Class of 2003-04
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements

Cash and Counseling: Long Term Home-Based Care
Beverly Atwater, D.O., Ph.D

Approximately 12 million Americans of all ages need some kind of long-term care. Most people needing assistance with daily living are elderly and reside at home. Community-based programs provide some home care, but more home-based services are needed to fit the needs of patients.

In about thirty states, consumer-directed services are authorized under Medicaid. In this model, participants receive a monthly allowance and hire and train their own health care providers, often their own family members. Supporters of consumer-directed services emphasize the advantages of consumer choice, individual independence and autonomy, and low cost. The issue of quality of care is controversial. Agencies feel they can provide higher quality of care than can untrained family members, but many homebound patients feel they can be better taken of by a family member.

Cash and Counseling (C&C) is a demonstration project emphasizing consumer-directed support services to homebound elderly and disabled people. It has been piloted in three states so far: Arkansas, Florida and New Jersey. In all three Cash and Counseling programs access to care and services increased. Quality as measured by satisfaction and health outcomes improved. Many participants stated the program had improved their lives. Nevertheless, more research is needed to create models for managing quality in a consumer-directed program where states must balance consumer responsibility and state accountability.

National Standards for Nursing Home Staffing Ratios
Michael K. Cope, Ph.D.

There are currently more than 1 million nursing home residents over the age of 65. Over the next 25 years that number is expected to double. As the number of nursing home residents increases, the possibilities of abuse and neglect due to inadequate patient-staff ratios will also increase.

Concern over the quality of care provided in nursing homes has existed since the 50’s and continues today. During 1999-2001, over thirty percent of nursing homes in the United States were cited for an abuse violation that had the potential to cause harm to patients.

Research done by the Centers for Medicare and Medicaid Services (CMS) has shown that as the ratio of staff to resident for nurse aids, licensed practical nurses and registered nurses increases, there is a decrease in the number of negative health incidents in nursing homes. Forty percent or more of current nursing homes do not meet these staffing levels. It will cost $9.09 billion to increase staffing levels, half of which will be paid by Medicare and Medicaid, but the expenses avoided by providing appropriate care in nursing homes will go a long way to offset the increases in costs.

The Nursing Home Staffing Act of 2003 /S. 1988/ H.R. 3355 would provide a national standard for staffing ratios in nursing homes that is commensurate with those levels found by CMS in its research, as well as increased funding to initiate the hiring of adequate staff.

Medical Charities and Faith-Based Organizations:
A Positive Impact on Access to Healthcare
D. Todd Detar, D.O.

Charitable Choice, part of the welfare reform act of 1996, allows faith-based organizations (FBOs) access to federal funding for social and health care programs. In 2003, the federal government awarded $1.17 billion to faith-based organizations – 8% of total funding for social programs. Charitable Choice has helped provide cost-effective services to many people. A Hudson Institute study showed $7.5 million was utilized to serve three thousand low-income citizens. In the DC area, 95% of African American congregations had outreach programs providing over a thousand community services to over a quarter-million clients. A University of Pennsylvania study found 85% of Philadelphia congregations provide critical social services, including health care clinics.

The church community, including Catholic Charities, Evangelical Lutheran Church of America, Presbyterian Church, the United Methodist Church, the Interfaith Community Ministry Network, Points of Light Foundation, the Christian Legal Society and the Center for Public Justice supports FBO funding. The First Amendment fuels the opposition, which includes Americans United for Separation of Church and State, American Civil Liberties Union (ACLU), Interfaith Alliance, American Atheists, Baptist Joint Committee on Public Affairs, American Jewish Committee (AJC), People for the American Way, Seventh Day Adventists, and the Coalition Against Religious Discrimination.

Charitable Choice allows faith-based initiatives to bolster the health care infrastructure and to support the safety net. Without this important safety net, communities would struggle to access health care and social services.

The Impact of HIPAA on the Confidentiality of
Electronic Medical Records
Gail J. Dudley, D.O.

