Class of 1999-00
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements

Peter A. Bell, D.O.
The Prudent Layperson Standard and the Cost Of Emergency Care

Patients, hospitals, physicians, and associated health care providers are experiencing increasing payment denials from health insurance plans for emergency medical services. (1) In response to public concern, Congress passed two bills (S.1344 and H.R.2990) during the summer and fall of 1999. The bills have been referred to conference committee where disparate points are under reconciliation. Collectively, these bills have been titled the "Patient Bill of Rights". Both bills contain a "Prudent Layperson" provision guaranteeing access to and payment of emergency medical care. The provisions also offer a standard, universal definition as to what a prudent layperson, with an average knowledge of medicine, would consider to be an emergency. While stakeholders have agreed to this definition, implementation of this provision will likely result in additional expense to insurers and consumers alike. Healthcare providers hope that passage of federal legislation will alleviate the struggle to agree on the medical definition of an emergency and help to expedite reimbursement of covered services.

Deborah M. Heath, D.O., M.D.(H), C.S.P.O.M.M.
State Children's Health Insurance Program ­ A Target of Competing Priorities

The number of uninsured children reached an alarming 11.6 million in 1997, up from 9.8 million in 1995. The consequences of uninsurance among this vulnerable population manifests in fewer doctor visits and increased morbidity and mortality. Concern for this increasing number of children without health insurance resulted in the largest expansion in funding for children's health coverage since the start of Medicaid in 1965. This expansion came from provisions in the Balanced Budget Act of 1997 which funded $48 billion over ten years in a program for uninsured children, the "State Children's Health Insurance Program" (SCHIP). This program was targeted at low-income children under the age of 18 who were without employer-sponsored coverage and not eligible for Medicaid, over three-quarters of the 11.6 million uninsured. Since 1997, over 2 million children have enrolled in SCHIP. As the program matures, the number of enrollees is expected to rise.

Martin S. Levine, D.O., FACOFP
Collective Bargaining by Health Care Providers

Individually, health care providers have found themselves at a distinct disadvantage when negotiating contracts with health maintenance organizations (HMOs). Many have suggested giving providers enough power to allow for equitable negotiations. Three competing methods of government intervention - the "messenger model", a federal collective bargaining bill, and individual states' collective bargaining bills - strive to even the challenges faced by providers. The existing messenger model, as outlined by the Department of Justice/Federal Trade Commission (DOJ/FTC) guidelines, may give health care providers the bargaining power currently sought through federal and state legislation, enabling collective bargaining as a method for negotiating with HMOs.

Myral R. Robbins, D.O., F.A.A.F.P.
The Debate Over Strategies to Reduce Teen Pregnancy

The debate over how to reduce the high rate of teen pregnancy in the United States is best see by focusing on the dilemma of whether it is prevention of teen pregnancy, or prevention of teen sex our society seeks. The U.S. has the highest rate of teen pregnancy and teen births in the industrialized world, whereas the rate of teen sexual activity falls somewhere in the middle. The emotional and social impact, as well as the health risks and exposure to sexually transmitted diseases are very real concerns of teen pregnancy. The Clinton administration, through federal initiatives has supported values and actions consistent with a pregnancy free adolescence. Most of the government-funded initiatives have been directed toward abstinence only programs. Over the past decade, through varying initiatives, several hundred programs have been developed with intent to reduce teen pregnancy and many have been evaluated for success, however with inconsistent application of standards. The most effective programs combine: cognitive developmental staging, exploration of values, review of age-appropriate social norms, development of interpersonal skills and self-worth, recognition of parental and family values, consideration for social and economic variables, and integrate them with factual STD/HIV risk and contraceptive options in order to model behavior. There has been no evidence that abstinence-only programs prevent teen pregnancy over the long term, and safe sex combined with contraceptive education programs have not been demonstrated to promote initiation or increase sexual activity. The development of future programs will need to incorporate scientifically sound protocols that measure effectiveness through outcomes.

Robert Trenschel, D.O.
Implementation of Healthy People 2010 in Florida

While the widespread use of Healthy People 2000 objectives by states, localities, and the private sector provides a base of experience upon which to build the Healthy People 2010 objectives, the voluntary nature of the initiative presents a distinct challenge with respect to disseminating 2010 goals and objectives to all physicians at the local level. Currently, the State of Florida has devised no concerted effort to clearly and systematically disseminate this information to physicians. Individual health is closely linked to community health and community health is closely linked to individual health, "The two should be considered inseparable" as quoted from the Healthy People 2010 document. Physicians are clearly the primary drivers of individual health and it should logically follow that their input into individual health should have an impact on the community. Consequently, physician awareness, input, and buy in is essential in realizing the quality goals of the Healthy People 2010 document.

