Class
of 2006
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements
Are Nurse Practitioners and Advanced Practice Nurses the Answer to a Physician Shortage?
Michael K. Cooper, DO
Nurses have always been an indispensable resource in providing medical care. The expansion of nursing roles has been driven by both a need for primary care providers and advanced educational opportunities for registered nurses. Many nurses are no longer providing nursing care, but are providing primary care. Nurse practitioners (NP’s) and advanced practice nurses (APN’s) are providing more autonomous care and making more independent decisions than ever before.
According to the American Academy of Nurse Practitioners, NP’s and APN’s can diagnose and manage most common and many chronic illnesses, either independently or as part of a health care team. Nurse practitioner programs were started in the mid-1960’s in response to a perceived shortage of primary care physicians. Today, about 103,000 nurse practitioners work in the US. Services provided by nurse practitioners include, but in many instances are not limited to, ordering, conducting and interpreting diagnostic and laboratory tests; prescribing medication and therapies; and teaching and counseling patients and their families.
There is clearly a disparity in the amount of training between the nurse practitioner and the physician. Nurse practitioners desire the same practice privileges as physicians with a fraction of the training. Nurse practitioners do not have the clinical background to diagnose and treat as comprehensively as a physician. Nurse practitioners are clearly not trained adequately for independent practice in primary care. To ensure patient safety, physician supervision is essential.
Establishing Academic Pre-Doctoral Medicine Fellowships to Alleviate the Trained Medical Educator Shortage
David E. Elkowitz, D.O.
Although there has been much talk about the upcoming physician shortage crisis, very little attention has been given to the imminent medical educator shortage. The Council on Graduate Medical Education recommends that medical schools expand the number of graduates by 3,000 per year by 2015, requiring the equivalent of about twenty new schools. However, expansion in class size and in the number of schools will require an increase in the number of trained academic physician instructors - approximately 5,000 new full-time professors over the next fourteen years.
The New York College of Osteopathic Medicine established an Academic Medicine Fellowship to train students to pursue careers in academic medicine, including medical education, research, and clinical practice in an academic health care setting. Fellows spend a total of five years in medical school, and the school pays for the last three years of education. Fellows not only work in labs and lectures, but also are enrolled in educational courses on campus and on line (AACOM Educational Modules), attend research seminars and journal clubs, and conduct research projects.
Good training and experience leads to an expert understanding of a specific content matter; however, it vital that medical educators be able to deliver that content in a way that is understandable and relevant. That is where the Academic Medicine Fellowship comes into play. Medical schools, both public and private, should implement a fellowship modeled after NYCOM’s program to meet the need for medical educators expert in clinical medicine as well as research and teaching methods.
Healthcare Insurance:
A Conflict in Public Policy
Kit McCalla, D.O.
The American health care system is based on an unsustainable framework based on subsidies and cost shifting. Medicare, Medicaid, insurance regulation, and tax laws subsidize the private insurance industry. Tax deductions allow corporations to defray part of the cost of providing insurance to their employees; in effect, these tax breaks subsidize the insurance industry. Without a policy of universal access to health insurance, Medicare and Medicaid will continue to indirectly subsidize the private insurers by removing the most costly population from their clientele: the elderly and the poor.
I recommend we end the policy of subsidizing private health care insurance by enacting federal legislation ensuring affordable access to healthcare insurance. By offering a public-private partnership of insurance carriers and using reinsurance mandates, we would create a risk pool of all Americans and stabilize gross cost shifting inequities in the healthcare system. Federal policy would eliminate exclusionary underwriting for chronic illness. More healthcare dollars could be focused on preventative care rather than palliative care. As a result, Americans’ health status would improve and spending would decline. It is not the role of government to compete with private industry, but it is the role of government to regulate the industry so that access to healthcare is available to the majority of citizens.
Fellowship in International Osteopathic Medicine Development
Terrence Mulligan DO, MPH, FACOEP
International Osteopathic Medicine Development (IOMD) is the study of international educational, clinical, administrative, and managerial systems of osteopathic medicine and osteopathy in all stages of international development. The osteopathic profession currently displays a paucity of osteopathic physicians trained in IOMD, despite a burgeoning need for osteopathic physicians and osteopaths abroad to share expertise and despite the recent surge of interest among US DO students, residents, and physicians in international osteopathic medicine.
This project proposes specific
avenues for professional development in the field of IOMD:
• Combined DO/MPH programs in IOMD among the US schools of osteopathic
medicine that offer MPH and other dual degrees, with national coordination
of projects, initiatives and outcomes.
• Post-doctoral and post-graduate Fellowships in IOMD for osteopathic
physicians and other health professionals, with the option of earning
an MPH.
• Collaborative projects, partnerships and exchanges in academics,
research, and administration between US schools of osteopathic medicine,
US national and international osteopathic professional societies,
and foreign national and international osteopathic medical schools,
schools of osteopathy, and professional societies.
Fellowships in IOMD would help over thirty countries currently undergoing the struggles of national development to learn, consider, and adopt strategies which have worked in other areas, and to avoid those which have not. Development timetables can be thereby shortened considerably, and much time, energy and resources can be saved.
Providing Primary and Preventative Care to Undocumented Immigrants: Issues of Access, Quality and Cost
Alina M. Perez, J.D
With the arrival of thousands of undocumented immigrants in the last decade, the already troubled health care system in the United States is faced with one more challenge: how to address the health care needs of the undocumented in a climate of anti-immigrant sentiment, federal and state fiscal problems, and diminished resources. Federal and state initiatives have created many barriers to prenatal, preventative and other primary care for undocumented immigrants that negatively impact quality and access to care.