Health care providers need quick access to patient medical information whenever and wherever patients present for care. A system to standardize electronic medical records (EMRs), such as the National Health Information Infrastructure (NHII), would provide quick access to patient information. Used correctly, patient electronic medical records can save lives; used incorrectly, confidentiality can be violated. In spite of the Health Insurance Portability and Accountability Act (HIPAA), there is no effective federal law protecting the confidentiality of medical information.

According to an ACLU survey, consumers have fewer privacy-protection options and little confidence in the privacy of their health information and health decisions. Three out of four people expressed particular concern about computerized medical records held in databases used without the individual’s consent. Privacy protection is a crucial part of maintaining access to quality care. If patients fear their records will not be private, they might tell their doctors less, or even refuse to seek care.

HIPAA regulations were designed to protect patients' identifiable health information, but the regulations don’t succeed in protecting patients’ privacy or confidentiality because researchers, banks, pharmaceutical companies, and insurers can still access information. Electronic medical records need comprehensive protection at the federal level. Federal legislation or an amendment to HIPAA protecting doctor-patient confidentiality would improve access to quality care. Without the assurance of privacy, patients may avoid medical care.

Cloning a Human or Potential to Cure Disease:
The Issue of Stem Cell Research
Brian H. Hallas, Ph.D.

Stem cell research has shown promise to provide cures for Parkinson’s, diabetes, Alzheimer’s and Lou Gehrig's disease, but research using stem cells is controversial because it relies on cells harvested from human embryos. Because President Bush “does not sanction further destruction of human embryos that have the potential for life,” he has limited federal support of stem cell research to that which uses only existing stem cell lines. This announcement has essentially halted government-sponsored research. The current policy on stem cell research compromises access to potential cures for debilitating disease and trauma.

Existing stem cell lines are inadequate. Although seventy-eight stem cell lines were initially listed, available lines were reduced to sixty-four and then to twenty-four. Currently only nine embryonic stem cell lines are listed in the NIH registry. Access to these nine lines is extremely difficult and limited.

The current restrictions on federal funding for stem cell research should be reversed, and a larger number of embryos should be made available for research. I support the 225 House members who seek to pass legislation to allow researchers to use discarded or stored embryos from fertility clinics in the United States. In addition, in order to increase access to cures for disease, we need to pass legislation to protect the right to pursue stem cell research for therapeutic purposes. The Human Cloning Ban and Stem Cell Research Protection Act of 2003/ S.303 would be a step in the right direction.

Medicare Modernization Act and its Impact on Access to Affordable Health Care: The Privatization of Medicare
Gary R. Hill, D.O

What "Modernization of Medicare" means is unclear to many Americans. The Bush administration and some members of Congress translate modernization to mean the inclusion of a prescription drug coverage program. Others see the Medicare Modernization Act as a way to bankrupt Medicare in order to privatize the system. The primary health policy focus of this controversy is whether a market-based system can deliver equal or improved access to affordable quality health care.

Affordable health care has not been a reality in the private health care market. Cost containment measures implemented by Medicare have exceeded those of other insurance providers and the Federal Employee Health Benefits Plan (FEHBP). According to Public Citizen, a congressional watchdog group, private plans are unreliable. They cite a CMS report, which revealed that from 1998 to 2003 over 2.4 million incidents occurred in which Medicare enrollees had been adversely affected by HMOs and Medicare Plus Choice plans that reduced services or left certain areas completely. In 2001, 13% of those enrolled in managed care plans were dumped. The report points out seventeen states have no Medicare HMO plan that offers drug coverage – an 89% increase from 1999.

Privatizing Medicare is not the best choice for the American seniors. Private plans will not stay in the high-risk pool if certain profits are not realized. Traditional Medicare’s guaranteed coverage and superior cost efficiency and cost containment measures have not been matched by private insurers.

Advance Directives
Maribeth Knight, D.O.

Appropriate care for patients at the end of life has long been a struggle for healthcare providers. Vital to providing quality care is understanding and respecting patients’ wishes. Identifying these wishes can be simple if the patient has completed advance directives when s/he is competent.

