CMS Issues Guidance on Part D vs. Part B Coverage Determination

In a Special Edition article, the Centers for Medicare and Medicaid Services (CMS) suggested a way for physicians to bypass the use of prior authorization forms for determination of prescription coverage under Part D (i.e., drugs available only by prescription and used for an indication not covered under Part B) versus Part B (i.e., drugs furnished and administered as part of a physician service, and selected others such as hemophilia clotting factors). Because prescription drug plans cannot pay for drugs that are covered under Part B, plan administrators have required prescribers to fill out authorization forms to verify a drug is being used for a Part D indication. For example, prednisone used to prevent organ rejection in a patient who has had a Medicare-covered transplant would be covered under Part B, but for other indications could be covered under Part D. To simplify the procedures, CMS has instructed that if the prescriber writes Part D on the prescription along with a Part D diagnosis, the prescription should be filled without the need for additional verification. For more information, and to download a copy of the guidance, visithttps://www.aafp.org/news-now/government-medicine/20060815formedicarepartd.html.

Residents, Students Adopt Resolutions on Drug Samples, Universal Care

During the National Conference of Family Medicine Residents, held in August in Kansas City, Mo., the National Congress of Student Members and National Congress of Family Medicine Residents adopted resolutions on the issues of pharmaceutical marketing and equal access to health care. Both congresses requested a workshop for the 2007 conference on alternatives to accepting and distributing free drug samples from pharmaceutical companies. They noted that a ban on free samples could prevent low-income or uninsured patients from receiving necessary medications, but expressed concern about starting patients on a therapy that may not be available to them later, and promoting newer medications over evidence-based care. Students also passed resolutions asking the American Academy of Family Physicians (AAFP) to investigate discrepancies between health care charges for insured patients and those for underinsured or uninsured patients, and to oppose legislation criminalizing physicians who provide care to undocumented patients. Both congresses called on the AAFP Task Force on Health Care Coverage for All to consider a single-payer system as a viable option for health care system reform. For more information, visithttps://www.aafp.org/news-now/resident-student-focus/20060814studentresidentresolutions.html.

CMS Proposes Changes to Outpatient Services Policies and Payment

The CMS issued a proposed Medicare payment rule for outpatient services that would tie payment rate increases to the reporting of quality measures. The rule would begin in 2007 and apply to payment rates under the outpatient prospective payment system (OPPS) for services provided to Medicare beneficiaries. Under the rule, hospitals that report quality measures for the update in the inpatient prospective payment system (IPPS) also would receive a full update on outpatient payments. Hospitals required to report quality measures for inpatient services to receive the full IPPS update but failing to do so would receive the OPPS update minus 2 percentage points. The CMS hopes that performance data submission and reporting of comparative information will encourage quality improvement for all hospital services, because activities in many of the inpatient measures are the same as those for outpatient care. It estimates that hospitals will receive an overall average increase of 3.0 percent in Medicare payments for out-patient department services in 2007 as a result of the proposed changes. For more information, visithttp://www.cms.hhs.gov/HospitalOutpatientPPS/HORD/list.asp#TopOfPage.

HHS Announces Final Regulations to Support Adoption of Health IT

Final rules displayed by the CMS and the Office of the Inspector General (OIG) in August created new exceptions and safe harbors to fraud and abuse laws regarding the donation of health information technology (IT) and services. The CMS rule creates exceptions to the physician self-referral law (which prohibits referral of Medicare patients to entities with which the physician has a financial relationship), and the OIG rule establishes safe harbors under the federal anti-kickback statute. The rules establish the conditions under which entities supplying designated health services may donate interoperable health software and training services, and under which hospitals and certain other entities may provide physicians with technology and training for electronic prescribing. The scope of donors and recipients under the final rules is broader than in the rules proposed in 2005, although recipients must pay 15 percent of the cost of technology and services. For more information, visit the CMS Web site athttp://www.cms.hhs.gov.

Researchers Develop Method to Assess Pandemic Potential of Viruses

Researchers at the Centers for Disease Control and Prevention (CDC) have developed a method of research to aid understanding about a virus’s pandemic potential. The avian influenza H5N1 viruses in circulation possess two of the three characteristics believed necessary for a virus to cause a pandemic: they are new viruses to which humans have little immunity, and they are able to infect humans and cause illness. The researchers aimed to learn more about the genetic changes viruses would have to undergo to acquire the third characteristic—the ability to spread easily from person to person in a sustained manner. They placed ferrets infected with H5N1 viruses, human H3N2 influenza viruses, or hybrids of the two viruses in close proximity to healthy ferrets and assessed the virus transmission. The H3N2 viruses transmitted effectively by droplets, but the H5N1 and hybrid viruses did not. The hybrid viruses also caused less severe illness than the originals. When the hybrid virus was passed through a series of ferrets, it produced only one genetic change, which did not enhance its transmissibility. The research suggests that significant changes in the H5N1 virus would be necessary before a strain with the potential to cause a pandemic is created. For more information, visithttp://www.cdc.gov/od/oc/media/pressrel/r060731.htm.

Study Finds Tailored HIV Program Reduces Risky Sexual Behaviors

A study funded by the National Institute of Nursing Research showed that use of a culturally appropriate human immunodeficiency virus (HIV) risk-reduction program was more effective among Hispanic adolescents than a program promoting general health. Both programs consisted of six 50-minute modules delivered to small groups. The HIV intervention emphasized abstinence and use of condoms as effective and culturally accepted methods to prevent sexually transmitted diseases, whereas the general health intervention addressed diet, exercise, and drug use. Participating adolescents were mostly of Puerto Rican origin and had an average age of 15 years. In follow-up surveys conducted up to 12 months after the program, adolescents who attended the HIV program were less likely to report engaging in sexual intercourse, having multiple partners, or having unprotected intercourse than those given the general health promotion. For more information, visithttp://www.nih.gov/news/pr/aug2006/ninr-07.htm.

NHLBI Offers Guide to Physical Activity for a Healthy Heart

The National Heart, Lung, and Blood Institute (NHLBI) has published a guide offering easy-to-understand information on physical activity to maintain a healthy heart. Your Guide to Physical Activity and Your Heart gives walking and jogging program suggestions, ideas for family activities, and instructions for finding your target heart zone, and addresses other benefits of regular physical activity. The guide can be downloaded free from the NHLBI Web site athttp://www.nhlbi.nih.gov or ordered from its Information Center by calling 301–592–8573.