepressant side-effects discussion.' Due to time constraints, they may just not want to go there."

A key solution, she says, is collaboration.

"The physician needs to work collaboratively with other healthcare workers and delegate someone to follow through on these types of things."

"You have to make delivering the right care easy. For instance, if the doctor needs to treat, go ahead and treat, and ideally, that can be accomplished with something like 1 click. Then someone else can do the 'Pandora's box' part of discussing the side effects with the patient."

Whereas clinicians may be inclined to believe that addressing the chronic conditions may, in itself, treat the depression, the assumption is risky, and the opposite can sometimes be the case.

"In psychiatry, we do encounter the idea from both patients and doctors that depression is a normal response to chronic illnesses, so why treat it, but in fact, clinical depression is not a normal response, and it does need to be treated," Dr. Beaubrun said.

"Ironically, the depression can be the lynchpin as to why so many other chronic conditions are happening," she added. "Treating the depression can in fact be central to getting the other conditions under control."

The authors and Dr. Beaubrun have disclosed no relevant financial relationships.

J Gen Intern Med. 2012;27:962-967. Abstract

Tool Makes Nursing Home Inspection Reports Easy to Search

August 15, 2012 — A new interactive tool makes it possible to search the results of government inspections in 14,565 nursing homes nationwide. The tool allows users to determine, for example, whether a given nursing home has a pattern of elopement among residents.

The tool, called Nursing Home Inspect, draws on government reports that were posted online in July 2012 by the US Centers for Medicare and Medicaid Services. Users can search reports by keywords such as "elopement," which refers to patients leaving the property undetected, and results can be sorted by severity of violation. Although up to 31% of nursing home residents with dementia wander at least once, a pattern of elopement at a home can be a sign of inadequate supervision.

Nursing Home Inspect is an application created by Propublica, an independent, nonprofit newsroom whose mission is "to expose abuses of power and betrayals of the public trust by government, business, and other institutions, using the moral force of investigative journalism to spur reform through the sustained spotlighting of wrongdoing." The Nursing Home Inspect effort was led by Charles Ornstein and Lena Groeger.

Ornstein and Groeger used the Nursing Home Inspect Tool to search nursing home inspection reports and described the results online in an article titled, "What We Found Using Nursing Home Inspect."

According to the 2010 Census, approximately 1.5 million people live in nursing homes. Nursing homes are inspected regularly, and additional inspections occur when there is a complaint. The Government Accountability Office has found that 19% of the complaints investigated nationally in 2009 were substantiated and resulted in at least one citation. The proportion of citations varies greatly from state to state.

Over the decades, federal auditors have flagged numerous dangerous and neglectful conditions. Auditors have found, however, that inspectors tend to be lenient, citing too few problems and ranking them as less severe than they actually are.

Among advocates, there has been a longstanding call those who for nursing home residents to make federal nursing home inspection reports available to the public.

Nursing Home Inspect now makes the recently released reports searchable online. When the word "elope" is typed into the interactive tool, the application returns 949 inspection reports. Other terms also return hundreds or thousands of results. For example, "injuries" returns 7912 results, "MRSA" returns 514 results, and "ignore" returns 275 results.

The search tool also allows users to compare the severity of the deficiency (ranked A through L) among institutions.

Advocates for residents hope that the reports and the application will be used as a tool for fixing the specific problems of each nursing home.

The reports do leave out valuable information; most notably, the things that the facilities are doing well. In addition, associated plans for correction are not included online, although they should be available at individual nursing homes. The reports also may be biased, in that inspectors for different regions have a tendency to issue citations for different things. Elopement, for example, may be defined differently, depending on the state.

Sara Singer, MBA, PhD, is an assistant professor of healthcare management and policy at Harvard University, Cambridge, Massachusetts. She is not affiliated with the creators of the tool, but discussed its implications withMedscape Medical News via email: "[Physicians] need to use this tool with care; eg, by searching for multiple keywords if they're interested in a particular topic. Moreover, it's important to consider what the nursing home is doing to address citations (ie, by reviewing the Plan for Correction and by talking to people at the home), and for nursing homes where their patients reside, they should consider ways they can be part of the solution to any problems identified. Physicians have an important role to play in leading and inspiring improvement in nursing homes."

Dr. Singer has disclosed no relevant financial relationships.

Two Physicians Charged in 9 Pain-Med Deaths

August 15, 2012 — The legal problems of 2 Florida physicians accused last year of participating in a massive painkiller "pill mill" deepened last month when federal prosecutors charged them with the overdose deaths of 9 patients.

