Class
of 2002-03
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements
MEDICARE PRESCRIPTION DRUG BENEFIT
JOHN BULGER, D.O.
Medicare beneficiaries need access to prescription drugs to ensure high quality care at a reasonable cost. The lack of a Medicare prescription drug benefit causes a decrease in compliance with prescribed drugs, higher out-of-pocket drug expenses, a lessened likelihood of use of effective medications, and higher rates of other services.
Employer-sponsored plans provided about a fourth of Medicare prescription drug coverage in 1999, but this number is shrinking as companies attempt to control costs. Medicare+Choice, Medicaid, and Medigap coverage is shrinking, too. Almost forty percent of seniors have no coverage.
The Congressional Budget Office (CBO) projects that Medicare beneficiaries will spend $1.8 trillion, or nearly fifty percent of total Medicare spending of $3.9 trillion between 2004 and 2013. Given the role of prescription drugs in health care, it is essential that we also take into account the cost of inaction. One study estimates reducing the amount of time that passes before patients seek prescription drug treatment from 15 years to 5.5 years will increase prescription drug spending per medical condition by $18 for the entire population, but will lower other medical spending by $129.
It is critical that we plug a large gap in access to quality medical care for our elderly and disabled. The Medicare Modernization and Prescription Drug Act of 2003/H.R. 1 and the Prescription Drug and Medicare Improvement Act of 2003/ S.1 begin the process of modernizing Medicare in a socially and fiscally responsible way.
Computerized Physician Order Entry (CPOE)
Norman Scott Howell, D.O.
Both health professionals and the public are concerned about medical errors. According to the institute if Medicine (IOM) report, nearly one million serious medication errors occur in the United States annually, injuring 770,000 people and causing 6,000 deaths. The same report found that significant adverse drug events occur in 2.9-3.7% of hospital admissions, costing an average of $2000 per admission and $2 billion annually.
Medical errors involving adverse drug events (defined as serious medication errors) are due in part to illegible handwriting leading to administration of the wrong drug; overdosing due to incorrect decimal positioning; and overlooked drug interactions and/or allergies. Many studies have shown that computer physician order entry (CPOE) systems reduce medication errors. Physicians enter a prescription into the computer, reducing or even eliminating the possibility of misinterpretation. CPOEs can also identify appropriate medication substitutions, reduce costs associated with unnecessary laboratory testing and imaging, and reduce malpractice litigation resulting from medication errors. I fully support the implementation of computer physician order entry systems in hospitals.
Changes in Oklahoma Medicaid
Duane G. Koehler, D.O., FACOFP
The Oklahoma Medicaid program is near collapse. The Oklahoma Health Care Authority (OHCA) has reduced coverage for children and is considering eliminating adult dental services, reducing prescription drug benefits, and reducing the limit on in-hospital days from twenty-four to fifteen days per year. The Eldercare program, which is intended to help keep Medicare patients at home by providing enhanced prescription drug coverage along with personal assistance, has been terminated. Up to 93,000 Oklahomans could be impacted by these changes. As of February 2003, cuts have resulted in a reduction of benefits to about 47,000 people.
Proposal four of the Health Care - Not Welfare Program is the best way to maintain access to care for the Medicaid population and the working poor. The proposal uses an annual application fee and funds from SCHIP to provide coverage, yet has no impact on those covered by traditional Medicaid. This program would generate an additional $12 million in revenue in addition to providing coverage for an additional 47,000 lives.
The Oregon Health Plan: A State Model for Universal Health Coverage
Boon to Bust
Pascuala C. Reyes, DO
The Oregon Health Plan (OHP), a Medicaid waiver program, sought to cover the greatest possible number of low-income residents while also managing limited financial resources. OHP’s founding commitment was to expand coverage for the uninsured, improve access to care for Medicaid clients, pay providers reasonable costs, and maximize federal funds. The plan achieved its goal to expand coverage: the number of uninsured individuals in Oregon dropped from 18% in 1990 to 12.2% in 2000, and the number of uninsured children dropped from 21% in 1990 to 8.5% in 2000. However, it has failed to reach the other goals and faces financial insolvency.
The Oregon Health Plan is not sustainable. The best hope Oregon has is securing additional federal support. Costs could be controlled two ways. Reducing medical errors will help reduce cost of care. Universal health care could replace state programs.
The Impact of Elementary School Physical Education Programs on Childhood Obesity
Thomas A. Scandalis, D.O., FAOASM
Obesity is currently recognized as a health threat to over half the population of the US, but the risks of being overweight aren’t limited to adults. The incidence of childhood obesity nearly doubled between 1980 and 1994, from six percent to eleven percent. Fifteen percent of children and adolescents between the ages of 6 and 19 are obese - a 300% increase over the previous forty years. Two factors make this finding especially problematic. First, 85 % of obese children become obese adults. Second, obese children are being diagnosed with the same diseases as obese adults: cardiovascular disease and type II diabetes.
