Class
of 1996-97
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements
Margaret
I. Aguwa, D.O., M.P.H.
The Professional Identification of a Recent Graduate Class of the
Colleges of Osteopathic Medicine
The findings of a recent survey of osteopathic medical school graduates suggest that a large majority of graduates regard the profession positively, but may express concerns about the limited public recognition and appreciation of osteopathic distinctiveness. This comprehensive survey of the graduates of the class of 1992 included questions regarding their identification with the osteopathic profession from application to medical school through residency selection and practice. The survey also explored current affiliations with professional organizations and use of Osteopathic Manipulative Therapy in practice.
Since osteopathic graduates are actively recruited by allopathic institutions for graduate medical education programs, osteopathic professional identification may be critical to the profession's survival. Researchers have concluded that an identity crisis exists within the profession's ranks. Challenges to the profession addressed in this paper include: creating an awareness of the need for visibility, producing effective public relations strategies to portray the osteopathic profession in the best light, and generating sufficient funds to carry out these strategies.
Jerome
A. Dixon, D.O., M.N.S.
Advance Directives: Will They Ever Advance?
Procedural barriers impede the efficient and effective implementation of advance directives, particularly in the emergency care setting. Advance directives, originally envisioned to improve, insure, and secure patient autonomy, and to provide for informed consent, are often disregarded during emergency situations.
Several critical procedural problems need to be addressed for advance directives to advance. First, less than 20 percent of the American population execute advance directives. Second, emergency medical personnel do not have timely access to advance directives to insure appropriate delivery of care. Third, conflicts between the physician and the person with healthcare power of attorney for the patient often result in a delay of directive execution.
This paper discusses recommendations based on research findings cited in the literature to correct these problems.
Walter
Grady, D.O., Lt. Col., USAF MC
Tricare-Medicare: A Health Policy Dilemma and Broken Promise for America's
Retired Military
This editorial study investigates a broken promise to America's retired military beneficiaries. The paper documents the promise of free lifetime healthcare to the military. Fiscal constraints, military downsizing, limited resources, and lack of space availability for dependent and retiree care have steadily eroded the promise since 1956. Viable alternatives and constructive solutions for restoration of the promise are proposed.
Military managed care (TRICARE) implementations in 1939 rendered Medicare-eligible retiree beneficiaries ineligible for CHAMPUS and TRICARE, making them the only group of federal retirees not allowed to carry the health plan they had before retirement, beyond age 65. The author identifies issues of discrimination, exclusion, military-civilian federal health plan non-parity, and unfavorable Medicare reimbursement laws.
An interview with George E. Day, Attorney and Colonel USAF RETIRED--the most decorated war hero since General Douglas MacArthur--reveals the emotional letdown of America's finest patriots and warriors. Day is spearheading a veterans class action lawsuit against the United States government to restore the promise. This paper supports the proposition to restore "the promise" for military retirees and examines potential methods and their cost.
Although the author is an active duty Air Force member whose intent is to provide an active duty perspective on the subject, his opinion in no way reflects that of the United States Air Force.
Terence
Grewe, D.O.
The Physician Workforce in Oklahoma: National Trends and Local Issues
In the 1970s, Oklahoma state leaders responded to a perceived physician shortage by implementing a public policy plan to educate more physicians and to induce more doctors to practice in rural and underserved areas. The plan expanded the state's allopathic medical school, allowed for the creation of a new osteopathic medical school, and created a Physician Manpower Training Commission. The medical schools addressed the supply of physicians. The Commission financially supported primary care post-graduate medical education and provided monetary incentives to motivate medical students and graduates to commit to rural areas.
This study analyzes characteristics and trends of Oklahoma's practicing physician population for type of practice, practice location, and medical school attended, compares the physician-to-population ratio and specialty distribution with national data, current benchmarking predictions, and per capita income figures. Data analysis reveals that Oklahoma currently occupies a position near the national mean for the number of physicians compared to per capita income, produces an adequate number of physicians in a desired ratio of primary-to-specialty care, and places an adequate number of physicians in rural communities. The Oklahoma experience provides a workable blueprint for other states wishing to increase physician presence and rural physician distribution.
John
G. Hohner, D.O.
Illinois Medicaid Restructuring: A Barrier to Preventive Foot Care
for Diabetes?
The Illinois legislative finance committee changed Illinois Medicaid policy on July 1, 1995 eliminating reimbursement for many previously covered services. Podiatric care for enrollees over the age of twenty-one fell under the ax. Preventive foot care for diabetics is essential to minimize complications. Illinois Medicaid records provided data to evaluate the impact of this policy change. This paper compares amputation rates in Medicaid enrolled diabetics for a two year block before and a two year block after the policy change. The number of amputations from July 1, 1993 through June 30, 1995 total 544. The number of amputations from July 1, 1995 through June 25, 1997 totaled 508. This provides a favorable budgetary impact to Illinois Medicaid.
