Class of 1998-99
Abstracts of Policy Papers
Submitted for Completion of Certificate Requirements

David G. Alexander, D.O.
Should the American Public Have Complete Access and Coverage for Emergencies?

Abstract: Patients who present to emergency departments should receive prompt, efficient, and quality emergency care. Emergent patients should not have to worry about getting prior approval from an HMO or insurance carrier, before being seen and treated in an emergency department. This paper has attempted to research current literature and articles on access to emergency care. Examples were found of patients who were harmed while waiting to receive care and HMO/insurance pre-approval. The prudent layperson is a far better advocate for himself, as in someone from an HMO on a phone line miles away from the emergency department he awaiting care at. In conclusion, the interests of the public would be better served if Congress passes the Access to Emergency Medical Services Act of 1999.

Jeff S. Benseler, D.O.
Graduate Medical Education: Physician Staffing Issues in Family Practice Residencies

Abstract: The number of paid and volunteer physician faculty varies considerably across the country from residency to residency. The author examines several possible explanations for this variation. Specifically, a significant difference exists between residency programs with regard to direct graduate medical education payments from Medicare that training institutions use to pay faculty salaries. One of the results of this difference in funding is disparity in residency programsí ability to employ paid faculty. Many residencies have turned to volunteer faculty to fill this critical gap. The use of physician volunteers as well as faculty requirements of accrediting bodies will be examined.

A survey of all family practice residencies in Ohio revealed an unequal ratio of paid physician faculty to residents across the state. The survey further demonstrated that nearly one-third of Ohio Family Practice residencies do not engage volunteer faculty to support their administrative/supervisory infrastructure.

The Balanced Budget Act of 1997 heralds the early stages of a major shift in graduate medical education funding. Proposals have been made to level the playing field for resident funding on a national basis, and, further, an all-payer funding system designed to relieve pressure on Medicare has been proposed in Congress. Whether or not these proposals move forward, medical educators must revisit current faculty requirements, prepare to engage in strategic planning and place emphasis on resource sharing in this changing healthcare environment. Additional studies to determine the optimal number of faculty and the relationship of faculty staffing to program quality would be extremely valuable.

Peter B. Dane, D.O.
Health Care Policies and Pain Management

Abstract: Physician misinformation about current developments in pain management strategies, as well as longstanding perceptions of adversarial regulatory medical board policies, have contributed to higher medical costs, limited patient access to appropriate medical care, and ultimately to less-than-optimal quality of care for thousands of patients who suffer chronic, intractable, debilitating pain. Professional pain management organizations such as the American Pain Society (APS) and the American Academy of Pain Management (AAPM) have promoted educational programs designed to dispel some of the myths, traditions, and flawed perceptions that constitute barriers to adequate pain control. State medical licensing boards have attempted to update their monitoring policies in order to mitigate their negative image as physician adversaries in the area of narcotic prescribing practices. Congress has proposed patient-advocacy legislation supporting more aggressive approaches to pain management. Despite these efforts, however, the attitudes and, consequently, the treatment strategies of the majority of physicians who treat patients with chronic pain remain unchanged. Recent developments suggest that the documented sub-optimal management of pain raises new issues of physician liability. The development of standards of care and clinical practice guidelines create accountability expectations previously absent from the patient-physician relationship. The author recommends 1) a national initiative to update the pre-doctoral medical school curriculum to include evidence-based instruction on pain management, 2) educational campaigns, supported by both medical organizations and legislative mandates, to provide practicing physicians and medical licensing boards with current information about contemporary perceptions of appropriate pain management, 3) the establishment of guidelines to keep state and federal regulatory and licensing board policies current with scientific progress in medicine, and 4) a federally sponsored review and revision of the thirty year-old Controlled Substances Act, which still serves as the reference standard for medical regulatory agencies.

John William Graneto, D.O.
Testing Osteopathic Medical School Graduates for Licensure: Is the COMLEX-USA the Most Appropriate Examination?

