ACP letter to CMS, regarding the CY 2014 Medicare Physician Fee Schedule

ACP Comment Letter to CMS Regarding MACRA Final Rule

Statement Opposing Decision to Discontinue Cost-sharing Reduction (CSR) Payments

Policy Compendium - Tobacco

Medicaid Managed Care.

Language Services for Patients with Limited English Proficiency: Results of a Nationa Survey of Internal Medicine Physcians

Letter to CMS regarding the South Carolina Community Engagement Medicaid Waiver Application

ACP Response to CMS Innovation Center RFI on Direct Provider Contracting Models

Letter to CMS regarding the Kentucky HEALTH 1115 waiver

Joint Letter to Congressional Leaders Urging Funding for CHIP and Workforce Programs

The Incubation Periods of Mpox Virus Clade Ib

Background: Mpox virus (MPXV) clade Ib, first detected in the Democratic Republic of the Congo (DRC) in September 2023, spread internationally within months, prompting an emergency declaration from the World Health Organization. Data on its incubation period, which both shapes outbreak dynamics and informs epidemic response strategies, remain limited. Objective: To estimate the incubation periods of mpox clade Ib, examining evidence for differences by route of exposure and demographic factors. Design: Bayesian analysis of clinical surveillance data collected between June and October 2024. Setting: South Kivu, DRC, the epicenter of the current mpox clade Ib global outbreak. Participants: Clinically attended persons with confirmed mpox clade Ib infection. Measurements: Demographic characteristics, exposure history, symptom onset, and transmission route. Results: Among 37 polymerase chain reaction–confirmed cases with high viral load (cycle threshold values <34), the median incubation period from exposure to rash was 13.6 days (95% credible interval [CrI], 9.6 to 19.0 days). Five percent of cases are expected to develop a rash within 3.1 days (CrI, 1.3 to 5.5 days) and 95% within 32.3 days (CrI, 22.4 to 45.8 days). The incubation period seemed to differ by putative transmission route: Sexual transmission had a shorter median (10.3 days [CrI, 3.1 to 20.3 days]) than nonsexual transmission (13.5 days [CrI, 9.5 to 19.1 days]), although the CrIs overlapped. Limitation: Surveillance data lacked detailed exposure histories and a lower bound for exposure periods, but models accounted for these uncertainties, yielding robust median estimates. Conclusion: Evidence from this study suggests that clade Ib may have a longer incubation period than other MPXV clades, and this may vary by transmission route. The shorter incubation for sexual transmission mirrors patterns seen in the predominantly sexually transmitted clade IIb outbreak, highlighting the potential role of exposure route in disease progression. These findings have implications for global recommendations on postexposure monitoring periods and prophylaxis. Primary Funding Source: Gates Foundation and Geneva Centre for Emerging Viral Diseases.

Projected Effects of Proposed Cuts in Federal Medicaid Expenditures on Medicaid Enrollment, Uninsurance, Health Care, and Health

In January 2025, the Republican majority in the House of Representatives’ Budget Committee offered a list of possible spending reductions to offset revenue losses from proposed tax cuts. In May, the Committee advanced a bill incorporating several reductions on the list. The Committee estimated that the 6 largest potential Medicaid cuts (for example, work requirements for some Medicaid enrollees) would each reduce the federal government’s Medicaid outlays by at least $100 billion over 10 years. On the basis of the Committee’s estimates of savings; Congressional Budget Office analyses; and peer-reviewed studies of the coverage, financial, and health impacts of past Medicaid expansions and contractions, the authors project the likely effects of each option and of the House bill advanced by the Budget Committee in May. Each option individually would reduce federal Medicaid outlays by between $100 billion and $900 billion over a decade, increase the ranks of the uninsured by between 600 000 and 3 900 000 and the annual number of persons forgoing needed medical care by 129 060 to 838 890, and result in 651 to 12 626 medically preventable deaths annually. Enactment of the House bill advanced in May would increase the number of uninsured persons by 7.6 million and the number of deaths by 16 642 annually, according to a mid-range estimate. These figures exclude harms from lowering provider payments and shrinking benefits, as well as possible repercussions from states increasing taxes or shifting expenditures from other needs to make up for shortfalls in federal Medicaid funding. Policy makers should weigh the likely health and financial harms to patients and providers of reducing Medicaid expenditures against the desirability of tax reductions, which would accrue mostly to wealthy Americans.

