Class of 2005
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements

Professional Liability Insurance Reform Legislation in Maryland:
Analysis and Recommendations – Time for a Paradigm Change

Murray R. Berkowitz, D.O., M.A., M.S., M.P.H

Physician Liability Insurance (PLI) reform has been a contentious issue for at least three years. Legislation desired by physicians has repeatedly not been enacted into law by the legislature. The Governor and the General Assembly both desire to reform the current situation, but remain at odds regarding major provisions and methods of funding. Patients wonder whether they will be able to find affordable quality health care.

Physicians claim increased costs force them to relocate to areas with lower rates, to restrict the range of medical services they offer, and even to cease the active practice of clinical medicine. Access to care decreases as a result. Physicians and malpractice insurance carriers blame increases on higher malpractice awards, judgments, and settlements. Lawyers counter that increases in malpractice premiums are due to the insurance economic cycle, to poor stock market returns, and the insurance carriers’ need to offset investment losses. Data shows malpractice award losses by the insurers has been the underlying cause of increases in medical liability insurance rates.

Patients need access to primary and specialist care. Recommendations for PLI reform include the establishment of a special medical malpractice court; defining expert witnesses; delineating attorney’s fees; payments for economic and non-economic damages; and limits on insurance rate increases.

The Peer Review Process and Patient Safety

David A. Bitonte, DO, MBA, FAOCA

The 1999 report from the Institute of Medicine (IOM), To Err is Human: Building a Safer Health System, claimed there are 44,000 to 98,000 preventable fatal medical mistakes made each year. More than a decade before the IOM report, a number of newspaper articles reported cases of physician ineptitude and substandard patient care. In response, the Centers for Medicare & Medicaid Services increased its efforts to limit the practice of incompetent physicians through implementation of professional peer review.

The peer review process promotes patient safety though application of professional standards of health care. Practitioners review qualifications, medical outcomes, and professional conduct of physicians to determine whether the reviewed physician met accepted standards of care. Voluntary, confidential reporting of medical errors publicly reported as aggregate data will encourage health care professionals to participate in reporting.

The peer review process should remain educational rather than punitive in order to encourage practitioners to participate in the process, thereby improving quality of care for all patients. Promoting a peer review system that allows for confidentiality, immunity, and the review of accumulated data, will encourage more health professionals to get involved with patient safety. Public access to aggregate data on care measures reported by physicians, hospitals, and insurance plans will give patients the information they need to intelligently choose their practitioner, facility of care, and health plan.

End of Life Care: Futility

John E. Bodell, D.O.

When questioned about their wishes at the end of life, most Americans say they do not want to suffer, and that they want to die at home surrounded by their loved ones. However, a proliferation of medical technology has dramatically increased the number of diagnostic and therapeutic options available in patient care, and the use of life sustaining or invasive treatment at the end of life may prolong the dying process and increase health care costs. The cost of healthcare in the United States is estimated at $1.3 trillion per year. Approximately 60% of health care dollars are spent on the last six months of care.

It is fundamental to our healthcare philosophy and practice that patients at the end of life will receive all care that will ensure their comfort and dignity, but that patients should not be forced to endure treatments which are not beneficial. The policies that I recommend to reach these goals are to educate physicians and families through the use of advance directives. Since homeland security is a major concern, I would support legislation that would require all United States citizens to have a personal identification card. Advance directives would be mandated to be included on the I. D. card.

The Use of Health Information Technology in Reducing Medical Errors: The Need for a Structured Governance of Standards and Interoperability

Carl G. Bynum, D.O., M.P.H.

While medical errors are certainly not new to medicine, a 1999 Institute of Medicine Report (IOM), To Err is Human: Building a Safer Health System, brought the issue into sharper focus. The report concluded that 44,000 to 98,000 people die in hospitals each year because of preventable medical errors. Beyond the cost in human lives, these errors also result in significant economic damage, with estimates in total costs of between $17 billion and $29 billion per year.

Improvement of patient safety can be achieved through a fully functional national health information exchange system based on computerized patient records. Some barriers to overcome include the lack of standardized technology and software, the cost of purchase and implementation, the lack of interoperability between applications, and the issues of security of patient data and safeguarding of patient privacy.