Those deaths, prosecutors say, are part of a much higher body count in a criminal operation that attracted drug addicts and traffickers from all over the Eastern United States.

The 2 physicians, Cynthia Cadet, MD, and Joseph Castronuovo, MD, were among 13 physicians and 19 nonphysicians originally indicted on lesser charges in a federal court in Miami, Florida, in August 2011. Of the 13 physicians, 10 eventually pleaded guilty to conspiracy to commit money laundering or conspiracy to commit wire fraud. An eleventh indicted physician, Irwin Beretsky, MD, died last October at the age of 77 years while awaiting trial.

All 13 physicians initially pleaded not guilty, and Drs. Cadet and Castronuovo are the only ones maintaining their original pleas. The 2 physicians also have pleaded not guilty to the new charge of dispensing a controlled substance for illegitimate purposes that leads to the death of a patient, which is punishable by life in prison. Their lawyers contend that federal prosecutors have drummed up the new charges to punish them for not pleading guilty like the others.

"I think it's a vindictive process," said Michael Weinstein, Dr. Cadet's attorney, in an interview with Medscape Medical News.

A fourteenth physician who allegedly participated in the pill-mill operation was charged in a state court with first-degree murder in an overdose death. That physician, Gerald J. Klein, MD, is awaiting trial.

When the 14 physicians and the 19 nonphysicians were originally indicted last year in federal and state courts, an FBI agent described them as "the nation's largest criminal organization" involved in illegally distributing oxycodone and other opioid analgesics.

Garbage Bags Full of Cash

As in other recent cases of criminal medicine, including Medicare fraud, the 14 physicians in the South Florida pill mill did not run the show, but answered to nonphysicians, according to prosecutors.

The bosses, convicted felon Christopher George and his twin brother Jeffrey George, operated a string of pain-medicine clinics and hauled in more than $40 million from illegal drug sales over one 2-year span. Most of the patients hailed from other states, descending on Florida because it lacked a prescription drug-monitoring program during the period covered by the indictment.

The clinic where Dr. Castronuovo worked — called Executive Pain — specialized in treating pain-med seekers who were discharged from a sister clinic because needle track marks and scars identified them as intravenous drug users, according to prosecutors.

The George brothers paid their physicians according to how many patients they saw per day, which averaged 40 to 100. They also received thousands of dollars for allowing the George brothers to store controlled substances at the clinics using their Drug Enforcement Administration numbers. Altogether, the average physician earned more than $1 million a year.

Prosecutors say the physicians prescribed a standard "cocktail" of controlled substances — specifically, oxycodone and alprazolam — on an assembly-line basis without obtaining prior medical records, ordering alternative treatments such as physical therapy, or referring anyone to specialists. The clinics also dispensed the prescribed pain pills and accepted only cash or credit cards as payment to avoid the scrutiny of third-party payers. The cash was hauled to the bank in garbage bags.

Earlier this year, Christopher George and Jeffrey George each pleaded guilty to a federal charge of racketeering conspiracy and received prison sentences of 17.5 years and 15.5 years, respectively.

The physicians who have pleaded guilty so far have fared a little better. Seven were given prison sentences ranging from 4 years to 6.5 years. Another physician received a 6-month sentence, and yet another, 4 years on probation. Jacobo Dreszer, MD, the father of convicted defendant Roni Dreszer, MD, pleaded guilty only to die several weeks before he was scheduled to be sentenced.

The ignominious ending of medical careers, the prison sentences, and the deaths of Dr. Dreszer and Dr. Beretsky were not the only circumstances darkening the case with tragedy. US District Judge Kenneth Marra recommended that 4 of the physicians whom he sentenced to prison enroll in a 500-hour substance-abuse program behind bars.

Number of Overdose Deaths May Never Be Known

The greater tragedy in the case was the death toll among patients. Prosecutors have charged Dr. Cadet with 7 overdose deaths and Dr. Castronuovo with 2, all of them involving oxycodone. However, there were many other deaths associated with the entire pill-mill operation, as US District Attorney Paul Schwartz recounted to US Magistrate Judge Linnea Johnson in an arraignment and pretrial detention hearing last year regarding Dr. Cadet.

"We found that there were over 53 overdose deaths that we have been able to identify with this case alone, just in Florida," Schwartz said. "Again, we don't know how many kids died behind barns in Tennessee, Ohio, Kentucky, and West Virginia, and 87% of the patients came from out of state.

"Seven Floridians per day die from drug overdoses. This is because of physicians like this who abrogate their duty to do no harm."