Multiple studies show that the majority of Americans prefer to die at home, as opposed to dying in a hospital or other healthcare setting. However, 75-80% of Americans die at a healthcare facility, while only 20% die at home. Advance directives are a health policy issue in that they improve quality of healthcare and decrease costs. Unfortunately, more people than not fail to complete an advance directive. When advance directive forms are filled out, they frequently are not followed. Patients rarely make directives a part of their medical record. Often, living wills are vague and difficult to implement. Also, physicians and other healthcare providers ignore the directives.

Patients should be required to fill out an advance directive form prior to admission to any hospital, nursing home, or other health care facility. Physicians and other health care providers need to be strongly encouraged to follow these directives, with appropriate safeguards put in place to protect physicians from litigation when they respect a patient’s wishes. If the directives are ignored, legal action should continue to be an option.

Children’s Access to Affordable, Quality Vision Care
Michael A. Krasnow, DO, PhD

Low socioeconomic status and its by products, poor nutrition, inadequate housing, and poor education, increase the likelihood that poor children will be in poor health. Currently, 8.5 million children without insurance are living just beyond the margins of poverty, and, unfortunately, this number will likely grow in the near future, as states will be forced to reduce their services under projected budget shortfalls. In families without insurance, the cost of eye exams, glasses and/or surgery can be an insurmountable barrier to accessing eye care. These circumstances serve to highlight the importance of improving children’s access to vision care.

Eye disease is rare in childhood; however, the need to screen children for visual problems from early infancy is well recognized. Between 130 and 160 children per 100,000 have a serious eye condition. Due to the low incidence of children with a serious eye condition, a quality screening strategy or program, which would work in coordination with existing federal and state programs to provide services to children, is most desirable.

Children’s Vision Care: Children’s Access to Vision Act of 2003/H.R. 3602 supports a screening system, a secondary exam system, and if necessary, surgery options. Vision screenings provided by this bill would provide a point of access to quality health care at a minimal cost for uninsured children.

Unequal Access to Care: The Dilemma of the Uninsured
Heidi A. Morris, D.O.

In 2004, approximately 43 million Americans do not have any health care insurance. Of this number, 80% live in households in which at least one of the individuals works. The working poor are hit hard, but middle class families also have trouble paying for insurance. The number of uninsured with incomes less than $25,000 has fallen by 17% as Medicaid and SCHIP programs have stepped in to cover more people. But since 1993, the number of uninsured in households with an annual income above $75,000 has increased by 114%. Households earning more than $50,000 account for approximately three-quarters of the increase in the number of uninsured.

This brief will analyze the effect of being uninsured and what the political candidates Bush and Kerry have to offer to address this critical problem. Both men support expanding the ability of small businesses and individuals to join larger purchasing pools, known as associated health plans, in order to help take advantage of group discounts. Both favor refundable tax credits for individuals who purchase their own health care insurance. Senator Kerry’s plan would insure approximately twenty seven million people at a price tag of $653 billion over a ten-year period, while President Bush’s plan would cover 2.5 million uninsured people and would cost $90 billion.
The plan as proposed by Senator Kerry is more comprehensive and would be a better plan for all Americans in terms of increasing access to health care.

Pain Management
Robin B. McFee DO, MPH

A primary role for clinicians is the relief of pain and suffering among patients with acute and chronic pain as well as terminal illness. In spite of the fact pain is a common complaint, pain remains significantly under treated worldwide. Almost half of nursing home patients live with chronic, severe pain. Up to 80% of terminally ill patients are not provided adequate pain relief because palliative care is not well understood by much of the public and many health care professionals.

Three reasons influence physician-prescribing practices for these drugs. First, there is a general societal aversion and prejudice against narcotics. Second, physicians fear creating more drug addicts in a nation already besieged by a growing drug culture. Third, doctors fear investigation from regulatory agencies such as the Drug Enforcement Agency (DEA) and state licensing boards. As a result, though pain management is a critical part of quality medical practice, interventions generally remain inadequate.