Abstract: Osteopathic and allopathic physicians receive authority to practice medicine through the licensing board of the individual states in which they practice. Each individual state has the responsibility to operate a licensing board for physicians and other medical professionals. These boards choose which examinations to accept as proof of a physicianís preparedness to be licensed to practice medicine. The National Board of Osteopathic Medical Examiners (NBOME) administers the Comprehensive Osteopathic Medical Licensing Exam (COMLEX-USA).

To determine the views of the educational leaders of the osteopathic profession regarding the NBOME and the COMLEX-USA, a survey was mailed to leaders in the osteopathic profession.

The survey respondents felt that osteopathic medical students receive a unique professional education and should, therefore, be tested by a unique process. The NBOME, through its testing procedures, continues to be the organization best suited to test the knowledge of osteopathic students and graduates. Overwhelming support exists among the practicing leadership of the osteopathic profession for the profession to retain the ability and the right to examine its own trainees from within. Therefore, the osteopathic profession at this time supports allowing the profession to develop and examine its own trainees.

Terry A. Johnson, D.O.
The Impact of the Balanced Budget Act on Osteopathic Graduate Medical Education

Abstract: The Balanced Budget Act of 1997 (BBA) brought far-reaching implications to many facets of American society. Graduate Medical Education (GME) did not escape the attention of congressional budget cutters. The changes made regarding GME will have a profound impact on the education of postgraduates and herald the possibility of even more budgetary reducing actions. This paper looks briefly at the origins of the BBA, its purpose, and its relevance to GMEóparticularly to osteopathic GME, which arguably has been disproportionately impacted by this act. One of the changes most worrisome to the osteopathic profession is the establishment of caps on existing GME programs. As the profession continues to open more osteopathic medical schools and expand its numbers, attention must be given to how these future physicians will be trained. One opportunity for continued expansion is through the establishment of either new or rural GME programs, a provision allowed under the terms of the BBA. New and rural programs are discussed and consideration is given to how they will be capped. Finally, the author examines the osteopathic rotating internship and its role in the new GME environment.

Al Juocys, D.O.
Dual Choice: A Step Forward or Back For Quality Managed Care ?

Abstract: In 1987, Blue Care Network (BCN) of Southeastern Michigan, a capitated HMO program, introduced a ìdual choiceî option for women enrolled through General Motors and Ford Motor Company. The dual choice benefit option, offered as an alternative benefit through negotiations conducted by the United Auto Workers, allowed women members to have two primary care physicians: a general internist and a gynecologist. A review of the literature and the Internet uncovered little information regarding this option. The researcher found limited information in managed care journals with respect to direct access to an OB/GYN for annual well-women examinations and routine obstetric care, as well as a limited number of Internet sites mentioning dual choice. The author obtained the majority of the information on this issue through interviews of managed care executives, assessing results of a medical chart review performed by nursing personnel, and by analyzing actual ìclaims paidî data. The researcher found that the quality of preventive care that women had grown accustomed to in the managed care environment was greatly reduced when the direct access to an OB/GYN was signed into law. Additionally, the cost of providing quality, well-woman healthcare had significantly increased since two primary care physicians were required to provide annual preventive examinations for women that met the guidelines of the managed care organizations.

Robert S. Maurer, D.O.
HMO LEGISLATIVE PROPOSALS: ERISA Waivers vs. Effective Appeals

Abstract: In this article, the author will attempt to give a general history and trace the development of Health Maintenance Organizations (HMOs) in this country, and review their current status in providing healthcare to a majority of Americans.

The author reviews the federal Employee Retirement Income Security Act (ERISA) of 1974 and explains of the preemption of states rights which specifically prevents a lawsuit for medical malpractice against an employer sponsored health benefits plan.

The author outlines the recommendations of the Presidential Advisory Commission of 1996, followed by a review of the major federal legislative proposals to reform the HMO control over its customers and their doctors, specifically the Patient Protection Act and the Patientís Bill of Rights.