Felecia S. Waddleton-Willis, D.O., F.A.C.O.F.P.
Medical Records Confidentiality: Critical Health Policy Concerns

Discussions of medical records confidentiality standards have impacted the healthcare industry, the legal sector, and the public domain. Since healthcare providers and other medical personnel may access medical data, regulations regarding information utilization, storage, and transfer have recently been proposed. The Federal Privacy Act of 1974 outlined the responsibilities of federal agencies regarding the collection, use, and dissemination of personal information contained in their record keeping system. This act was not effective in eliminating the arbitrary release of medical records to HMOs (Health Maintenance Organizations) and other related organizations. Consequently, patients have developed distrust in revealing pertinent medical history, which may jeopardize proper diagnosis and treatment and result in diminished quality of care. In 1996, Congress enacted the Health Insurance Portability and Accountability Act (HIPAA). This act outlined a process to achieve uniform national health data standards and health information privacy in the United States. In 1999 three medical records confidentiality bills were introduced. This policy brief explores the policy implications regarding medical records confidentiality legislation (with special emphasis on S.573) and its impact on the quality of healthcare.

Michael D. Weiss, D.O., F.A.C.O.O.G.
The Rationale for Adopting a Comprehensive National Educational Campaign for the Management of Osteoporosis

Osteoporosis is a major public health threat for an estimated 28,673,453 women and men age 50 and over in the United States. Eighty percent of these people are women. The revolution in the field of osteoporosis detection has been aided by the advent of bone mass measurement technologies. The new Healthy People 2010 national health promotion and disease prevention initiative brings together national, state, and local government agencies; nonprofit, voluntary, and professional organizations; businesses; communities; and individuals to improve the health of all Americans. Although economics can assist decision-makers by helping to identifying efficient strategies and associated trade-offs, the impact of any program cannot be used alone to determine the appropriate strategy. The consequence of osteoporosis is seen in the incidence of costly and devastating fractures, predominantly of the vertebra, hip and wrist. Unless comprehensive programs to detect and treat osteoporosis are adopted soon, the economic and social costs are expected to rise as the population of the United States continues to age.

Roger L. Wohlwend, D.O.
Reducing Errors in Health Care

The people who deliver health care are highly trained and strive every day to deliver safe and compassionate care. They believe in the dictum: "First do no harm." Health care today is extremely complex, and even the best intentions can have unwanted and unintended consequences. On November 29, 1999 the IOM report brought to public light the long recognized concerns regarding health care delivery in America and suggested methods for improvement. Under the assumptions upon which the IOM report rests, errors in patient care would become the eighth leading cause of death in the United States; the report estimates that between 44,000 and 98,000 Americans die each year as a result of medical errors at a cost to the nation between $17 billion and $29 billion. This report has sparked controversy that has spurred Congress to hold hearings, given the President an opportunity to advance his health care agenda, and provided public debate through the media.

Joseph M. Yasso, DO, FACOFP
The Effects of Collaborative Practice on Access to Health Care

In 1993 the Missouri Legislature and Governor provided statutory legitimacy to advanced practice nursing with the passage of House Bill 564. This bill was passed in an effort to alleviate access problems in rural and urban underserved areas. Legislators envisioned that the achievement of this goal would be through collaborative agreements between physicians and nurse practitioners (NPs). Prior to 1993, NPs and physicians could not legally collaborate in Missouri. The legislation has not achieved its intended results of widely increased access in Missouri's underserved areas. Nurses claim that legislative regulations limit incentives to collaborate, while physicians are concerned that the regulations can be ignored allowing NPs to border on independent practice.

Susan C. Zonia, Ph.D.
The Impact of Direct-to-Consumer Marketing by Pharmaceutical Companies

The Food and Drug Administration (FDA), the Federal agency responsible for regulation of the industry, has always permitted pharmaceutical companies to advertise over-the-counter drugs to the public. However, not until 1997 did the FDA allow pharmaceutical companies to market prescription drugs to the public. The marketing of prescription drugs has resulted in an increased cost to bring these products to the market, a cost that is often passed on to consumers. Representatives of pharmaceutical companies argue that marketing helps to create a more educated consumer, thus justifying the increased costs of prescription drugs. Consumer groups, hospitals, and insurance companies argue that marketing needlessly increases the costs of products and prohibits some individuals from obtaining necessary medication. This brief will explore the impact of direct-to-consumer marketing of prescription drugs on the pharmaceutical industry and on the public.