OHHPF Research Abstracts 2001

Class of 2000-01
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements

J. Steven Blake, D.O.
The Patients' Bill of Rights Act: A Focus on Employer Liability

For a number of years consumers have been voicing concern over strict limits on accessing healthcare. While these limitations have helped control escalating healthcare costs, many feel that they have decreased the quality of care, contributed to a number of deaths, and allowed some medical conditions to worsen unnecessarily. Advocates of a Patients' Bill of Rights believe that the increased accountability demanded of Managed Care Organizations' (MCOs) will force them to be less concerned about profits and more about patients' health. Proponents of a Patients' Bill of Rights believe that this "accountability attitude" is well past due. The Senate's Kennedy-McCain bill S.283 stands as the most current bill under debate.

Some opponents have expressed concerns that passage of S.283 will result in large numbers of workers losing employer-provided health insurance, as well as an increase in litigation concerning access to care and denial of coverage. A large part of the country feels that litigation driven by trial lawyers has gotten out of control, and employers, large and small, feel that under S.283 they would be unfairly included with MCOs for potential escalating liability suits. Sen. John McCain (R-AZ) read and introduced Senate bill 283 on February 7, 2001. The original language of the bill created heated debate, because it sought to preempt the Employment Retirement Income Security Act of 1974 (ERISA), allow state-based lawsuits, and permit state law actions against any person (including any "directly participating" employer plan sponsor) for harm caused by reason of a "medically reviewable" decision.

The Congressional Budget Office (CBO) analysis of the economic impact of S.283 stated that premium costs would rise approximately 4.2%. Given the CBO's estimates over a million people could become uninsured with passage of S.283. The controversy surrounding employers' liability was addressed by an amendment introduced by Sen. Olympia Snowe (R-Maine). S. 1052 (originally S.283) successfully passed the Senate on June 29, 2001 and the nation's patients are steps closer to finally having a long overdue patients' bill of rights.

Paul J. Bruner, D.O.
The Direct Graduate Medical Education Improvement Act of 2001

Graduate medical education (GME) funding remains an important pillar supporting the high quality of medical training in United States (U.S.) and the provision of health care for many disenfranchised patient populations. The Balanced Budget Act (BBA) of 1997 significantly cut funding for GME, and teaching hospitals now face narrowed operating margins as a result. Although the Balanced Budget Refinement Act (BBRA) of 1999 restored approximately 10% of the BBA's cuts, many teaching programs have stated that these cuts have hampered their missions of patient care, research, and education. In a further effort to improve direct medical education (DME) funding, Senator Feinstein (D-CA) introduced S.135, The Direct Graduate Medical Education Improvement Act of 2001. This act would increase the floor for the national average per resident DME payment from 70% in fiscal year 2001 to 100% by 2006. This paper explores the positions of stakeholders regarding S.135, and also reviews the "all-payer" system, an alternative to government-only support of GME. Finally, this position paper recommends that the AOA Council on Federal Health Programs support S.135 to preserve the financial integrity of osteopathic training and the patient access to the quality care these teaching hospitals provide.

Larry D. Cherry, D.O.
Utilization of Unused Prescription Medications (HB 1297)

Long-term care facilities in the state of Oklahoma assemble health care professionals on a regular basis to destroy unused prescription medications. These prescriptions are not, and indeed cannot be, recycled. A 1961 state law prohibits the use of a prescription medication for other than the original intent by the prescribing physician. This law, and the practice that it entails, results in millions of destroyed drugs totaling in the millions of dollars. The destruction of these drugs also wastes health care workers' valuable time. Oklahoma House Bill 1297 directs the appropriate state agencies to jointly develop a program to transfer unused prescription drugs from long-term care facilities to a county pharmacy for distribution to medically indigent Oklahoma residents. As the nation struggles to conserve scarce health care resources, similar situations in other states should be reviewed and antiquated laws overturned.