Although inadequate school-based physical education curricula have contributed to unsatisfactory outcomes to date, innovative and cost-effective school physical education programs hold the greatest potential for implementing physical activity and good nutrition in order to maintain health and fitness and reduce the incidence of childhood obesity. State and local school districts should require physical education for all students, and state and federal funding to school physical education departments should be increased in order to provide all children, from kindergarten through grade 12, with quality daily physical education.
Improving Access to Specialty Medical Care
in Rural Missouri
Philip Slocum, D.O.
Rural Missourians are sicker and have higher death rates than their urban counter parts because they don’t have adequate access to sub-specialty health care. Only sixteen surgical and medical sub-specialists work in rural areas, including one full-time cardiologist, one gastroenterologist, one part-time pulmonologist, and two obstetrician-gynecologists.
Local economic support for rural sub-specialists has limited their recruitment. Between eight and ten referring primary care physicians are required to support one general surgeon. Federal programs such as the National Health Service Corps and the Conrad 20 program have failed to increase access to specialists.
I recommend that the state of Missouri use improved telemedicine technology to provide specialty and sub-specialty services in the counties of northeast Missouri, and endorse the Medicare Telehealth Validation Act of 2003/H.R.1940 as a means to provide funds for this service.
Future Funding for Graduate Medical Education: Who Should Pay?
Charlene E. Smith, Ph. D.
From inception, strategies to fund graduate medical education (GME) have been flawed because of 1) a wavering stance on health care as a public good, 2) insufficient knowledge about discrete costs, 3) juxtaposition of workforce management and indigent care issues, and 4) political consideration for stakeholders. Despite protracted discussion and periodic adjustments, Congress has not passed proposed legislation that would require all third-party health insurers to contribute to GME.
Most associations representing physicians and medical schools (both allopathic and osteopathic) support such legislative reform, as do teaching hospitals and congressional advisory boards such as the Council on Graduate Medical Education (COGME) and the Medicare Payment Advisory Commission (MedPAC). Insurance companies concerned about reduced profits, third party payers interested in a broader funding base, and those averse to an increase in mandatory fees viewed as new taxation, oppose the change.
I recommend federal legislation that protects access to quality care through an all-payer system of payments from Medicare as well as from managed care organizations and private and public health insurers. GME reimbursement should be consistent with actual, verifiable costs and teaching programs should be protected by a rational, phased transition from old to new funding mechanisms.
RESIDENT WORK RULES LEGISLATION
Ken Steier, DO
The excessive hours worked by resident-physicians are inherently dangerous to patients. A multitude of scientific studies have demonstrated significant cognitive impairment in sleep-deprived residents, yet many residents frequently work over 100 hours per week. In addition to cognitive deterioration, ‘burnt-out’, overworked residents are also prone to accidents and illness
The revised American Council for Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) work hour standards are a step in the right direction, but they do not go far enough in restricting hours, nor do they guarantee effective internal monitoring of work hour violations.
Resident work hours need to be limited in order to decrease medical errors, to improve quality of care, and to improve the quality of life of residents. Because the federal government spends $8 billion a year funding graduate medical education for resident physicians, it has a responsibility to monitor the quality of care provided by those residents, and therefore a duty to monitor resident physician work hours. I recommend support of The Patient and Physician Safety Act of 2003, which proposes effective enforcement of reasonable resident work hours in order to improve patient safety and the well being of resident physicians.
The Need to Control the Proliferation of Specialty Hospitals
Kelli M. Ward, D.O.
Specialty hospitals, for profit hospitals that offer limited specialty services such as cardiac care, orthopedics, or neurosurgical services, are controversial because they have the potential to cause a decrease in access to care at general hospitals and an increase in costs to the patient. General hospitals won’t be able to survive if for-profit specialty facilities ‘cherry-pick’ the profitable services the full-service hospitals rely on to underwrite unprofitable but vital departments such as maternity and emergency services.
Placing specialty hospitals in areas without a designated need will negatively impact access to care, quality of care, and cost of care for those least able to pay. It is unjustifiable to increase the supply of specialty services to one consumer group while decreasing the supply of services to those most vulnerable.
To control the growth of specialty hospitals I recommend limiting specialty hospitals to areas with a designated need for such services; equalizing the disparate Medicare reimbursement rates to general and specialty hospitals that currently provide an advantage for specialty hospitals; and limiting the hospital ownership exception to physician self-referral to interests purchased on terms generally available to the public, as proposed by the Hospital Investment Act of 2003/H.R. 1539.