Class of 1994-95
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements

Michael D. Adelman, D.O.
The Effects of Tort Reform on Defensive Medicine

Recent studies assert that tort reform has failed to significantly alter the number of malpractice claims in those states which have enacted such legislation. Although tort reform may not have reduced the number of malpractice claims, it is possible that such reform may have reduced the cost of medical care by impacting the number of medical tests and procedures ordered by physicians practicing defensive medicine. The objective of this study is to determine whether tort reform has increased the cost and practice of defensive medicine. This paper will present the rationale behind the practice of defensive medicine and explain the methods that will be used to study this assumption. The results and conclusions derived from this study will be presented in a future paper.

David Broder, D.O.
Mandating Advance Directives: A Unique Opportunity for Health Care Reform

Health care expenditures could be significantly reduced in America, without rationing or infringing on patients' rights, by mandating the use of advance directives. Significant health care resources are spent on heroic but futile measures. Similarly, many people do not want these procedures, nor do they wish to be kept alive artificially, but they no longer possess the capacity to decide when it becomes necessary. Advance directives allow people to make these decisions while they are still able to do so. Given the opportunity, many people would choose not to have cardiopulmonary resuscitation done or to be kept alive artificially resulting in significant reduction of expenses. Since their widespread use has not been achieved by voluntary measures, mandating advance directives is a possible approach. This is a unique opportunity to reduce health care costs by actually increasing patient autonomy and self-determination.

James W. Cole, D.O.
Centralized Verification System

In the process of credentialing physicians in the United States today, hospitals, state boards of licensure, HMOs, managed care entities, and many other organizations must address at least two core issues for each applicant. One of these deals with confirming that the basic background information, such as graduation from an accredited medical school, satisfactory completion of a residency, certification, etc. is valid. Secondly, and distinctively different, the credentialing institution must act on the applicant's request for the privilege to perform certain procedures or care for a defined spectrum of patients. As there is considerable variation in the criteria used to privilege physicians among hospitals, this position paper will address only the first issue. However, the potential to include verification of relevant information regarding privileging also exists within this system.

Bruce Dubin, D.O., J.D.
Teaching Osteopathic Professional Infrastructure to Osteopathic Medical Students: A Study and Proposal

Osteopathic medicine has always placed great emphasis on the relationship between structure and function. This philosophy should also serve as a sound framework for representative associations that address the needs of the osteopathic profession. The author sampled the knowledge base of new graduates from osteopathic schools about groups that represent the profession. Results of the study demonstrate poor comprehension of both the local, state and federal levels. The author recommends the development and incorporation of curricula that will inform osteopathic students about the politics, structure and function of their profession and its association. This will permit new osteopathic physicians a much needed understanding of how their profession is organized and allow for easier access and involvement into the health policy arena.

Howard L. Feinberg, D.O.
Practice Guidelines: Have They Met Their Goals?

There has been a proliferation of practice guidelines over the past 10 years. These guidelines have been issued to increase access, decrease the cost, and improve the quality of medical care. While these are admirable goals, the current evidence shows that these goals are not being met.

Recent research has indicated that practice guidelines may increase the costs related to malpractice. There appears to be no cost savings from their application in medical practice. Despite their availability, there is no evidence that practice guidelines have increased access to care. To date, practice guidelines have not been subjected to a scientific assessment of their ability to improve quality.

Practice guidelines at this time should be considered an experimental treatment approach. Further work is required to determine if they will be of use in improving the quality of medical care. The idea of cost savings and increased access are good theories which did not occur in actual practice. The development of guidelines for the purpose of cost containment and improved access should be abandoned.

Ronnie B. Martin, D.O.
The Dangers of Piecemeal Health Policy: An Example From the Pharmaceutical Industry

Representative Bill Brewster's (D-OK) 1994 legislation to eliminate prescription samples, although not advanced, represents a classic example of stakeholder motivated policy benefiting a select few stakeholders at the expense of millions of medically indigent and elderly Americans. Winners of this medical policy change would have been the nation's retail pharmacists and the pharmaceutical manufacturers. Patients in need could still be the losers.

In the absence of comprehensive health care reform, with its goal of universal access and necessary reform of the pharmaceutical industry, the economic impact of such legislation could run into hundreds of millions of dollars annually. Money would flow from the pockets of patients into the coffers of the stakeholders and their agencies. It would place the health and well being of people already at risk, the sick and poor, in further jeopardy.

Thomas E. McWilliams, D.O.
A Promising Development in Postgraduate Education: D.O./M.D. Collaborative Training for Family Practice

We are involved in a crisis in osteopathic postgraduate education. Due to a combination of factors, we have lost many osteopathic hospitals. Expanding numbers of osteopathic schools and an increase in class sizes at existing institutions has resulted in our no longer having the capacity to offer a sufficient number of internship and residency positions to our graduates. AOA accreditation of some existing allopathic family practice residencies is a promising development which offers a partial short-term relief to the demand for quality postgraduate training opportunities. When these programs have been modified to incorporate osteopathic principles and practices, the strengths of these two medical training systems can be successfully combined. Although these programs may compete with existing osteopathic internships and residencies, it is the author's contention that the benefits of such collaborative training far outweigh the inherent risks.