Meredith A. Davison, Ph.D.
Scope of Practice of Nonphysician Clinicians: The PA Perspective

Several factors have led to nonphysician clinicians challenging physicians' traditional dominance of health care. Dramatically increasing numbers of these professions, combined with changing modes of reimbursement, have led to increasing autonomy of practice among several nonphysician groups. These changes have been fueled by the "managed care mentality" that has demanded cost-effective health care services. Other professionals, primarily nurse practitioners (NPs) and physician assistants (PAs) have been increasingly offering those services previously provided only by physicians. Physician groups have begun to respond with organized attempts to limit the increased scope of practice of these professions. This paper urges that any policies or legislation concerning scope of practice for PAs should retain the ability for the PA and physician to work together to best serve patients. The author argues that restricting the PA/physician team from providing patient care in a manner deemed appropriate by the supervising physician is not justified and ultimately undermines the PA/physician collaborative relationship. Ultimately, the individual supervising physician can best define physician authority and control of health care, not laws or regulations designed to cover all situations.

Guy A. DeFeo, D.O.
The Treatment of Pain at End-of-Life

The healthcare industry has been faced with addressing many issues regarding the treatment of the nation's elderly. A significant component of healthcare involves treatment of patients at the end-of-life. One of the more complex issues involving end-of-life care involves pain management and palliative care of terminal patients, which seems to invoke controversy when palliative treatment and the treatment of pain are perceived as hastening the ultimate death of the patient. The focus of end-of-life care should be on the alleviation of suffering while upholding respect for patients and their families. Although end-of-life treatment has been the subject of controversy in the past, from ethical issues to insurance reimbursement, this paper will focus on the role of pain management and implications of it. The introduction of legislation in the state of Maine will be used as an example to demonstrate the complex issues surrounding end-of-life care. An Act To Improve End-Of-Life Care In The State of Maine is legislation introduced in 2001 that addresses insurance coverage of palliative and end-of-life care as well as education regarding end-of-life care and pain management. This legislation also proposes a system to monitor quality indicators for the care of terminally ill patients. In the future appropriate legislation will be utilized to assist both the healthcare provider and the families of terminally ill patients in making appropriate decisions.

Martin Diamond, D.O.
Prescription Drugs for the Medicare Population

Currently there are 40 million Medicare beneficiaries, and an estimated 12 to 15 million of them have no drug coverage.(1) Prescription drugs have become the mainstay in the care of most American lives, especially the elderly. However, the Medicare program has never included a comprehensive prescription drug benefit, and for this reason a great number of elderly say they have not filled a prescription because of the increasingly high costs of prescription drugs. Recently, several prescription drug benefits plans have been advanced for the Medicare population.(2) A majority of Americans, as well as the current administration and Congress, favor adding a prescription drug benefit to Medicare, even if it entails increased government spending. The controversy, however, remains how to provide the benefit, which beneficiaries will receive the benefit, and how much of a benefit each beneficiary group will receive.(3) Stakeholders in the debate include the elderly, the tax paying public, the American Association of Retired Persons (AARP), the insurance industry, pharmaceutical companies, the pharmacies, pharmacy benefit managers.(4) Proposals that attempt to ensure universal comprehensive prescription drug coverage for all seniors will help to avoid many problems of program fragmentation and reduce the complexity of varying eligibility thresholds. Further, the creation of an adequate prescription drug benefit plan for all seniors may help to avoid unnecessary suffering and hospitalizations due to acute and uncontrolled chronic illnesses; this may, in fact, reduce total Medicare expenditures by keeping this population healthier in their later years.