Dr. Castronuovo has maintained his innocence regarding the overdose deaths attributed to him. He claims that 2 expert forensic pathologists reviewed the 2 patient deaths and concluded that neither was caused by the medications he prescribed, according to court records.

Thomas Sclafani, Dr. Castronuovo's attorney and a former federal prosecutor, described his client as a conscientious physician, especially when it came to patients who feigned illness and exaggerated their pain levels in the quest for opioids. "Dr. Castronuovo was able to use his 35 to 40 years of practice to weed out the people who were not legitimate," Sclafani told Medscape Medical News. "He threw them out."

Dr. Castronuovo, in his early 70s, has asked the court to sever his case from that of Dr. Cadet, arguing that the enormous amount of evidence to be entered against her will taint him. The government opposes that move.

Dr. Cadet, in turn, contends that her actions were legitimate and medically appropriate. A former attorney of hers noted in the arraignment and pretrial detention hearing last year that Dr. Cadet offered to take an FBI polygraph test to exonerate herself, a proposal turned down by US District Attorney Schwartz.

"She's been screaming from the rooftop since day one that she's innocent," said Michael Weinstein, Dr. Cadet's current attorney. "Just because another doctor takes a plea doesn't mean that she's done something wrong."

The government has asserted that Dr. Cadet, in her early 40s, should have figured out that the George twins were operating a criminal enterprise, which was acknowledged by the physicians who eventually pleaded guilty.

"They saw hundreds of...junkies lined up every morning before the clinic even opened," said Schwartz in last year's hearing. "They saw fights in the waiting room. They saw seizures in the waiting room. They saw the cops come in every day.

"They cannot distance themselves from the facts of the case. They can try to argue medicine, but the facts in this case sink them."

Weinstein counters that Dr. Cadet was hired to see patients, not help run the clinic. "There's no connection between her care of patients and the day-to-day operation of the clinic," he told Medscape Medical News.

US Magistrate Judge Linnea Johnson had something to say on that subject, too.

"It doesn't take a rocket scientist to know a pill mill," she said during Dr. Cadet's hearing last year. "So it is a little difficult for one to assume that the physicians behind the desk don't see what the folks standing on the corner see regarding these pill mills, but (Dr. Cadet's) guilt or innocence remains for a jury."

Obama Pushes for State Help on Health Exchanges

By David Morgan

WASHINGTON (Reuters) Aug 13 - The Obama administration this week will try to encourage reluctant U.S. states to move forward with health insurance exchanges amid fears that time is running out for states to act on a reform provision meant to extend coverage to millions of low-to-moderate income uninsured Americans.

The U.S. Department of Health and Human Services has scheduled four regional meetings this month to discuss the exchanges and other aspects of President Barack Obama's healthcare reform law with state officials and others.

The meetings begin on Tuesday in Washington, D.C., and continue in Atlanta, Chicago and Denver until August 22.

Experts say time is short for states to begin setting up health-insurance exchanges - regulated online marketplaces where families and individuals can purchase private insurance plans at rates subsidized by the federal government.

Because the healthcare law requires Washington to set up federal exchanges in states that do not create their own, the administration could face the daunting task of establishing federal exchanges in dozens of states - raising questions about a possible delay in the implementation of reform.

"They need a lot of cooperation from the states in order to succeed," said Joel Ario, a former director of the administration's Office of Health Insurance Exchanges.

The idea of exchanges, much like the overall healthcare reform law known by critics as "Obamacare," has become an election-year flashpoint for several Republican governors who reject the exchanges plan along with the Medicaid expansion as too costly and bureaucratic.

The exchanges are key to the Patient Protection and Affordable Care Act's goal of providing coverage to more than 30 million uninsured people.

As originally envisioned, the exchanges would provide subsidized coverage for 16 million uninsured Americans with annual incomes of up to about $88,000 for a family of four.

The law calls for states to decide later this year about whether they will set up exchanges themselves, and calls for the exchanges to open enrollment in October 2013 with full operations beginning January 1, 2014.

But some analysts wonder if the administration can cope with the bureaucratic and political logistics necessary to have federally facilitated exchanges running on time in a large number of states.

"It is a distinct question, which makes you wonder if at some point next year there will be a decision made to give states more time, or let the ones that are ready move ahead on their own," said Paul Ginsburg of the Washington-based Center for Studying Healthcare Change.

Only 15 states have passed legislation or issued executive orders to establish exchanges, while seven have decided not to create exchanges at all, according to the nonpartisan Kaiser Family Foundation, which tracks healthcare issues.

