Class of 2008
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements

A Report Card on Medicare Part D and Access to Prescription Drugs

Denise K. Burns, DO

Medicare Part D has benefited millions of elderly Americans who before 2006 either had no insurance coverage for prescription drugs or had limited access to prescription drugs. However, Part D has serious flaws in its design. The Medicare Modernization Act forbids government negotiation for prescription drugs and also prohibits the establishment of a standardized drug formulary or uniform price structure for reimbursement. Because individual insurers don’t have the purchasing power of the federal government, Medicare is a less efficient system with higher costs. Many beneficiaries are paying higher prices than before the program started.

Patient compliance with medication has decreased since Medicare Part D was enacted. Recent studies have demonstrated that up to 41% of low-income seniors avoid filling prescription medications owing to cost. This behavior has potentially important public health implications, including worse blood glucose control in diabetic patients and an increased risk of angina, heart attacks, and strokes among patients with cardiovascular disease. Increasing drug prices create a barrier for patients and burden CMS with unsustainable costs.

Government prescription drug negotiation has been shown to be cost effective for the VA, Department of Defense, Medicaid, and for Rural Health Initiatives. Applying the ‘best price rule’ to Medicare drug purchases would improve drug accessibility and affordability for seniors. Federal legislation is needed to permit the federal government to negotiate prices for Part D drugs and to establish a formulary.

The Role of Continuous Certification in Patient Safety and Quality of Care

Sherman Dunn, D.O., FACOOG

People paying for healthcare - employers, insurers, and patients - are looking for quality and value from healthcare providers. They want proof physicians are really improving health and using best practices in clinical care. Physician associations have responded to quality of care issues by updating competency-based standards and by approving an on-going process for physician certification. In 2008 the American Osteopathic Association (AOA) Board of Trustees approved Osteopathic Continuous Certification (OCC) as an ongoing process of ensuring physician competence and patient safety.

The expanded requirements for maintenance of board certification for both MDs and DOs include four components:
• Evidence of Professional Standing (licensure)
• Evidence of Lifelong Learning and Self-Assessment
• Evidence of Cognitive Expertise
• Evidence of Performance in Practice

In recent years there has been greater willingness to recognize that it is not enough to test the credentials of practitioners only once at the beginning of their careers, to let physicians evaluate themselves, or to assume licensure equals competence. Studies show quality of physician performance decreases as the number of years in practice increases. Self assessment is subjective and does not provide the same degree of public accountability third party assessment affords. Regardless if the motivation for certification is for professional ideals or a response to public demands for transparent information, continuous certification is the hallmark for professional excellence as well as a social contract for public accountability.

Increasing Access to Electronic Medical Records

Charles D. Hanshaw, D.O., FACOI

Electronic medical records provide a complete, up-to-date patient health record that helps physicians practice better medicine. Accurate records lead to fewer adverse drug reactions, medical errors, and less redundant testing. Availability of a patient’s medical information will result in faster diagnoses and treatment of serious chronic illnesses, and allow for timely provision of preventative care and services.

Primary care clinics and small practice groups often lack the health information technology (HIT) needed to collect and transmit comprehensive patient information. Research in the February 2007 edition of the Journal of the American Medical Association shows that “poor information transfer and discontinuity are associated with lower quality of care on follow up as well as clinical outcomes.”4 Major obstacles to HIT evolution include

• High initial acquisition and implementation costs
• Disagreement over who should bear the cost for implementation of HIT
• Slow and uncertain financial payoffs for providers
• Limited funding by payers for support to providers

One solution is to encourage patients to collect and store their personal health record via free on-line medical data management systems in order to make medical information accessible to physicians who have not yet purchased HIT systems. But if we are to reach the president’s goal for all Americans to have access to electronic health records by 2014, more federal funds are needed to help physicians implement health information technology in their practices.

The Future Graduate Medical Education in Ambulatory Settings

Shannon Ramsey Jimenez, D.O.

Our healthcare system is at a crossroads. We don’t have enough physicians in underserved areas and despite increased enrollment in and numbers of medical schools, the 1997 Balanced Budget Act’s cap on residency slots will make it increasingly difficult to establish and fund enough residency positions to train physicians. We need to collaborate to fulfill both needs.

Training residents in Federally Qualified Community Health Clinics (FQCHCs) would provide access to care for underserved populations, as well as provide quality training opportunities for physicians at a lower cost. One 1995 California study calculated it cost $7,700 to train a resident in a CHC; another study by Brown University estimated an annual cost of $13,496. These cost estimates are modest compared with the cost of training in inpatient settings; in 1992, CMS paid an average of $56,000 per resident per year for hospital-based residents.

The most fiscally and academically efficient way to train residents in ambulatory settings will involve a collaborative effort between a hospital, community health clinic, and AHEC. But for this to happen, current rules must be changed. CMS should roll back the “all or substantially all” rule; allow cost sharing between hospitals and clinics; increase the cap on certain residencies; and shift their philosophy to encourage instead of penalize innovative programs that could improve quality and access and save money in the not so distant future.

Access To Affordable Health Care Through Retail Medical Clinics

Harry E. Manser, D.O., MBA

Convenient care clinics in retail stores are rising to meet the challenge of providing quick and inexpensive medical care. For about half the cost of a physician office visit, clinic nurses diagnose and treat common health problems such as sore throats, and provide immunizations, preventative care screening, and patient education. The relative ease in accessibility and affordability are attractive to consumers seeking basic health care.