Lorenzo
L. Pence, D.O.
Practice Patterns of Osteopathic Family Physicians
Purpose: The first step in meeting the need for family physicians in both urban and rural areas consists of an examination of the practice locations of osteopathic family physicians to determine any practice patterns.
Methods: This study analyzes data for osteopathic graduates of the class of 1986 who completed family practice residencies for residency location, practice location, and population size of locations. Retrospective analysis of data from the American Osteopathic Association master data file provided data for the study.
Results: Osteopathic family physicians tend to move from urban to rural areas. Thirty-nine percent of the osteopathic family physicians from this class continue to practice in the same community where they started. The residency site is not a predictor of practice location.
Conclusions: This study generates more questions than answers. Additional information is needed to determine why osteopathic physicians locate or relocate to a certain type of geographic area. Future studies need to address why osteopathic physicians, who remain in the same community, stay in that community.
George
J. Pramstaller, D.O., FACOFP
Medicaid's Move to Managed Care in Michigan: Maintaining Access to
Care in Rural Areas
Recent changes in federal Medicaid rules on the use of managed care entities, coupled with the growth of managed care in the private sector have contributed to recent dramatic increases in Medicaid managed care enrollments. Many states rely on managed care arrangements as a primary strategy to reduce expenditures and better manage the care of Medicaid populations. This paper identifies the major barriers encountered and surmounted by states that have moved large numbers of Medicaid beneficiaries into managed care systems. By learning from the experiences of pioneering states, the Michigan Department of Community Health (MDCH) constructed a managed care program that successfully addresses the majority of Michigan's Medicaid beneficiaries. Although the program accommodates the specific traits common among Michigan's largest urban centers, the program does not appear well configured for the state's expansive rural communities. Differences in demographic characteristics, health seeking behaviors, and underlying health status along with problems of significant geographic distances and lack of transportation necessitate innovative approaches to conquer rural barriers. Michigan's rural areas cannot presently comply with the criteria outlined for the Comprehensive Health Benefits Plan prompting the need for temporary changes in financial solvency levels, information systems requirements and fully capitated risk bearing to facilitate rural implementation.
Ebb
Reeves, D.O.
Planning for Managed Care: Can Physician Leadership Make It Work?
The market move to managed care puts physician practices at increased economic risk. This study examines the proactive strategic transition of a traditional fee-for-service (FFS) Medicare practice to a capitated managed care system by a 105-physician primary care group.
The group focused on a strategic plan to insure economic survival by actively involving the physicians in policymaking and management leadership roles to aid in reducing resource utilization, achieving a greater degree of operating efficiency, acceptance of capitated managed care risk, and the use of quality improvement measures. The study reviews resource utilization and patient satisfaction data for Medicare managed care patients. When compared to the general FFS Medicare population, the Medicare managed care population experienced a marked reduction in hospital days of care. Overall patient satisfaction rates equaled or exceeded national norms, and low disenrollment figures accompanied the reduction in resource utilization.
Though limited in scope, the study suggests that strong physician leadership and dedication to value-centered care can make acceptance of managed care risk an effective strategy for success.
Robert
J. Stomel, D.O., FACOI, FACC
Practice Guideline Lessons From A Chest Pain Management Model
Guidelines, critical pathways, and "report card" incentives do not empower physicians to change medical practice patterns. Only when community-based physicians have ownership in guideline development will behaviors change. Guideline development that recognizes and includes the five critical elements described in this study will gain physician endorsement, facilitate future compliance, and result in improved quality at a lower cost.
Recent reports presented at the 1997 American College of Cardiology demonstrate that national chest pain management guidelines have failed to change physician practice patterns. Despite national endorsement, a significant number of physicians fail to use aspirin to treat chest pain, potentially resulting in the loss of thousands of lives per year. Recent data also shows a 225% variability in the treatment of acute myocardial infarction. Obviously, current strategies to influence physician behavior, though guideline implementation, have failed.
In 1995, Botsford General Hospital redesigned its chest pain center critical pathway to include five critical elements of physician practice behavior modification: established best science, prospective protocol research pathways, community ownership, physician leadership, and feedback.
Utilizing the five critical elements, Botsford General Hospital physicians created guidelines and monitored compliance. The admission rate for chest pain decreased by 20% between 1993 and 1996, and outpatient admissions increased by 1,725%. Total inpatient days decreased from 2,024 to 981, and the average length of stay fell from 3.4 to 2.1 days. The hospital maintained a high quality level, saved $2 million, and experienced no deaths associated with the new guideline use.