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Teaching Hospital Update - March 15-19, 2010


Email Alert

By Leah Voigt*

March 19, 2010

Record Match Day Sees Increase in Primary Care Placements

"Follow the money" is advice that resonates with many debt-burdened seniors at U.S. medical schools. That usually means fierce competition for residency training in high-paying specialties such as dermatology and orthopedic surgery, and on Match Day 2010 that trend is holding, according to the National Resident Matching Program.

Once again, the most competitive residency positions in the match were neurosurgery, orthopedic surgery, dermatology, and otolaryngology, with 90% of the available training slots in those specialties filled by seniors at U.S. medical schools. But there was also good news in primary care--which has suffered from declining interest in recent years. There was a 9% increase in the number of U.S. medical school seniors who sought positions in family medicine residency programs, along with a 3% increase in internal medicine, and a 2% increase in U.S. seniors matching to pediatrics.

Overall, the National Residency Match Program said today's match was the largest ever, with 30,543 applicants, including more than 16,000 U.S. medical schools seniors. In family medicine, the increase was somewhat surprising since the 2,608 residency slots offered this year include seventy-three training posts that were available last year when there was a 7% decline in U.S. seniors matching to family medicine training programs. Still, less than half of the offered family medicine slots, 1,169, were snatched up by U.S. seniors, which means that most of the family medicine residency positions will be filled by international medical graduates.

Internal medicine, by contrast, offered 4,999 positions of which 2,722 were filled by U.S. seniors, while pediatrics matched U.S. seniors to 1,711 of the 2,428 positions offered. Likewise, all but five obstetrics and gynecology slots were filled, and most them (915 of 1,187 offered positions) were filled by seniors at U.S. schools. Emergency medicine was the choice of 1,182 U.S. seniors who were matched to the 1,556 available slots.

Peggy Peck, Record Match Day Sees Increase in Primary Care Placements, MedPage Today (Mar. 18, 2010).

Court Says Hospital's Discharge of Intern Who Was Not Qualified Did Not Violate ADA

University of Maryland's health system did not violate the Americans with Disabilities Act (ADA) in discharging an intern who was unable to perform the essential functions of his job with or without reasonable accommodation, a federal appeals court ruled March 11 (Shin v. University of Maryland Medical System Corp., 4th Cir., No. 09-1126, unpublished 3/11/10).

The U.S. Court of Appeals for the Fourth Circuit said in an unpublished decision that, even assuming Frank Shin was disabled or regarded by his colleagues and supervisors as disabled, he failed to present evidence that he was qualified to perform his job as a hospital intern or that the accommodations he sought--reduced patient loads and a nurse practitioner to assist him--were reasonable under the circumstances. The court noted that Shin's performance was rated as deficient during several rotations prior to his dismissal and that he was provided substantial assistance--tutoring, mentoring, and help in completing patient orders and other work--in an effort to help him complete his internship. When Shin requested additional accommodations, however, the hospital balked.

These additional accommodations were not reasonable, it claimed, because they would prevent him from reaching the minimum number of intern admissions required for him to successfully complete his first-year program, and that the additional time and assistance he sought to help him process and synthesize patient information was counterproductive to his gaining the skills he needed to become a physician.

A federal trial court found that these additional efforts were not necessary under the reasonable accommodation mandate of the ADA and granted the motion for summary judgment filed by the University of Maryland Medical System Corporation and its residency program director. The Fourth Circuit affirmed.

Court Says Hospital's Discharge of Intern Who Was Not Qualified Did Not Violate ADA, BNA's Health Care Daily Report (Mar. 17, 2010) (note: registration is required to view this content).

Medical Product Research, Approval Get New Push from NIH, FDA

The National Institutes of Health (NIH) and the U.S. Food and Drug Administration (FDA) have announced a new joint effort to accelerate the regulatory review process and streamline biomedical research in the hopes of getting new medical products to market more quickly. On February 24, 2010, the agencies announced the formation of an NIH-FDA Joint Leadership Council to spearhead collaborative work on public health issues. The council's mission will be to help ensure that the latest science is integrated into the regulatory process. The NIH and the FDA will jointly issue a request for applications, making $6.75 million available over three years for work in the field of regulatory science.

