B USH P ROPOSES 2009 M EDICARE , M EDICAID C UTS ,
THE LEADER
Skin & Allergy News
VO L . 3 9 , N O. 3
About 75% of patients in the 90-mg group had psoriasis rated as
“cleared or minimal,” according to Dr. Kenneth B. Gordon.
Ustekinumab’s Next
Psoriasis Stop: FDA
BY SHARON WORCESTER
Southeast Bureau
S A N A N T O N I O — Long-term,
continuous use of ustekinumab
for maintenance therapy in pa-
tients with moderate to severe
plaque psoriasis is efficacious
and generally well tolerated, ac-
cording to phase III study find-
ings reported at the annual
meeting of the American Acad-
emy of Dermatology.
The results of the PHOENIX I
trial—a randomized, double-blind,
placebo-controlled crossover trial
of the human monoclonal anti-
body against interleukins 12 and
23—showed that treatment re-
sponse was better maintained at
76 weeks in responders who re-
ceived 45 mg or 90 mg of ustek-
inumab every 12 weeks, compared
with those who discontinued
treatment at 40 weeks, Dr. Ken-
neth B. Gordon of Northwestern
University, Chicago, reported dur-
ing a poster session.
Just days after the data were
presented, the drug’s manufac-
turer (Centocor Inc.) announced
that its Biologics License Appli-
cation for ustekinumab (CNTO
1275) had been accepted for re-
view by the Food and Drug Ad-
ministration.
The results of another phase III
study (PHOENIX II) of ustek-
inumab, which were reported in
October at the World Congress
PAGE 61
IN NEWS
AND
MEETING
COVERAGE
www.skinandallerg ynews.com
T he Leading Inde pendent Ne wspaper for Medical, Surgical, and Aesthetic Der matology MARCH 2008
INSIDE
Melanoma Quality
Measures Dropped
From Medicare P4P
Emphasis is placed on EMRs, e-prescribing.
©PAUL D OUGHTY / PKDOG . COM
Mohs Nose BY ROBERT FINN suitable for dermatology prac-
Tissue-sparing technique San Francisco Bureau tices, according to Dr. Mark D.
may be best for critical Kaufmann.
T
anatomic sites. hree melanoma measures A smoking cessation measure
that were added to the also exists, but reporting it makes
PAGE 23
Physician Quality Report- dermatologists subject to report-
ing Initiative in mid-2007 have ing a cluster of preventive care
been eliminated, leaving derma- measures. Many dermatologists
Botox tologists with limited opportuni- are not satisfied with these limit-
News ties to qualify for bonus pay- ed opportunities.
FDA issues warning;
injections show promise as
Raynaud’s treatment.
ments from the Center for
Medicare and Medicaid Services
that could have totaled up to
“It’s clear to me, and it has been
for several years now, that the
government has convinced itself
PAGE 13
1.5% of Medicare billings.
Like physicians in other spe-
cialties, dermatologists can still
that we are going to save billions
of dollars by going electronic, and
I think that’s where the push is go-
qualify by using certain electron- ing to be from now on,” Dr. Kauf-
of Dermatology in Buenos Aires, ic medical record (EMR) and e- mann said in an interview. And, at
showed that ustekinumab was prescribing systems. The e-pre- a talk during the 2008 American
effective and safe in more than scribing measure can be reported Academy of Dermatology meet-
two-thirds of 1,230 patients with alone and appears to be the most See P4P page 61
moderate to severe disease who
received two subcutaneous doses
of the drug. A 75% improvement
in the psoriasis severity area index Controversy Lingers Over
score (PASI 75) was achieved in
67% of patients randomized to
receive 45-mg doses, 76% of Hands Off
Sunscreen Seal Program
those randomized to receive 90- Even after diarrhea resolves, BY JOHN R. BELL available for cosmetics/moistur-
mg doses, and 4% of those in the C. difficile spores remain on Associate Editor izers, clothing, hats, laundry ad-
placebo group, the investigators patient’s body. ditives, shade structures, and
reported. S A N A N T O N I O — The Amer- window films/tints that meet ev-
For the current study, 766 pa- PAGE 42 ican Academy of Dermatology’s idence-based criteria for reducing
tients were randomized to re- Seal of Recognition program sun exposure.
See Ustekinumab page 7 continued to raise concerns At the AAD’s annual meeting,
among some dermatologists at Dr. A. Bernard Ackerman sub-
CASE OF THE MONTH the Academy’s annual meeting. mitted to academy officials a pe-
Since the program was ap- tition signed by 80 members op-
proved in July 2006, two prod- posed to the program; that action
ucts have been selected to carry caused a special meeting of
C OURTESY D R . J OELY K AUFMAN
the seal: Aveeno Continuous members to be held on Feb. 4.
Protection Sunblock Lotion SPF The meeting was open to all
55 and Aveeno Baby Continu- AAD members; 97 voting mem-
ous Protection Sunblock Lotion bers were present and 80 voted in
SPF 5, according to the AAD. a closed ballot straw poll, ac-
The Seal of Recognition is also See Controversy page 10
A 66-year-old fisherman with a history of chronic sun expo-
sure presents with a 2-month history of a slowly growing
plaque that began as a bump and grew into a ring. The lesion
was completely asymptomatic. He has no known allergies or any
other pertinent history, except for hypertension. Physical exam
reveals a nontender, nonscaling annular plaque on his right fore-
arm. No other similar lesion is observed. The lesion is KOH neg-
ative. What’s your diagnosis? See Case of the Month, page 75.
 M a r c h 2 0 0 8 • w w w. s k i n a n d a l l e r g y n e w s . c o m Practice Trends 61