Martha A. Simpson, D.O., R..N.
An Evaluation of Practice Location and Specialty Choice Among Female Osteopathic Physicians

Purpose: To determine the impact of marital status on specialty choice and practice location among female Osteopathic physicians.

Methods: The 1992 AOA database was utilized to group physicians by practice location (MSA, nonMSA) and specialty choice (FP, nonFP). These groups were then sub-grouped by gender (M, F) and marital status (S, M). These variables were compared to see if any differences could be seen in the practice location and specialty choice between married and single women. A subgroup of D.O./D.O. couples were identified and examined to see if dual physician marriages will influence practice location and specialty choice.

Results: When evaluated as a whole, female osteopathic physicians do not differ from male physicians in choice of specialty or practice location. When men and women are divided into groups based on marital status, single men and single women are both less likely to practice in nonMSAs than either married men or women physicians. Overall, women are slightly more likely to be FP/GP. Single women are less likely to be FP/GP than married women physicians. D.O./D.O. couples are more likely to be FP/GP than other married physicians not married to a D.O.

Conclusions: The limited available data indicates that there is little practice pattern variation between men and women. The small numbers of women and the poor response rate to the question on marital status limit the use of existing data. Improved date collection is needed. As more women enter the workforce, trends may develop that have an impact on the overall physician workforce. These need to be identified and evaluated. Further analysis of D.O. couples is needed to quantify this phenomenon as it relates to the physician workforce after the turn of the century.

Mary L. Theodoras, D.O.
The Dayton Area Health Plan: A Model Mandatory Non-Profit Managed Care Medicaid Program

In this paper, I describe a program which not only treats Medicaid constituents but also those people who are on general relief, Aid to Dependent Children, and Healthy Start. Included in the paper are the following: what circumstances initiated the program; what was necessary for this program to get approved by waivers from HCFA; what hurdles had to be jumped in order to get the program started; what characteristics make this program a model for similar programs; a look at the new and innovative programs that were started through savings generated by the program's nonprofit status; an examination of the advisory council comprised of providers and consumers; a description of the general operation of this program and how it continues to make changes as needed--often in response to items generated by the various advisory councils; an analysis of quality assurance issues and outcome studies between this program's performance with comparative data; and finally, what the future will hold for this program.

Amelia G. Tunanidas, D.O., FACOFP
Health Care Reform and the Business of Insurance

Managed care initiatives by the insurance industry have evolved in multiple forms and are progressing at a rapid pace despite the failure of passage of a Health Care Reform Act or comprehensive plan by the U.S. legislature. Health care has become a huge business subject to vigorous antitrust scrutiny under specific antitrust statutes which have been in existence since the 1890s to prevent anti-competitive business practices. The insurance industry has emerged as the leader of managed care initiatives in the marketplace, but has maintained distinctive immunity to antitrust legislation and statutes. This immunity has afforded the insurance industry a definite advantage in the reformation of health care delivery systems and their standards, without formal scrutiny or oversight. Various initiatives that have occurred in the reform process and current ventures developing within the insurance industry are described. Federal antitrust statutes that businesses are subject to--in particular, anti-competitive efforts in health care, are identified. The current playing field in health care reform and provision of health care reform and provision of health care is uneven. Government needs to revisit and carefully scrutinize the insurance industry as a health care "provider," subject to--and not exempt from--antitrust statutes in the current marketplace. Only when this occurs will the public interest be protected and free market competition be maintained.

Larry Wickless, D.O., FACOI
Board Certification and Managed Care

The policy of some managed care organizations utilizing certification as a sole exclusionary criterion for participation in the Physician Provider Panel is felt by many to be an inappropriate use of the certification process. Because of the increasing participation in the United States population (estimated at 262,000,000), 50 million people were receiving their care in a Health Management Organization (HMO). This figure will increase rapidly over the next few years, particularly if there are more Medicare recipients entered into Managed Care Organizations (MCOs). Certainly, with the extreme success that MCOs have had in recent years, any policy developed by an MCO is going to have a great impact upon practicing physicians. As of year end 1993, there were 545 HMO plans involving primary model types with 45 million plus enrollees.

Quality and outcome measures have to be developed to standardized and validated performance measures, which can be utilized for comparative purposes. These measures can be referred to as a yardstick or "report card" to allow consumers, employers and other entities to compare the quality and value of the individual MCO health care product. This is particularly important in the cost management of health care delivery, because in satisfying the pressure to decrease health care costs, one must be sure that quality is maintained. If most people adhere to this comparative standard, it will be easier to assess comparable data.