Finally, the author specifically reviews the proposal to reverse ERISA, an action that would make HMOs or other ìcarriersî liable for professional malpractice litigation. The author enumerates and discusses the ìpros and consî of instituting such legislation on either a federal level, or on a state-to-state basis.

After careful consideration of all the facts and discussion by the interested parties, the author concludes by recommending that ERISA preemption not be reversed, but that physicians and their patients would be much better served by the development of a more expeditious and effective appeals system.

Bernard C. McDonnell, D.O.
Local Implementation of National Clinical Guidelines in the Treatment of Acute Myocardial Infarction: The Effort to Increase Quality, Decrease Cost

Abstract: Clinical practice guidelines or pathways are one result of merger and consolidation in the health care industry. Local input in the formation and implementation is crucial to their success. This has enabled physicians to correlate and rationalize local needs and issues to the national standard.

Acute myocardial infarction was chosen as a representative guideline due to its complexity, severity and traditional individualized treatment. Studies in Cincinnati, University of Pittsburgh, and the University of Alberta are reviewed and support this thesis.

Local experience with the Mercy Health System illustrates the interaction between local, sub national and national guideline implementation. Quality has improved and costs have decreased with the establishment of interdisciplinary guideline/pathway teams.

This paper will show that national guidelines require local implementation and input to be successful.

Scott A. Steingard, D.O.
The Impact of Physical Education on Childhood Obesity: An Arizona Perspective

Abstract: The problems associated with childhood obesity continue in the United States; over the past thirty years, the number of children classified as obese has doubled. The health related problems of childhood obesity have been well documented. Of particular concern is the positive correlation of childhood obesity with a high incidence of adult obesity and the associated comorbidities.

A strong connection exists between physical activity and positive health, mortality, and quality-of-life outcomes; the benefits of physical activity argue for early and continuous physical education instruction. Despite this, physical education has been progressively cut from elementary and high school curricula during the past fifteen years. The schools systems in Arizona, like those throughout the rest of the United States, have experienced consistent cuts to physical education to allow for increased instruction in more "academic" subjects. These continuing cuts have significantly frustrated efforts to improve physical education in the state. However, evidence shows that vigorous physical education can actually improve academic performance.

Policy experts and educators acknowledge a number of mechanisms to improve physical education programs. Changing the mission of physical educationófrom an immediate performance and award-based program to a more ìlifetimeî focused fitness regimenówould provide the opportunity and incentive for more children to get involved. In addition, instructing children in proper physical education habits at a young age can positively influence physical activity behaviors throughout life. The participation of parents, school nurses, and physicians is a key to the success of programs such as The Prudential Fitnessgramóa program promoting physical exercise and youth assessment. Regardless of sporadic efforts to reverse this troubling trend, childhood obesity remains a serious health challenge to the nation. If the current trends continue, the health and fiscal consequences of obesity will put a tremendous strain on the already taxed American healthcare system.

Larry Suess, D.O., Ph.D.
Antidepressants Pharmacoeconomics: A Comparison of State Medicaid Reimbursement Policy

Abstract: Prescriptive medications constituted approximately 9% of the $159.9 billion Medicaid expenditures in 1998, which covered medical expenses for 41.3 million Americans across the United States. A review of the roughly $14.4 billion paid for prescriptive medications shows Medicaid paid markedly different prices for the same medication in neighboring states and across the country. This disparity has resulted from federal regulations that allow each state to determine its own medication reimbursement formula. The Medicaid national guidelines established by Congress and monitored by the Health Care Financing Administration (HCFA) provide a broad base from which each state sets its Medicaid prescriptive pricing policies. In order to examine the pricing policy effective in Kentucky, this study examines how Kentucky and the states contiguous to Kentucky set their prescriptive pricing policy for Medicaid recipients. A review of the different reimbursement formula among the states points out the disparity in policy and the wide variability of costs between these states, and reveals the myriad variables that influence the actual cost of medications. The author suggests that HCFA take a stronger stance in its policy to contain costs by devising a standard formula to guide states in determining charges for medication.