The council's formation is necessary because although remarkable biomedical sciences have been made over the years, more progress can be made in reducing the time it takes for a new scientific discovery to translate into needed treatment for patients, said U.S. Department of Health and Human Services Secretary Kathleen Sebelius. "Collaboration between NIH and FDA, including support for regulatory science, will go a long way toward fostering access to the safest and most effective therapies for the American people," Sebelius said.

While the two agencies have teamed up before on health initiatives, the council represents the most extensive cooperative use of their respective capabilities, said Francis S. Collins, MD, PhD, NIH's director. The collaboration "is the first of its kind and will use the NIH's breadth of experience as a leader in biomedical sciences to help make the regulatory review process at the FDA as seamless as possible," he said.

The NIH and the FDA will hold a public meeting this spring to solicit input on how the agencies can work better together. Access more information about the partnership.

Chris Silva, Medical Product Research, Approval Get New Push from NIH, FDA, Am. Med. News (Mar. 12, 2010).

Providers, Payors Praise FCC Broadband Plan as Practical for Advancing HIT

The Federal Communications Commission's (FCC's) sweeping broadband plan that was sent to Congress March 16, 2010, is being lauded by healthcare providers and payors for making practical recommendations on how hospitals and doctors, particularly in rural areas, can take advantage of the efficiencies of telemedicine technologies and improve chances that all doctors and hospitals could become "meaningful users" of electronic health records.

"The FCC has gone beyond what any other federal agency has done," American Telemedicine Association President and pediatric cardiologist Karen Rheuban said during a March 17, 2010, briefing on the healthcare recommendations in the plan. The briefing was sponsored by the Health IT Now Coalition.

The FCC's broadband plan, which was mandated by Congress in the American Recovery and Reinvestment Act (ARRA), addresses a vast spectrum of issues in addition to healthcare and is expected to shape federal communications policies for decades. Among the plan's far-reaching goals are FCC efforts to extend high-speed Internet access to all corners of the country within ten years. The Senate Commerce, Science, and Transportation Committee and the House Energy and Commerce Committee have already scheduled hearings to review the plan. The Senate committee will hold its hearing March 23, 2010, and the House panel will hold its hearing on March 25, 2010. All five FCC commissioners are expected to testify.

Among recommendations that the FCC made for its own agency was to reform the Rural Health Care Program, which includes assistance funding for urban and rural telecommunications services, assistance funding for Internet access, and a pilot project to extend broadband to rural and urban hospitals that currently have limited access. The plan specifically calls for replacing the existing Internet access fund with a healthcare broadband access fund that would assist rural and urban providers in paying for broadband services in areas where adequate services for healthcare uses are cost prohibitive.

Kendra Casey Plank, Providers, Payors Praise FCC Broadband Plan as Practical for Advancing HIT, BNA's Health Care Daily Report (Mar. 18, 2010) (note: registration is required to view this content).

Genetics Add Little to Breast Cancer Risk Prediction

The addition of genetic information only modestly improved breast cancer risk assessment in an analysis of 5,600 cases. In a model that included age, study characteristics, and four conventional risk factors, the inclusion of ten genetic factors improved risk assessment by less than 7%. The absolute increase was less than 4%.

About 40% of the time, a randomly selected patient with breast cancer had an estimated risk that was no greater than the estimate for a woman who did not develop breast cancer during the follow-up period. "Our results indicate that the recent identification of common genetic variates does not herald the arrival of personal prevention of breast cancer in most women," the researchers concluded. "Even with the addition of these common variants, breast cancer risk models are not yet able to identify women at reduced or elevated risk in a clinically useful way." Their article was published in the March 18, 2010, issue of the New England Journal of Medicine.