Michael L. Kuchera, D.O., FAAO
Osteopathic Physician Reciprocity Between Ontario & Michigan

The Canadian province of Ontario and the state of Michigan share a common border; they do not share a common definition or practice environment for osteopathic medicine. Prior refusal of the College of Physicians and Surgeons of Ontario (CPSO) to regulate licensure for osteopathic physicians has blocked the pathway to unlimited practice for D.O.s in that province. This limits options for health policy discussions between the osteopathic profession and stakeholders on both sides of the border seeking "win-win" solutions for their respective interests. Michigan Senate Bill 178 seeks occupational reciprocity for healthcare providers between that state and Ontario. The present status of osteopathic licensure in Ontario, however, renders this bill moot with respect to the D.O. graduates of schools accredited by the American Osteopathic Association (AOA). This paper notes the current physician shortage in Ontario and proposed Canadian solutions. It examines physician access, quality, and costs implications of involving osteopathic physicians in Ontario and the impact of the reciprocity promoted by Michigan SB178. It also recommends a series of proactive international stances by the AOA, including discussions with the CSPO, support of Michigan SB178, changes in written OPTI guidelines to allow initiation of demonstration projects in Ontario, and ongoing participation in international health policy.

Trudy Milner , D.O.
Federal Standards for Privacy of Individually Identifiable Health Information

Protection of one's privacy has been of significant importance since the signing of the Declaration of Independence and the articulation of the Bill of Rights. It remains a high priority in America today. One of the key provisions of the Health Insurance Portability and Accountability Act (HIPAA) deals directly with insuring the protection of individual private health information. Some groups, however, fear that the act interferes with quality of care. The new privacy rulings, by ensuring appropriate limited access to private medical information, preserve the current quality of health care delivered.

Alfred M. Pheley, Ph.D.
Development of a National Health Care Information Technology Infrastructure

In its continuing effort to improve the health care delivery system of the United States, several recommendations were proposed by the Institute of Medicine (IOM) in March of 2001. Citing limitations of the traditional paper medical chart and the continuing advance of information technology, the IOM supports the development of a National Health Care Information Technology Infrastructure. This effort will provide guidelines, standards, and governance related to the Infrastructure's operation. This system would facilitate point-of-service patient encounters (scheduled and emergent), the referral process, reimbursement, and population-based research to name only a few. To assure acceptance, however, several barriers must be addressed prior to implementation. The AOA and AACOM are being asked to support the development of education programs designed to minimize barriers to provider and patient acceptance and to support legislation that moves forward with Infrastructure development, implementation, and evaluation.

M. Bridget Wagner, D.O.
Medical Issues Regarding the Use of RU-486: Safeguards or Medically Unnecessary

Representative David Vitter (R-LA) introduced House Bill H.R. 482, the "RU-486 Patient Health and Safety Act," in the 107th Congress. This bill places unreasonable restrictions on the use of drug RU-486. House Bill H.R. 482, which maintain a high prominence primarily an abortion issue, places strict limitations on a physician's ability to prescribe RU-486. These medically unnecessary restrictions, termed safeguards by the bill sponsors, hamper widespread access to this drug and can be seen as a challenge to physician autonomy, a clear intrusion into the patient-physician relationship, and a potential violation of a basic right to privacy by both patient and physician.

Amanda L. Weaver, M.B.A.
Health Care Reform in Arizona:
An Incremental Approach to Expand Coverage for the Uninsured

As of 1999, 42.1 million Americans - almost one in five people under the age of 65 - were uninsured. Throughout the 1990s, states primarily sought politically acceptable policies to reduce the ranks of uninsured. Public sector funding has been an incremental approach used by the states to lay the foundation for expanding healthcare coverage. The state of Arizona recently experienced a tumultuous political battle over two voter initiatives to expand eligibility for Medicaid. The resulting consensus bill emerged at the end of the 2000 legislative session. The public sector funding methods to be utilized will combine tobacco settlement funds and a Medicaid expansion. This example of close interplay between state and federal health reform efforts and funds has been termed "catalytic federalism." This analysis addresses Arizona�s incremental approach to health reform utilizing public sector funding, and the estimated impact on the uninsured. Many of the "working poor" still remain as a group of the uninsured population in Arizona who has been left out of the health reform equation. Other incremental expansion strategies must be combined with this first step in order to further expand access to healthcare. The osteopathic profession is encouraged to articulate positions supporting legislation and other efforts to increase access to healthcare.