Undocumented immigrants suffer disproportionately from chronic and infectious diseases that may represent a threat to the communities in which they live. Instilling fears of deportation in undocumented immigrants and those who help them is not sound health policy. Quality of care is affected when pregnant women do not receive prenatal care and give birth to low weight babies who are US citizens. Untreated diabetes ultimately costs millions in emergency care when allowed to progress without treatment. When infectious diseases go undetected and untreated, the whole community suffers.
Given the magnitude
of the problem and the current debates and constraints, a combination
of measures is imperative for a positive impact on access, quality
and cost. Such measures will have the potential to affect not only
the undocumented immigrants but the uninsured population as well.
• Increase capacity of community health centers and federally
qualified centers with federal grants;
• Eliminate questions regarding immigration status as a requirement
for services;
• Require employers to carry insurance for employees or to pay
a fee if they do not; fee paid should be used to finance primary and
preventative care;
• Use of some funds from the Medicare reform bill to provide
primary and preventative care in the community with emphasis on culturally
sensitive health education campaigns for immigrants.
The Problems with the President’s Emergency Plan for AIDS Relief (PEPFAR)
Robyn Phillips-Madson D.O.
The President’s
Emergency Plan for AIDS Relief (PEPFAR), a $15 billion, five-year
unified US government initiative, has goals of supporting treatment
for two million HIV-infected people, preventing seven million new
HIV infections, and supporting care for ten million people with and
affected by HIV/AIDS, in fifteen focus countries.
Concerns about the program have surfaced:
• PEPFAR’s spending requirements interfere with teaching
about condoms as part of the “ABC” (Abstain, Be faithful,
use Condoms) approach to prevention, and preclude working with high-risk
populations of sex workers.
• PEPFAR grantees are required to sign an anti-prostitution
and sex-trafficking agreement.
• The Global Gag Rule (Mexico Policy) compromises care.
• PEPFAR requires use of more expensive brand-name antiretroviral
drugs approved by the Food and Drug Administration (FDA), creating
confusion and extra work in settings where generics are available.
Solutions for these problems include the following:
• “Best practices” prevention education should be
taught by all NGOs in the appropriate settings when allowed by the
focus country’s government. Each ABC component has documented
effectiveness in certain populations.
• While the anti-prostitution agreement is now moot for US NGOs,
prostitution and sex trafficking must be opposed as a matter of human
rights.
• The Global Gag Rule should be omitted from the PEPFAR document,
to improve access to HIV/AIDS prevention and treatment for vulnerable
women.
• Intellectual property (IP) protection is vital for economic
growth. The WTO and World Intellectual Property Organization (WIPO)
must negotiate better solutions to IP rights relating to global public
health issues.
The 75% Rule – A Barrier to Health Care Access for a Vulnerable Population
J. Michael Wieting, D.O.
In spite of increasing demand for comprehensive medical rehab services, the Center for Medicare and Medicaid Services (CMS) 75% Rule forces inpatient rehabilitation facilities (IRFs) to limit access to patients by requiring the majority of them to fit one of thirteen specified diagnoses. CMS is using what was originally a hospital classification tool as a means to assess medical necessity for inpatient rehabilitation, an application that was never intended. As a result, 64,000 fewer patients will be treated in IRFs during the current fiscal year.
Proponents of the Rule feel quality care can be provided to patients in less intensive settings at a much lower cost to taxpayers - roughly $325 a day vs. $850 a day in IRFs. This estimate doesn’t account for additional long term costs to Medicare from rehospitalization caused by preventable complications and potentially longer lengths of stay. In addition, data is not available to compare patient outcomes in other post-acute settings to IRF patient outcomes. Research does show, however, that longer nursing home and skilled nursing facility stays are associated with increased rates of acute care, more expensive readmission, and increased use of outpatient services
Legislators should support the Deficit Reduction Omnibus Reconciliation Act of 2005/S.1932, which would prevent further restrictions on access to medical rehabilitation care to thousands of patients by extending the 50% level for two years, and would allow additional study to examine the type of patients, medical conditions, and providers needed to optimally serve disabled persons.
Impact of Medical Student Debt on the Physician Workforce
Rodney M. Wiseman, D.O., FACOFP
State budget crises nationwide have translated into decreased funding for medical education and particularly for public medical school. In response, schools are raising tuition at record rates. In-state tuition and fees at some public schools exceed the amount that can be borrowed through federal Stafford loans, forcing students to accept high-rate private debt to continue their education. Presently, loan payments consume between 40% and 50% of the average resident’s after-tax salary.
High levels of student debt may dissuade potential applicants from attending medical school at a time when the country is facing a physician shortage, particularly in primary care. The debt burden on medical school graduates could have a major impact on how many physicians pursue primary care or jobs in underserved areas. A direct unintended consequence of higher student debt load will be a decrease in access to care for millions of Americans.
Keeping higher education affordable will make it more possible for the US to produce enough physicians to provide access to care for its citizens. The federal government should offer student borrowers lower interest rates, increase funded positions in the National Health Service Corps (NHSC), and provide increased opportunities for repayment through selection of primary care physician training and serving in underserved areas, and increase the numbers of federal loans to medical schools that have more graduates going into primary care positions.