The overarching premise of personalized medicine is that application of preventive measures or therapeutic interventions on the basis of individual patient characteristics will result in better outcomes compared with use of the same strategy for every patient.

For breast cancer, the Gail model incorporates information about a woman's reproductive history, family history of breast cancer, and breast biopsy results to estimate an individual patient's risk of breast cancer. The model has been used as an aid in patient counseling for making decisions about use of tamoxifen, and in determining sample size for randomized clinical trials of prevention strategies, the authors wrote.

To examine the impact of recently discovered genetic variants associated with breast cancer, the researchers evaluated ten factors as an alternative to the Gail model and as a supplement to it. They applied the risk-assessment strategies to 5,590 breast cancer patients ages fifty to seventy-nine, and to 5,998 similar women without breast cancer. The patients and the control group came from the NCI Cancer Genetic Markers of Susceptibility genome-wide association study of breast cancer.

The breast cancer patients and controls participated in four U.S. cohort studies and one case-control study from Poland. The authors used information on components of the Gail model that was collected from the five studies. The components were number of first-degree relatives with a diagnosis of breast cancer, age at menarche, age at first live birth, and number of prior breast biopsies. The authors also analyzed genotypes for ten single nucleotide polymorphisms (SNPs) with established breast cancer associations.

Primary source: S. Wacholder et al., Performance of Common Genetic Variants in Breast-Cancer Risk Models, 362 N ENGL J MED 986-93 (2010).

Charles Bankhead, Genetics Add Little to Breast Cancer Risk Prediction, MedPage Today, (Mar. 18, 2010).

As Medicare Pay Shrinks, Some California Docs Hike Patient Fees

One California cardiology group has confronted steep Medicare cuts with a tactic that may irk patients who already face soaring healthcare costs in that state. Beginning April 1, 2010, Pacific Heart Institute, in Santa Monica, will charge some patients annual fees ranging from $500 to $7,500, in addition to the regular fees paid by patients and insurers. These steep fees provide an unusually vivid example of a phenomenon called "cost-shifting," one of the many reasons economists say health insurance costs so much.

The premise is that doctors and hospitals charge privately insured patients higher rates to make up for the lower fees paid by Medicare and other public programs, as well as uncompensated care for uninsured people. One report refers to cost-shifting as a "Hidden Health Tax."

The new annual fees were announced in a February 25, 2010, letter to patients of the nine-doctor cardiology group. The fees will offset recent cuts to Medicare, the letter says, and will help cover things like "Direct doctor/patient e-mail communication" and "Notification of non-urgent laboratory and test results." Patients could choose the level of extra services they want by purchasing one of three annual plans. A $500-a-year plan would buy "priority appointments" and other basic services; for $1,800, patients get to email doctors and schedule same-day visits, among other things; for $7,500, they would have doctor's personal cell phone numbers and could get a doctor's attention even on nights and weekends. Without upping fees, the "unprecedented" Medicare cuts "are incompatible with maintaining a viable practice," the letter says. "For instance in 2009 Medicare directly paid us $110.74 for a mid-level new patient evaluation, for which we typically schedule one hour; the current payment is $87.07. In March it is scheduled to be cut to $68.78."

Physicians are not usually allowed to charge Medicare patients fees in addition to the set Medicare rate for covered services--such as "new patient evaluations"--but they may charge separate fees for things Medicare does not cover. The annual fees described in the letter are said to pay for "ancillary" services above and beyond what insurers and Medicare finance.

Christopher Weaver, As Medicare Pay Shrinks, Some California Docs Hike Patient Fees, Kaiser Health News (March 16, 2010).

AHLA Teaching Hospital Updates are intended to provide quick summaries of cutting-edge issues of interest to teaching hospitals and their counsel. Additional information and more in-depth coverage on these topics may be available from AHLA Health Lawyers Weekly and appropriate AHLA Practice Groups.

*We would like to thank Leah Voigt, Esquire (Squire Sanders & Dempsey LLP, Washington, DC), for providing this week's update.

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