Many of the remaining 28 states are waiting to see which party controls the White House and Congress after the November 6 election.

Republicans led by the party's presidential nominee Mitt Romney have vowed to repeal the Affordable Care Act and replace it with their own policies, although Republicans have released few details for such a plan.

Experts say the federal government should have little trouble setting up an information technology system for consumers to shop for health insurance plans online.

A greater harbinger of success for federal exchanges is the degree of cooperation the administration receives from states in vetting insurers and health plans, determining eligibility and providing consumer service and support including call centers.

"If they have to do that in 40 or 45 states, that's a very tall order," Ario said.

Ario said the administration has sought to show flexibility for states, including a decision to allow states to set their own benchmarks for the essential health benefits that would be offered through their exchanges.

The administration has also given states the option of running an exchange in partnership by sharing operations with the federal government.

Officials say the aim is to assist states with partnership exchanges and federal exchanges that can later transition into state-run operations.

Register for the CMS and PAHCOM Webinar on Stage 1 of the EHR Incentive Programs

Join CMS for a Webinar Providing a Detailed Look at Stage 1 of the EHR Incentive Programs Today

The Centers for Medicare & Medicaid Services (CMS) and the Professional Association of Health Care Office Management (PAHCOM) are holding a free and open webinar on the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs Today, from 1:30 – 3:00 pm ET.

 

Description:

The webinar, CMS Presents: Medicare and Medicaid EHR Incentive Programs - Stage 1 Meaningful Use, Deep Dive, will provide an overview of how the Medicare and Medicaid EHR Incentive Programs are structured and administered, and will provide key insights for providers regarding Stage 1 of meaningful use.

 

Presenter:

Robert Anthony, a Health Specialist in the Office of E-Health Standards and Services at CMS, will present on details about Stage 1 requirements. He contributes to policy development and implementation of the Medicare and Medicaid EHR Incentive Programs.

 

To Register:

Interested individuals can register online.

 

Want more information about the EHR Incentive Programs?

Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Reminder for Important EHR Incentive Program Deadline

October 3rd is the Last Day for EPs to Begin their 90-Day Reporting Period for 2012

Wednesday, October 3rd, is the last day for eligible professionals (EPs) to begin their 90-day reporting period for calendar year (CY) 2012 for the Medicare EHR Incentive Program. For EPs, this means that they must begin their consecutive 90-day reporting period by October 3rd in order to attest to meeting meaningful use and be eligible to receive an incentive payment for CY 2012.

 

For EPs who have already completed their reporting period, CMS has a number of tools available to help prepare for attestation. EPs can use the CMS Eligible Professional Attestation Worksheet to record their meaningful use measures to have as a reference when attesting for the Medicare EHR Incentive Program in CMS' web-based Registration and Attestation System. The Meaningful Use Attestation Calculator and Attestation User Guide for Eligible Professionals can also help EPs to successfully attest to meeting meaningful use.

 

CMS encourages EPs not to miss the opportunity to participate in the Medicare EHR Incentive Program this year. Begin your reporting period by October 3rd to get on the path to payment for CY 2012.

Looking Ahead

Take a look at all of the other EHR Incentive Program important dates that are coming up by going to our CMS Medicare and Medicaid EHR Incentive Programs Milestone Timeline, or reviewing the “Important Dates” section of the EHR Incentive Programs’ Overview page.

Want more information about the EHR Incentive Programs?

Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Learn How to Send CQM Data Electronically

Did you know that you can now submit your CQM data for the Medicare EHR Incentive Program electronically?

The Physician Quality Reporting System (PQRS) Medicare Electronic Health Record (EHR) Incentive Pilot allows eligible professionals to meet the clinical quality measure (CQM) reporting objective of meaningful use requirements  for the EHR Incentive Program through electronic submission while also reporting for the PQRS program. 

 

A provider who wishes to participate in the electronic reporting pilot must submit 12 months of clinical quality measures data. Eligible professionals must submit the data between January 1, 2013 and February 28, 2013.

 

CQM data for the electronic reporting pilot must be derived from certified EHR technology.  If you decide to submit the data directly from your EHR, your EHR also needs to be PQRS “qualified.” You can also have a PQRS-qualified data submission vendor submit quality measures data for the electronic reporting pilot on your behalf. 

 

A list of the 2012 PQRS-qualified EHR and data-submission vendors is posted on the PQRS website. 

 

You can register for the electronic reporting pilot program while attesting for the EHR Incentive Program on the online registration page.  Simply check “Yes” on the eReporting page as you go through the attestation process.

Want more information about the EHR Incentive Programs?

Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.