Class of 1997-98
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements

Jack D. Bragg, D.O.
Osteopathic Internal Medicine Training and Cost Containment

Cost-containment measures and financial incentives/disincentives have been instrumental in driving recent reforms in the evolution of healthcare delivery. Managed care organizations (MCOs) have responded to the call for cost containment by placing a greater reliance on the care delivered by generalist and family practitioners, and demanding that these practitioners act as the first point of access when caring for enrollees. The osteopathic medical profession has achieved an impressive record of producing an abundance of primary care practitioners. Recent studies have shown that osteopathic primary care physicians can deliver less expensive care with equal success when compared to care delivered by allopathic physicians in some situations. General internists provide a large portion of the primary care delivered by osteopathic physicians. Discussion regarding the differences in the training of allopathic internists and osteopathic internists has recently taken place. Osteopathic internists suggest that osteopathic internal medicine programs provide a more extensive and broad-based exposure to most of the sub-specialties and their procedures. This study attempts to quantify these differences by surveying their scope of training and their practice patterns. From a health policy point of view, any variation in training shown to reduce the cost of care could have important implications for future cost-containment efforts.

Russell G. Gamber, D.O.
Patient Satisfaction with Osteopathic Manipulative Treatment:
A Clinical Outcomes Research Study

This study tested the hypothesis that patients experience greater satisfaction with the health care provided by osteopathic physicians when compared with care given by other types of providers. The hypothesis was tested using the experience of patients attending the Manipulative Medicine Clinic at the University of North Texas Health Science Center at Fort Worth. We developed and validated a standardized research instrument, the Osteopathic Manipulative Medicine Patient Satisfaction Questionnaire, which was used in the project. The Osteopathic Manipulative Medicine Patient Satisfaction Questionnaire was administered to all consenting patients attending the Manipulative Medicine clinic between March 31 and July 31, 1998. We surveyed 100 study participants. A standardized patient satisfaction score was computed for each subject and summary measures were computed for the entire study population. These data were compared to standardized patient satisfaction scores based on the current data reported in non-osteopathic, ambulatory health care settings as determined by our previous meta-analysis. We tested our primary hypothesis by comparing the observed standardized patient satisfaction scores with those previously reported in the literature. We demonstrated a 17 percent greater satisfaction with osteopathic physicians compared with other providers. We used a two-tailed, Student's t-test at the 0.005 level of statistical significance. The power of our study was greater than 75 percent. The research was based on two previous studies. The first was a published study of two dimensions of patient satisfaction with ambulatory health care in the Veterans Administration. The second, which is currently being prepared for publication, was a major review of the literature on patient satisfaction. The review initially started with 714 citations, and included a more thorough review of 384 articles. Eventually, 46 articles were included in the mega-analysis of patient satisfaction with the process of ambulatory health care in the United States.

Steven D. Hinshaw, D.O.
The Expanding Scope of Practice of Non-Physician Clinicians:
What Osteopathic Physicians Need to Know

Osteopathic physicians should be conscious that there is an ever-advancing force of non-physician clinicians (NPCs) into the provision of patient care. NPCs have been using the legislative vehicle to facilitate the advancement of the scopes of their practices. The process is incremental and effective. Consequently, the total number of these providers is poised to explode. There does not appear to be a consistent advancement in training to correlate with the expanding scope of practice that they are obtaining. This raises concerns that they may not be adequately trained to provide quality services at that level. However, some legislatures are willing to allow these changes due to the pressures to control cost and expand access of care. Physicians as a whole have become complacent in their political involvement. They are more reactive than proactive, and subsequently are left behind at their political involvement. They are dealing with better prepared and financed non-physician provider lobbying groups. Physicians have a responsibility to their patients to safeguard the care that they are providing to the public. In this, they need to be more active in the political sphere involved in monitoring the legislative front and this potential risk to public safety and well being.

Gary D. James, D.O.
Policy Implications of Pain Treatment

Pain is a major health problem in the United States today. Thirty-four million Americans suffer from chronic pain with an economic impact estimated to be over $100 billion. Pain is one of the most common complaints seen in a Family Physician's office, yet it is estimated that 40 percent of pain patients are inadequately treated. Barriers to treatment include lack of knowledge by consumers and healthcare professionals about pain management, fear of addicting patients to pain medication, and fear of medical board and DEA scrutiny. As these barriers are addressed at all levels--undergraduate medical school, post-graduate medical education, and state and federal legislatures--tens of thousands of patients with pain will no longer suffer needlessly.

Hollis H. King, D.O., Ph.D.
Occurrence of Meconium-Stained Amniotic Fluid, Pre-Term Delivery, Umbilical Cord Prolapse, Use of Forceps, and Cesarean Section Delivery in Women Who Received Osteopathic Manipulative Treatment During Pregnancy

Since the inception of the osteopathic profession, osteopathic manipulative treatment (OMT) has been applied during pregnancy. The subjective observation by a number of osteopathic physicians was that women treated with OMT during pregnancy reported a low rate of complications occurring during labor and delivery. Studies published since 1970 pertaining to the musculoskeletal system during pregnancy and delivery have focused on the treatment of low back pain. The reviewed literature revealed only a few objective or subjective reports on the possible relationship between OMT during pregnancy and pregnancy outcomes.

In the present retrospective study, the charts of 87 (expected to have 150-180) women who received OMT during pregnancy, were evaluated for the occurrence of meconium-stained amniotic fluid, pre-term delivery, umbilical cord prolapse, use of forceps (any kind), and cesarean section delivery. These outcomes of labor and delivery were selected because of structure-function relationships directly associating OMT effects with the anatomy and physiology of a pregnant woman, and the need to focus the data collection process.