Does the Patient Want TV?

Gout

Gout is characterized by deposition of monosodium urate (MSU) crystals in or around joints, tendons, bursae, and other tissues, resulting in painful recurrent flares and tissue damage. Gout is the most common form of inflammatory arthritis, with a prevalence of 5.1% in the United States, affecting 12.1 million adults. When urate levels exceed the limit of solubility (6.8 mg/dL [400 μmol/L]), MSU crystals may form or grow. Gout flares are the result of inflammatory responses to MSU crystals. The primary method to prevent and reduce gout flares, tophi, chronic inflammatory arthritis, and joint damage is to reduce urate levels below the saturation threshold. The pathophysiology of gout is well understood, and inexpensive and effective therapies are available. However, outcomes for patients with gout remain poorly optimized.

Care of Bereaved Persons: A Systematic Review: Annals of Internal Medicine: Vol 179, No 4

Background: Bereavement after the death of someone close is universal, and clinicians may be uncertain if or what interventions may be beneficial. Purpose: To synthesize effects of health care interventions for bereaved children and adults. Data Sources: Eight databases were searched from inception in September 2025, supplemented with screening reviews, guidelines, federal register entries, and expert input. Study Selection: Dual independent reviewers selected randomized controlled trials (RCTs) comparing interventions for bereaved or soon-to-be bereaved persons with usual care, no intervention, or an alternative intervention. Data Extraction: Outcomes were evaluated using the abstractor-checker model. Risk of bias was assessed; random-effects meta-analysis was used for effect estimates; multiple effect modifiers were explored; and applicability, generalizability, and strength of evidence (SoE) were determined. Data Synthesis: A total of 169 RCTs reported in 303 publications evaluated psychotherapy; expert-facilitated support groups; pharmacotherapy; peer support; self-help interventions; writing, music, and art therapy; enhanced provider contact; and integrative medicine for bereaved persons. Risk of bias was substantial, and only 15 RCTs included children. There was moderate SoE that individual psychotherapy improves grief disorder, grief, and depression symptoms and low SoE that expert-facilitated support groups and enhanced contact with health care providers may improve depression symptoms. Other interventions showed conflicting results, indicated no benefit, or had insufficient SoE. Limitations: Research focused on grief in adults, study populations were complex, and the review may have missed culturally specific interventions. Conclusion: Psychotherapy can improve key outcomes in bereaved adults, and expert-facilitated support groups and enhanced provider contact may also provide benefits. Evidence for other bereavement interventions, approaches for children, and outcomes beyond general grief or grieving, grief disorder, and depression symptoms is limited. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42023466057)

The Cost-Effectiveness of Semaglutide and Tirzepatide for Patients With Knee Osteoarthritis and Obesity

Background: Glucagon-like peptide-1 receptor agonists (GLP1RAs) lead to substantial weight loss and pain reduction in persons with knee osteoarthritis and obesity. Objective: To evaluate the cost-effectiveness of 2 GLP1RAs, semaglutide and tirzepatide, for patients with osteoarthritis and obesity. Design: Osteoarthritis Policy Model, a validated microsimulation model of knee osteoarthritis, to estimate lifetime benefits and costs of weight loss strategies. Data Sources: Published data to derive treatment-related weight loss, pain reduction, and costs of GLP1RAs from the U.S. Office of Health Policy. Target Population: Persons with knee osteoarthritis and obesity in the United States. The base-case cohort had a Western Ontario and McMaster Universities Osteoarthritis Index pain score of 71 (0 to 100, 100 worst) and a mean body mass index (BMI) of 40 kg/m2. Time Horizon: Lifetime. Perspective: Health care, societal. Intervention: Semaglutide, tirzepatide, laparoscopic sleeve gastrectomy (LSG), Roux-en-Y gastric bypass (RYGB), and diet and exercise. Outcome Measures: Quality-adjusted life-years (QALYs), cost, and incremental cost-effectiveness ratios (ICERs). Results of Base-Case Analysis: Tirzepatide provided greater health benefits at lower costs than semaglutide and yielded a $57 400 per QALY ICER versus diet and exercise. For those eligible, RYGB provided greater health benefits at lower costs than the 2 GLP1RAs and had a $30 700 per QALY ICER versus LSG. Results of Sensitivity Analysis: Tirzepatide’s ICER was most sensitive to changes in medication costs, treatment efficacy, and cohort baseline BMI. Tirzepatide had a 64% and semaglutide had a 34% probability of being cost-effective at a $100 000 per QALY threshold. Limitation: Data from multiple sources. Conclusion: Both tirzepatide and semaglutide would be widely considered cost-effective when compared directly with usual care. Tirzepatide would offer the most favorable return on investment to decision makers whose cost-effectiveness thresholds exceed $57 400 per QALY. Primary Funding Source: The Arthritis Foundation and National Institute of Arthritis and Musculoskeletal and Skin Diseases.