CVS operates over 150 Minute Clinics. Walgreen’s operates fifty clinics, and by the end of 2008, they plan to open an additional 400. Wal-Mart recently opened four clinics in Arkansas with the anticipation of expanding to 400 by 2010. Retail clinics partner with hospitals to enhance their image, and hospitals are realizing the potential of co-branding with clinics for a source of referral. Aetna, Cigna, Humana, and United Health Care all have contracts with Walgreens, CVS, and HEB to provide inexpensive services for their members.

Primary care physicians have many concerns about quality of care and ‘cream skimming’ - treating patients that require the least care while physicians are left with the more complicated patients who yield lower reimbursements. Nevertheless, given the rising cost of health care and limited access to physicians, particularly during non-scheduled hours, there is an evolving market for the services of retail clinics. Convenient care clinics should be allowed to develop as long as they meet guidelines for a safe environment, practice evidence-based medicine, and are directed by physicians who oversee appropriate scope of practice by clinic staff.

Health Literacy and the Elderly

Lynn G. Mark, D.O., MA

A 2004 Institute of Medicine report, Health Literacy: A Prescription to End Confusion, reported 90 million people lack the “capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions,” even though a majority are native-born English-speaking adults. These patients may not be able to read appointment information, understand how to take their medications, or be able to complete medical forms. Patients’ lack of ability to effectively communicate with health care providers decreases health care access, increases cost, and compromises quality of care.

Of the 38 million seniors aged 65 and older in 2007, approximately 11 million of them currently lack the skills they need to manage their health, and that number will grow as the baby boomer population reaches 71 million by 2030. Studies have shown that individuals with lower levels of health literacy are more likely to be hospitalized and have worse disease outcomes. Patients’ lack of understanding – especially about effective management of chronic disease - drives up costs. Treatment of chronic disease cost $510 billion in 2000, and is projected to cost more than $1 trillion in 2020.

Patients are being encouraged to take on more responsibility for their health, but approximately one out of three senior citizens does not have the health literacy skills to do so. Health literacy needs to be addressed by physicians and other healthcare providers in health literacy pilot programs, as well as by legislation at the federal level.

Healthy Children for School Act

Gregory E. Peterson, DO, FACP

Our children are rapidly becoming physically unfit, overweight, and obese. For the first time in history, the life expectancy of children may be shorter than their parents. The rate of obesity and its related diseases have tripled since 1980, affecting nearly twenty percent of children. Obesity is associated with diabetes, heart disease, and cancer. At this rate, by the year 2025, nearly half of adults will be obese and one out of three will have diabetes. The rates of heart disease and cancer may be even greater, since studies have shown that when adolescents are obese, the rate of cancer is two times greater and the rate of heart disease is about three and a half times greater than non-obese adolescents in early adulthood.

The Healthy Children for School Act would include the following:
• All children entering elementary school will have a primary care provider who will provide health screening every two years.
• All children at risk for diabetes will have blood glucose monitoring.
• All schools would create a student health council that has at least one primary care provider as a member.
• All school districts and schools would implement two of three policy recommendations established in the Child Nutrition and WIC Reauthorization Act of 2004.

Using school wellness plans to fight childhood obesity conjoined with preventive, comprehensive primary care, will increase access to health care and improve the quality of care.

Improving Access and Quality of Care for Children in the Texas Medicaid Program

Damon A. Schranz, D.O., FACOFP

In the Texas Medicaid system, coverage does not equal accessible, quality medical care, at least not yet. In 1993, a class action lawsuit, Frew v. Hawkins, was filed against the state alleging that Texas did not adequately provide Medicaid Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. The main arguments of the lawsuit stemmed from inadequate notification of parents of potential Medicaid benefits for their children, problems accessing those benefits after qualification, and lack of assistance with transportation. The agreement allocated $707 million per year ($1.8 billion in state and federal funds combined), to improve outreach and education to Medicaid-enrolled families, to increase physician and dental reimbursement rates, and to improve the availability of medical and dental services in rural and border regions of the state.

The additional funding of children’s Medicaid in Texas set forth in the Frew vs. Hawkins lawsuit will increase physician and dental participation in the children’s Medicaid program. Effective patient-centered case management will identify children who have fallen behind in required physical and dental exams and provide all required social services including non-emergent medical transportation. Concentrating on case management and increasing the number of Medicaid providers of dental and medical services will positively affect the future health of children in the state of Texas and will meet the objectives of the mandates set forth in Frew vs. Hawkins.

Florida’s Experience with Medicaid Reform

Samuel Snyder, D.O., FACP, FACOI, FASN

Florida’s Medicaid reform demonstration seeks to control costs by increasing the role of private managed care providers, encouraging marketplace efficiencies, and capping state contributions. This brief examines the market-based plan and its potential impact on access to affordable care for Florida’s vulnerable populations, and comes to the following conclusions:

•The project does not mandate or implement specific quality measures to assure quality of care; rather, managed care entities are expected to implement these independently.
• Because the plan was established through a Section 1115 Waiver, federal contributions to the state’s MA cannot be increased, a major impediment to increasing access. The state has expressed no intention to change eligibility requirements to allow the uninsured to qualify for MA.
• Under the old system of defined benefits, subscribers received all benefits appropriate for a particular diagnosis. Under the new system of defined contributions that caps state expenditures, subscribers may have to pay greater amounts out of pocket to receive equivalent levels of care.
• The plan does not address costs of long term care, the largest single component of the current system.

Surveys suggest bureaucratic obstacles reduce access to providers and prescription drugs, and benefit offerings may be less generous in the second year of the demonstration than the first. It is too soon to tell whether or not the state is saving money. Until all these issues can be resolved, statewide rollout of the program should be postponed.