Preliminary results showed meconium-stained amniotic fluid 9.2% (literature rates 13% to 26%). Pre-term delivery was 4.6% (literature rates 8% to 10%). Umbilical cord prolapse was 0% (literature rates 2% to 8%). Use of any kind of forceps was 9.2% (literature rates 10% to 21%). Cesarean section delivery was 16.1% (literature rates 11.6% to 28%).

Conclusions are that OMT may be beneficial for the pregnant woman. Health policy issues are explored. A prospective study is proposed.

G. Bradley Klock, D.O.
The Impact of Osteopathic Manipulative Medicine on Inpatient Outcomes

Osteopathic manipulative medicine has long been recognized as an effective treatment for spinal pain. To date, there is no more than anecdotal evidence to suggest that this distinctly osteopathic modality should be utilized in the hospital setting. If it could be demonstrated that manipulative treatment reduced mortality, or length of stay, then perhaps it would become the standard of care within the profession. The question remains, does it lessen human suffering or reduce the cost of medical care? This paper is based upon data collected in a retrospective review of inpatient charts. The study revolves around four hundred seventy-nine patients who underwent percutaneous transluminal balloon coronary angioplasty, with or without stent placement. One hundred twenty-one of these patients received osteopathic manipulative care, the others did not; the outcomes were compared between the two groups. Since the sample was so small, patients were not segregated as to severity. Some underwent the procedure on an elective basis while others required the procedure as an emergent, life-saving measure.

It is the author's hope that this pilot study will demonstrate the need to design a prospective study to fully evaluate the effect of manipulative medicine in the acute care hospital setting.

Carol L. Monson, D.O.
Osteopathic Distinctiveness: Is It Alive and Well?

The process of researching the origins of osteopathic medicine, the journey of osteopathic medicine to its place in today's world of medicine, and the direction of osteopathic medicine toward the twenty-first century became an appealing adventure. The goals of this paper are to explore osteopathic medicine in regard to its "distinctiveness," to look at the attitudes of some of its more recent graduates with regards to their osteopathic identity, and to examine the implications of these findings for future health policy in the osteopathic profession. The author will define osteopathic distinctiveness and review discussions by other authors of why it does or does not exist today. The attitudes regarding osteopathic identity, osteopathic affiliation, and Osteopathic Manipulative Treatment (OMT) use of respondents of the Class of 1992 will be examined. Compared respondent groups will include "backdoor" osteopathic graduates, graduates of AOA-approved primary care and non-primary care residencies, and graduates of ACGME or military primary care and non-primary care residencies.

A discussion of the good news and bad news of the finding of the study will lead to the health policy issues for the osteopathic profession. The osteopathic profession must take definitive steps to move into the twenty-first century with distinctiveness. Osteopathic principles and practice, as well as OMT, must be integrated into the osteopathic medical continuum so they become second nature to our students and graduates rather than second class.

David Plundo, D.O.
The Impact of the Balanced Budget Act on Osteopathic Family Practice Residencies

The Balanced Budget Act of 1997 will reduce federal healthcare spending by at least $128 billion over five years. A portion of these savings will be realized by a decrease in funding of graduate medical education. The impact on graduate medical education is far-reaching, affecting both the indirect Medicare reimbursement to training institutions and the direct Medicare reimbursement for residency training.

To assess the impact of the Balanced Budget Act on osteopathic family practice residencies, the author conducted a survey of all osteopathic family practice residency programs. The purpose of the survey was to determine 1) the number of osteopathic family practice residency training "slots" actually lost, and 2) if individual training institutions are alternatively funding training slots independent of Medicare reimbursement. The results of the survey are discussed.

Tom A Stevenson, D.O.
Multi-State Licensure in the Telecommunication Age: A Review of Proposed Strategies for Care

The telecommunication age has created many new opportunities for the practice of interstate medicine. Issues regarding the licensure and oversight of physicians who practice across state lines have arisen and created a debate as to the best means to modify the current system of licensure.

This paper addresses the history of licensure including the basis for the current system of state medical boards, explores the conflicts between state rights and federal commerce laws preventing restraint-of-trade, and reviews the proposed alternatives to medical licensure. The paper also reviews the recommendations for licensure reform proposed by several medical organizations and concludes with my recommendation(s) for a system of limited licensure.

Keith Watson, D.O.
Strategies for Promotion of Osteopathic Graduate Medical Education

Osteopathic graduate medical education (OGME) is unique because of its methodology, site of delivery, and the optimal ratio of primary care to specialty graduates. The historical factors surrounding OGME have produced a community-based training system producing a predominance of primary care practitioners. However, the supply of Doctors of Osteopathic Medicine (D.O.s) is insufficient to appropriately infuse osteopathic principles throughout the United States' healthcare system.

Generally accepted policy assumptions about reforming national GME funding and the balancing of physician production are not being appropriately applied to the osteopathic GME paradigm. Osteopathic methods of GME delivery are already producing the results desired by national GME reformers. Assumptions about OGME must be osteopathic-profession specific to preserve and protect the uniqueness of this training approach.

Strategies to promote the OGME approach should be based on firm assumptions that accurately reflect the osteopathic profession's goals and objectives for health care delivery. Osteopathic Postgraduate Training Institutes (OPTIs) are innovative consortia models that will provide opportunities to strengthen OGME in several specific ways. This author proposes new and mandatory accreditation standards for OPTIs that include: 1) debt management training for each resident; 2) financial consultation and strategic planning for each consortium; and 3) the pursuit of innovative funding streams by each consortium.