Effectiveness of Psychological Therapies for Depression During the Perinatal Period: A Systematic Review and Meta-analysis: Annals of Internal Medicine: Vol 178, No 12

Background: Perinatal depression can have a deleterious impact on mothers and infants. Purpose: To evaluate psychological therapies for perinatal depression. Data Sources: 6 databases from January 2000 to March 2025. Study Selection: Randomized controlled trials (RCTs) of psychological therapies for people with depression during pregnancy and up to 1 year postpartum. Data Extraction: 6 researchers extracted study data and assessed the risk of bias and strength of evidence (SoE). Data Synthesis: Forty-four RCTs were included. Cognitive behavioral therapy (CBT; k = 25, n = 2962) was probably more effective than treatment as usual (TAU) in reducing depressive symptoms by an equivalent −1.7 points (95% CI, −2.0 to −1.3 points) on the Edinburgh Postnatal Depression Scale (EPDS; range, 0 to 30 points) (moderate SoE) and may have greater recovery rates from depressive symptoms (relative risk [RR], 1.7 [CI, 1.3 to 2.3]) (low SoE). Behavioral activation (k = 3, n = 508) may be more effective than TAU in reducing depressive symptoms by an equivalent −1.5 EPDS points (CI, −2.6 to −0.5 points) (low SoE). There may be no differences in depressive symptoms between CBT and counseling (k = 3, n = 226; EPDS, −0.5 [CI, −1.5 to 0.5]) or counseling and TAU (k = 3, n = 247; EPDS, −0.8 [CI, −2.6 to 1.0) (low SoE). Interpersonal therapy (IPT; k = 9, n = 1003) was probably more effective than TAU in reducing depressive symptoms by an equivalent −1.7 EPDS points (CI, −2.9 to −0.5 points) (moderate SoE) and may have greater recovery rates from depressive symptoms (RR, 1.2 [CI, 0.97 to 1.5]) (low SoE). Limitations: Participants were not blinded to treatment, study variation in country, interventions, populations, or reducing SoE. Differences may not be clinically important. Conclusion: For treatment of perinatal depression, CBT, behavioral activation, and IPT may be effective. Primary Funding Source: Agency for Healthcare Research and Quality (AHRQ).

How Would You Manage This Patient With Recent-Onset Atrial Fibrillation? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Atrial fibrillation (AF) is the most common arrhythmia. Risk factors for AF include obstructive sleep apnea, physical inactivity, obesity, cigarette use, and alcohol misuse. Atrial fibrillation substantially increases the risk for stroke and is associated with higher rates of mortality than for individuals without AF. Strategies to prevent these risk factors and to optimize those that already exist reduce the risk for subsequent AF. Physicians play an important role in proposing strategies to reduce the risk for AF among patients. Decision making regarding management of AF is often complex and requires consideration of symptoms, burden of AF (the percentage of time in AF), comorbid conditions that increase stroke risk, and the risk for bleeding. In particular, novel risk scoring systems to predict stroke risk, and consideration of factors beyond those in these tools, refine the ability to identify patients with AF who are most likely to benefit from anticoagulation to reduce stroke risk. Early use of catheter ablation of AF in selected patients improves symptoms and reduces the potential for progression from intermittent to persistent AF. A 2023 collaborative guideline from the American College of Cardiology, American Heart Association, American College of Chest Physicians, and the Heart Rhythm Society addressed multiple aspects of care of patients with AF. Here, a general cardiologist and a cardiac electrophysiologist discuss recommendations derived from this guideline and how to apply them to the care of a particular patient.