Bush Proposes Medicare, Medicaid Cuts for 2009

B Y M A RY E L L E N The proposal would reduce in- cuts make it impossible for physi- American Diabetes Association, Under the plan, the human
SCHNEIDER direct medical education add-on cians to continue to invest in a said in a statement. “The Ameri- drugs program would receive
Ne w York Bureau payments from 5.5% to 2.2% health care infrastructure that fa- can Diabetes Association calls on $984 million in FY 2009, an in-
over the next 3 years, and would cilitates data collection and qual- Congress to align their priorities crease of $68 million. The in-

I
n the final budget proposal of
his presidency, President
Bush is planning substantial
cuts to hospitals, skilled nursing
facilities, and graduate medical
education.
Leaders in the Democrat-con-
trolled Congress immediately
declared the proposal dead on
arrival.
Under the plan, the Bush ad-
ministration has put forth leg-
islative and administrative pro-
posals that would cut $12.8
billion from the Medicare pro-
gram in fiscal year 2009 and
about $183 billion over the next
5 years, largely from hospital and
other provider payments. The
idea is to slow down the growth
rate of the program from 7.2% to
5% over 5 years. But critics say
the cuts would harm hospitals
that care for low-income patients
and train physicians.
The FY 2009 budget proposal
calls for freezing payments to in-
patient hospitals, long-term care
hospitals, skilled nursing facili-
ties, hospices, outpatient hospi-
tals, and ambulance services
from 2009 through 2011. Pay-
ments would then drop 0.65%
annually under the proposal.
The proposal also outlines a
eliminate the duplicate hospital
indirect medical education pay-
ment for Medicare Advantage
beneficiaries.
Hospitals would also face ad-
ditional cuts under the plan. For
example, the proposed budget
would reduce hospital capital
payments by 5% in 2009, and
hospital disproportionate share
payments would drop 30% over
the next 2 years.
The FY 2009 budget plan also
includes proposed legislative and
administrative changes aimed at
cutting nearly $18 billion from
Medicaid over the next 5 years.
The administration’s budget
would reauthorize the State Chil-
dren’s Health Insurance Program
(SCHIP) through 2013. The plan
calls for a $19.7 billion increase to
the program over 5 years, in-
cluding $450 million in outreach
grants to states and other orga-
nizations to help enroll uninsured
children in the program.
One area that the administra-
tion’s budget proposal does not
address is the 10.6% physician
pay cut scheduled to take place
this July.
The administration’s budget
“falls short” by not including a
proposal to fix the Medicare
ity improvement while ensuring
that patients have access to high
quality care.”
In total, the administration is
requesting $711.2 billion for the
Centers for Medicare and Medic-
aid Services to cover mandatory
and discretionary outlays for the
Medicare, Medicaid, and SCHIP
programs. The request is a $32.7
billion increase over the FY 2008
funding level.
Federal research agencies are
also facing funding cuts or
freezes under the FY 2009 budget
proposal.
The administration is propos-
ing no increase for the National
Institutes of Health, keeping the
agency’s budget at approximate-
ly $29.5 billion. Health advocates
say the failure to expand NIH
funding will hurt research efforts
in several critical areas.
For example, the National In-
stitute of Diabetes and Digestive
and Kidney Diseases would re-
ceive an increase under the ad-
ministration’s proposal, but the
$2.6 million bump amounts to a
0.15% increase over FY 2008. The
American Diabetes Association
is urging Congress to disregard
the president’s proposal and pro-
vide $112.5 million in additional
and provide funds to remedy this
growing health crisis.”
The administration’s budget
proposal also calls for $8.8 billion
in funding for the Centers for Dis-
ease Control and Prevention, a
$412 million drop from FY 2008.
The Agency for Healthcare Re-
search and Quality would also
face a cut under the proposal. The
president is calling for $326 mil-
lion in funding for the agency, a $9
million decrease from FY 2008.
The Food and Drug Adminis-
tration would receive a $130 mil-
lion increase over FY 2008, bring-
ing the total funding to 2.4 billion
in FY 2009. The FDA budget pro-
posal includes increases in the
human drugs and devices pro-
grams at FDA.
D A T A
Adults Who Did Not Receive Needed Health Care
Because They Could Not Afford It
8.1% 7.7%
crease includes estimated user
fees coming into the agency. The
increases are slated to fund im-
provements in drug safety and
regulation of biologic therapies.
The budget includes a funding
commitment of $389.5 million
for drug safety, an increase of $36
million in FY 2008. In addition,
the budget includes a proposal to
grant the FDA new authority to
approve follow-on biologic pro-
teins through a new regulatory
pathway. The administration also
is seeking user fees to cover the
costs of the new activity.
Under the administration’s
budget request, the medical de-
vices program at FDA would re-
ceive $291 million, an increase of
$7 million. ■
W A T C H