Federal enforcement and state regulatory agencies play a critical role in patients’ access to pain control drugs and in a clinician’s ability to prescribe these drugs. Organized medicine and state and federal governmental agencies must collaborate to enhance the delivery of appropriate pain management by addressing perceptual, educational, and legal barriers to the manufacturing and prescribing of pain medication.

IMPROVING ACCESS TO AFFORDABLE HEALTH CARE FOR UNINSURED FAMILIES
Ira P. Monka , D.O.

Counting on the private sector to provide health care coverage for employees is becoming a financial burden to small businesses. Currently 43 million Americans are uninsured, and over three-fourths of them work for a small businesses that cannot afford to offer medical benefits. Health insurance costs are rising by double digits year after year, and cost more for small businesses than for large corporations. 98% of large companies provide health care benefits, but only a little over half of small companies can afford to do the same. There is a direct association between health insurance and health outcomes. Uninsured Americans use fewer preventive or health screening services, and so are much sicker when diagnosed.

The Small Business Health Fairness Act, (H.R. 660) which passed the House in May, proposes that associated health plans (AHPs) be implemented across the country. Associated health plans would allow small businesses to join together through trade associations to purchase health insurance for their workers at lower costs. Associated health plans would increase small business’ bargaining power with health providers, and would make it possible to negotiate more affordable benefit packages for their employees.

According to the Congressional Budget Office, associated health plans would lower premiums by 13% and would provide health insurance to as many as two million Americans who are currently uninsured. Some figures have shown that number to be as high as eight million. I recommend associated health plans as a way of increasing access to insurance.

Mandatory Continuing Medical Education (CME) Requirement by State Licensing Boards
Susan M. Rose, D.O.

The vast majority of states require mandatory continuing medical education (CME) for the renewal of a medical license to help assure the public that licensed physicians are competent. Studies have failed to prove that current CME requirements, or the lack thereof, impact the competence of physicians and the quality of medical care.

Regulations require attendance at a CME activity, but no state has implemented testing of knowledge gained or has measured impact of the educational experience on the quality of practice. Studies show that lecture-style presentation of CME is the least efficient for gain in knowledge and change of practice, yet it is the most common format at CME events. Board certification might be a more accurate measure of physician competence;
studies show that physicians who are more than ten years past training and who are not board certified are more likely to be sanctioned by a medical board.

I recommend revamping the CME system in this country to coordinate with competency based testing for maintenance of licensure. The requirements should be consistent from state to state and among specialties to help assure all patients have access to quality medical services and to allow for more efficient medical license portability. As Neil Donen of the University of Manitoba recommends, say “no to mandatory continuing medical education, and yes to mandatory practice auditing and professional educational development.”

The Effectiveness of the New Initiative: Advancing HIV Prevention: New Strategies for a Changing Epidemic Among African American Women
Bettye D. Stanley, D.O., Pharm.D.

The new face of HIV/AIDS in the United States is that of the African American (AA) woman. Although women in general account for thirty percent of new HIV infections as well as a growing share of new AIDS cases, women of color, particularly AA women, have been especially hard hit and represent the majority of new infections among women. Currently, HIV is the number one cause of death for AA women ages 25 to 34.

Advances in treatment have not been experienced equitably. Almost half of PWLA are not in regular care, and as many as one-fourth of people infected do not know they are positive, many of whom are AA women. Many barriers prevent AA women from being tested and accessing quality medical care: low income, family responsibilities, disparities in care and treatment, and lack of transportation, education and health insurance.

The CDCs Advancing HIV Prevention Initiative (AHP) acknowledges that HIV can be detected before symptoms occur using a reliable and inexpensive test, and that quality healthcare and treatment given before symptoms develop is more effective than waiting until after symptoms develop. The AHP strategies should provide an effective means of reducing further HIV transmission, not only in AA women, but also in other US citizens.