Recommendations include requesting Governor Blunt to create the Missouri Commission on Health Information Exchange to study ways to improve patient safety using health information technology (HIT) and to seek state and federal funding. Based on the results of the Exchange, the state should establish Regional Health Information Organizations (RHIO) to develop the financing, business rules, technology, and governance structure necessary to permit providers and healthcare systems to share electronic patient information in a defined community or region.

Mental Health Parity

Pablo J. Calzada, D.O., M.P.H.

The enactment of mental health parity legislation in 1996 sought to eliminate disparities in access to care for mental illness. Nevertheless, incomplete and often inaccurate conceptions of mental illness and the cost of treatment have made the enactment of coherent public policy and parity in coverage exceedingly difficult. Some groups, such as The National Alliance for the Mentally Ill (NAMI) and the National Mental Health Association (NMHA), advocate strongly for nothing less than full parity for mental health and substance abuse treatment. Equally adamant are the National Association of Independent Businesses (NFIB), American Benefit Council (ABC) and National Restaurant Association (NRA), who oppose parity because they believe it will lead to increases in health care costs and an eventual increase in the number of uninsured.

Millions of people with mental illness - approximately half of those diagnosed with these conditions - go untreated. Failure to provide access to treatment results in over $180 billion in losses as the result of decreased productivity and absenteeism. Mental illnesses are strongly associated with poor quality of life, suicide, and homicide victimization.

I support the enactment of further legislation, similar to The Senator Paul Wellstone Mental Health Equitable Treatment Act, which would expand access to mental health services by correcting areas not clearly defined in the language of the original Mental Health Parity Act of 1996.

Increasing Enrollment of Under-Represented Minority Students in Medical School

Brenda J. Connolly, D.O.

The growing need for quality health care in underserved ethnic/minority populations is a major concern as the population becomes more diverse. An Agency for Health Research and Quality (AHRQ) report on racial disparities and access to quality care indicates there is a correlation between disparities in care and racial, cultural, and language barriers between minority consumers and health care providers. A 2000 Health Affairs survey indicated patients would prefer physicians of their same race in part due to language concerns and also because minority physicians are perceived to be more culturally sensitive to their populations. Research has shown that minority students tend to practice more often in underserved ethnic communities.

Over the past ten years the number of under represented minority students in medical schools has decreased, but ethnic and minority populations have increased. In 1995, twenty-six percent of the population was made up of Black Americans, Hispanic Americans, Asian Pacific Americans and American Indians/Alaskan Natives. By 2010 the above population will compose one-third of the population, and by 2050, they will make up almost half of all Americans.

If underrepresented minority (URM) students are not recruited into medical school and encouraged to practice in underserved areas, access to culturally competent healthcare for ethnic and minority populations will continue to be compromised. In order to establish a physician workforce who mirrors the diversity of the population and who can provide culturally competent care to minority populations, we need to double the number of Blacks and Hispanics and triple the number of Native Americans graduating from medical school.

Graduate Medical Education Funding: Making an Impact in Primary Care with
Community Based Training

Dee H. Grimes, MBA

The Council on Graduate Medical Education (COGME) recommends providing resident physician training opportunities in community settings representative of those in which the physicians will eventually practice. Data show residents are more likely to practice in or near areas in which they receive training.

Federally qualified health centers (FQHCs) improve access to affordable care for millions of Americans. In the next ten to fifteen years, over 10,000 providers, especially primary care and dental providers, will be needed to staff FQHCs strategically located where people are most in need of access. A 4% increase in vacancies for providers - from 9% in 2000 to a current 13% vacancy rate - indicates the need for effective strategies to fill these positions in order to maintain access to care.

Centers for Medicare and Medicaid Services (CMS) regulations can make direct graduate medical education (DGME) payments to certain non-hospital settings, including federally qualified health centers (FQHC), rural health clinics, and Medicare Advantage organizations. Nevertheless, as of December 2004, the Office of the Inspector General reports that fewer than ten of these organizations have sought payment under this provision.