E LSEVIER G LOBAL M EDICAL N EWS

payment freeze for inpatient re-
habilitation facilities and ambu-
latory surgical centers in 2010
and 2011, followed by annual
cuts. And home health agencies
would also see a 0% update from
2009 through 2013 followed by
annual payment cuts.
physician payment formula, the
American College of Cardiology
said in a statement.
“Physicians are willing to do
their part, but quality cannot be
achieved under a zero-sum sce-
nario,” according to the state-
ment. “Continued deep payment
2.5%
funding, a 6.6% increase.
“We cannot afford not to invest
in diabetes research, treatment, 18-44 45-64 욷65
and prevention—the conse- Age (years)
quences for our health care sys-
tem and our society will be too se- Note: Based on 2005 data from the previous 12 months.
vere,” Dr. John B. Buse, president Source: Centers for Disease Control and Prevention
of medicine and science for the

NQF Failed to Endorse Measures
P4P from page 1
ing, he said, “It appears the government be-
lieves that they will save a lot more money
having [physicians] use EMR systems than
saving melanoma patients’ lives.”
Dr. Kaufmann of Mount Sinai Medical
Center, New York, has a special expertise
in EMRs. He serves as a juror for the Cer-
tification Commission for Healthcare In-
formation Technology (CCHIT), the non-
profit organization formed to develop
standards on the functionality and inter-
operability of EMR systems.
According to the 2008 list of eligible
measures from the Physician Quality Re-
porting Initiative (PQRI), qualifying EMR
systems must either be CCHIT certified
or capable of producing a medication
list, generating a problem list, and enter-
ing laboratory tests as discrete searchable
data elements.
During the last half of 2007, the PQRI
list of eligible measures included three re-
lated to melanoma. Dermatologists would
be eligible for bonus payments from CMS
if they could demonstrate that they asked
about new or changing moles, performed
a complete skin exam, and counseled the
patient to perform self-examination for
new or changing moles.
The melanoma measures were added af-
ter being endorsed by the AQA Alliance
(formerly the Ambulatory Care Quality
Alliance), but they were later removed
because they failed to be endorsed by the
National Quality Forum (NQF).
“If it’s an AQA-endorsed measure, the
federal government may recognize it,”
said Dr. Dirk Elston, director of the de-
partment of dermatology at the Geisinger
Medical Center, Danville, Pa. “If it’s an
NQF-endorsed measure, the federal gov-
ernment must recognize it as a national
standard other than by act of Congress.”
There were several reasons for the
NQF’s failure to endorse the melanoma
items, Dr. Elston said. First, “they were
specific to dermatology and would be dif-
ficult to report for any other type of physi-
cian who was seeing patients with skin
disease. And second, both AQA and NQF
considered them low-bar measures.”
But other items in the 134-item list for
2008 appear to be specific to certain spe-
cialties. For example, item 14 calls for pa-
tients with age-related macular degenera-
tion to receive a dilated macular
examination, item 43 calls for surgeons to
use the internal mammary artery during
coronary artery bypass grafting, and item
100 calls for colorectal cancer patients to
receive a certain type of histologic staging.
The full list of reported measures is avail-
able through the PQRI Web site at
www.cms.hhs.gov/PQRI.
Dr. Elston emphasized that complying
with PQRI measures is voluntary, with the
payments reaching at most 1.5% of the
Medicare Physician Fee Schedule allowed
charges for covered services. To receive
payments, physicians must report mea-
sures for at least 80% of eligible patients.
While the benefits of participating in
the PQRI program are modest and there
are no penalties for noncompliance, Dr. El-
ston noted that private payers are likely to
adopt similar quality measures, and their
quality platforms are likely to include both
bigger carrots and bigger sticks.
“Not participating in private-payer pro-
grams carries the risk of having a lower
quality rating on the Web site where the
carrier lists their participating physicians,”
Dr. Elston said. “It also carries the risk of
higher patient copays when they come to
visit you.” Some states are even discussing
the possibility of making physician reli-
censure dependent on participation in a
performance improvement plan, he said.
In late 2007, the White House proposed
that physicians who meet quality bench-
marks would have their Medicare reim-
bursements frozen at current levels, while
those who did not would be subject to a
10% cut in payments.
Meanwhile, the PQRI, the AQA alliance,
and the NQF are working on new lists of
quality measures, from which Dr. Elston
hopes that dermatologists will have a
menu of items from which they can
choose relevant quality reporting mea-
sures. Among them may be measures re-
lated to glucocorticoid-induced osteo-
porosis, proper antibiotic use, and other
areas of patient safety. ■