Exposure to Computed Tomography Before Pregnancy and Risk for Pregnancy Loss and Congenital Anomalies: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 178, No 11

Background: Animal studies show ovarian follicle damage and mutagenesis after ionizing radiation exposure. Computed tomography (CT) imaging is commonly done outside pregnancy, but risks to future pregnancy are unknown. Objective: To evaluate the risk for spontaneous pregnancy loss and congenital anomalies in offspring of women exposed to CT ionizing radiation before conception. Design: Population-based observational study. Setting: Ontario, Canada. Participants: 5 142 339 recognized pregnancies and 3 451 968 live births identified between 1992 and 2023. Measurements: The exposure was the cumulative number of CT scans up to 4 weeks before conception. Outcomes were spontaneous pregnancy loss (miscarriage, ectopic pregnancy, or stillbirth) among recognized pregnancies and congenital anomalies diagnosed within the first year of life among live births. Results: Mean maternal age was 29 years. Diabetes, hypertension, obesity, and smoking were more common in those exposed to CT imaging. Among recognized pregnancies, rates of spontaneous pregnancy loss were 101, 117, 130, and 142 per 1000 pregnancies with 0, 1, 2, and 3 or more preconception CT scans, respectively, and adjusted hazard ratios (aHRs) were 1.08 (95% CI, 1.07 to 1.08) for 1 CT scan, 1.14 (CI, 1.12 to 1.16) for 2 CT scans, and 1.19 (CI, 1.16 to 1.21) for 3 or more CT scans. Among live births, rates of congenital anomalies were 62, 84, 96, and 105 per 1000 births in those with 0, 1, 2, and 3 or more CT scans, and aHRs were 1.06 (CI, 1.05 to 1.08) for 1 CT scan, 1.11 (CI, 1.09 to 1.14) for 2 CT scans, and 1.15 (CI, 1.11 to 1.18) for 3 or more CT scans. The risk observed with head CT was not consistently lower than with CT of the abdomen, pelvis, or lower spine. Limitation: Incomplete ascertainment of CT exposure and underlying indication may have contributed to residual confounding. Conclusion: Exposure to preconception CT imaging may be associated with higher risks for spontaneous pregnancy loss and congenital anomalies, but causal mechanisms remain to be elucidated. Alternative imaging methods should be considered when appropriate. Primary Funding Source: Canadian Institutes of Health Research.

Comparison of Initial Artificial Intelligence (AI) and Final Physician Recommendations in AI-Assisted Virtual Urgent Care Visits

Background: Whether artificial intelligence (AI) assistance is associated with quality of care is uncertain. Objective: To compare initial AI recommendations with final recommendations of physicians who had access to the AI recommendations and may or may not have viewed them. Design: Retrospective cohort study. Setting: Cedars-Sinai Connect, an AI-assisted virtual urgent care clinic with intake questions via structured chat. When confidence is sufficient, AI presents diagnosis and management recommendations (prescriptions, laboratory tests, and referrals). Patients: 461 physician-managed visits with AI recommendations of sufficient confidence and complete medical records for adults with respiratory, urinary, vaginal, eye, or dental symptoms from 12 June to 14 July 2024. Measurements: Concordance of diagnosis and management recommendations of initial AI recommendations and final physician recommendations. Physician adjudicators scored all nonconcordant and a sample of concordant recommendations as optimal, reasonable, inadequate, or potentially harmful. Results: Initial AI and final physician recommendations were concordant for 262 visits (56.8%). Among the 461 weighted visits, AI recommendations were more frequently rated as optimal (77.1% [95% CI, 72.7% to 80.9%]) compared with treating physician decisions (67.1% [CI, 62.9% to 71.1%]). Quality scores were equal in 67.9% (CI, 64.8% to 70.9%) of cases, better for AI in 20.8% (CI, 17.8% to 24.0%), and better for treating physicians in 11.3% (CI, 9.0% to 14.2%), respectively. Limitations: Single-center retrospective study. Adjudicators were not blinded to the source of recommendations. It is unknown whether physicians viewed AI recommendations. Conclusion: When AI and physician recommendations differed, AI recommendations were more often rated better quality. Findings suggest that AI performed better in identifying critical red flags and supporting guideline-adherent care, whereas physicians were better at adapting recommendations to changing information during consultations. Thus, AI may have a role in assisting physician decision making in virtual urgent care. Primary Funding Source: K Health.