By encouraging training in FQHCs, rural health clinics, and Medicare Advantage organizations, quality of future care will be enhanced, costs of providing care to uninsured and underserved patient populations will be reduced, and access will be increased. This proposal should be embraced not only by funders of GME, but also by the organizations who accredit primary care residencies.

Resident Work Hours and Patient Safety

Gregory Hill, D.O.

Postgraduate training of residents and interns is extremely demanding. Some programs require residents to work shifts greater than 36-48 hours straight with little or no sleep. Residents have reported work hours in excess of one hundred hours per week. Research has shown excessive work hours have been linked to costly and serious patient errors as well as the risk of accidents to post-call physicians driving home. Other industries that impact public safety, such as aviation and trucking, have well established work hour policies.

In 2001 the House passed the Patient and Physician Safety and Protection Act which would have mandated an 80-hour work week, allowed physicians in training to report violations anonymously with out fear of retribution, and provided a mechanism to monitor complaints concerning programs that violate the work restriction policy.1 The same week the Senate was to vote on the companion bill, the American Council of Graduate Medical Education (ACGME) and the American Osteopathic Association (AOA) established 80-hour work hour standards for interns and residents. However, two years later, the ability of the AAMC and AOA to effectively monitor and enforce work hour limits is under scrutiny.

Violations of the ACGME/AOA policies can result in significant monetary penalties.30 In hospitals with small training programs, policy citations can affect the bottom line. Nevertheless, all hospitals should adhere to the ACGME/AOA policies to ensure quality of care and the safety of patients, as well as quality of training and the personal well-being of resident physicians.

Quality of Care in Nursing Homes

Frank J. Prerost, Ph.D.

In 1986, the Institute of Medicine (IOM) revealed deficiencies in the quality of care in nursing homes. After passage of the Omnibus Budget Reconciliation Act (OBRA) of 1987, which set standards of care for nursing homes, approximately 92% of facilities were still not staffed at a level sufficient to provide adequate physical, medical, and mental health care; 33% were cited for abuse violations; and 20% of nursing homes were cited for actual harm of residents. There were also significant deficiencies in food sanitation, fall prevention, protection against pressure sores, and prescribing appropriate medications (Government Accountability Office (GAO) reports).

Nursing Home Staffing Act of 2003/S. 1988/H.R. 3355 would have mandated increased staffing levels, but a 2004 review in Health Services Research concluded a number of other essential nursing staffing practices influence quality of care, including reasonable wages, benefits, low turnover, improved training, opportunities for advancement, flexible work hours, less stressful working conditions, and consistent supervision. In response to the continuing concern about the quality of care, CMS began the Nursing Home Quality Initiative (NHQI) in April of 2002 to identify, collect, and publish nursing home quality of care information to the general public. Since implementation of the NHQI, the percent of residents in restraints and the percent reporting moderate to severe pain have significantly decreased.

I recommend that the NHQI should be continued and expanded to increase its visibility and availability to the general public and it should add additional quality of care indicators that would increase information presented to the general public.

Prescriptive Privileges for Psychologists (RxP)

Jan D. Zieren, D.O., M.P.H.

Since 1990, psychologists have made significant efforts to gain prescriptive authority. By gaining prescription-writing privileges (RxP), psychologists contend they would improve quality of mental health care, increase access to care in underserved areas, and help control costs.

Workforce shortages are clearly a problem in the mental health field and access to care is limited in rural areas. However, psychologists are found where psychiatrists practice – in urban areas - the location of best reimbursements. Rural residents have comparable rates of insurance as urban residents, but have less comprehensive coverage. Because cost of care is a major barrier, treatment combining medication and psychotherapy is usually not an option for people in rural areas.

The major concern over RxP is lack of consensus about what constitutes an adequate training program. Stakeholders against RxP feel it is in the patients’ best interest to restrict psychotropic medication prescribing to the medical doctors. There is no demonstrated health care need that warrants granting psychologists prescribing authority. While there is room for improvement in diagnosis of mental and substance abuse issues by primary care physicians, and a contentious debate on the safety of psychologists prescribing psychotropics, my recommendation is that a mutual consultative and collaborative relationship between psychologists and physicians offers a wiser solution without duplication of prescriptive authority or loss of psychotherapy benefits.