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January 2000 • Volume 6 • Number 1

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Access to health care It's one hot potato for presidential contenders BY JANE STOEVER

Health care issues are hot in the 2000 presidential race. Some candidates already argue about the issue of the uninsured; others have access-to-care positions posted on their Web sites.

Yet a few years ago, political analysts pronounced access to care the kiss of death. Why the change?

"The economy is growing, unemployment is at record low levels, but we have more uninsured than ever before -- 44 million uninsured," says AAFP President-elect Richard Roberts, M.D., J.D., of Madison, Wis. "This may be a catalyst for universal coverage."

Robert Reischauer, Ph.D., of the Brookings Institution in Washington, D.C., offers a historical perspective.

"Because President Bill Clinton's effort of 1993-94 was widely viewed as a political disaster, most observers thought the uninsured would not be a focus of presidential candidates for two decades," says Reischauer, who headed the Congressional Budget Office from 1989 to 1995.

"And yet here it is, front and center again," he says. "We can thank Bill Bradley for that. His proposal would get the percentage of the uninsured down from 17 percent of Americans to 6-7 percent. Al Gore's proposal would chip away at the numbers of uninsured, and Republican candidates are also moving in that direction." (See chart below.)

What doomed the 1993-94 effort?

"While Americans believe something should be done to reduce the number of people without insurance and to simplify the health care marketplace, when faced in 1993-94 with the steps that would have to be taken, they feared the insurance protection they had might be threatened," says Reischauer.

Six years later, workers may be coming to grips with the fact that if they lose their jobs, they could end up without adequate health insurance, he says.

The country has no shortage of health care resources, but they are poorly distributed, says Reischauer. Redistribution will mean taking away some resources currently enjoyed by one sector of the population or another. "For example," he says, "in 1994, I was covered by my wife's policy as well as my own at my place of work, at no real additional cost. We had relatively high income and double coverage. That's not right when many have no protection at all."

No pot of surplus gold
Several candidates plan to fund health proposals from the federal surplus. Their plans may not pan out.

"The notion that somehow the government is awash in money, and therefore there's an opportunity for lots of new initiatives in health care, is probably not accurate," says Marty Gold, J.D., a leader of the Legislative Strategies Group in Washington and former counsel to past Sen. Howard Baker Jr., R-Tenn.

Gold says Congress resorted to smoke-and-mirror gimmicks to be able to claim it passed a budget that maintains a surplus and does not invade the Social Security trust fund. "What gets you through the budget for the year 2000 creates pressures for 2001," he says.

Republicans are suggesting tax breaks for the self-employed, expansion of medical savings accounts and pooling arrangements for small employers. "These are all intended to reduce the number of uninsured," says Gold.

However, he says the climate in Washington since the 1998 elections has been the political equivalent of Stalingrad during World War II. In 1998 -- against all odds -- Democratic and Republican candidates broke even in the Senate, and Democrats won five more seats in the House than Republicans did.

"It is a veritable war," says Gold. "The 1998 elections put the Democrats on the cusp of power, and there is no bipartisanship in the sense of compromise between the White House and Republican leaders in Congress."

That doesn't bode well for access-to-care bills, no matter what the presidential contenders propose.

What FPs can do
The Academy has a 10-year-strong policy promoting universal coverage, and family physicians have the chance to advance the access-to-care debate in local and national political campaigns.

"AAFP's policy has focused family physicians' efforts at the local level, reminding us we have a responsibility to be sure everyone in our community has a way into the health care system," says Roberts.

"At the national level, those in high positions have more awareness of the Academy because of the consistency and clarity of our position -- and our persistence," says Roberts. "The most palpable example was the September press conference at which Clinton announced his health agenda for the rest of his term. The only organization asked to give an address at that event was the Academy."

Key presidential candidates' access-to-care policies* Bill Bradley Prenatal care fully subsidized for many families Health insurance for all children from birth Private plans for federal employees also available to other adults Medicare prescription drug benefit New program helping seniors stay home and assisting care givers Source: www.BillBradley.com George W. Bush Medicare with more choices, more private-sector alternatives Medicare prescription drug benefit Medical savings accounts as an option for all Americans Protections (similar to those enacted in Texas) for beneficiaries in federally governed plans Reforms already enacted by states not to be superseded by federal laws Source: www.GeorgeBush.com Al Gore Access to health care by 2005 for all children through three steps: expanding the Children's Health Insurance Program, allowing families with incomes above 250 percent of poverty level to buy into Medicaid or CHIP, and giving states incentives to enroll uninsured children Federal matching payments for states to provide insurance coverage to uninsured parents of children eligible for Medicaid or CHIP New tax credit available for individual health insurance Source: www.AlGore2000.com John McCain Tax incentives for employers and individuals to gain affordable coverage Expanded efforts to enroll in existing programs all those eligible for them Resources pooled by individuals and businesses for less costly coverage More health plans and care options available to working poor Block grant for states to help seniors pay for prescription drugs Health coverage for all children Source: www.McCain2000.com * For other candidates' policies,, access www.cnn.com/ELECTION/2000/ and, under "candidate bios," click on "White House hopefuls." The Web sites may or may not be as current as daily media reports.

Into the fray! Voice your concerns this election year La Jolla, California

With local and national election campaigns heating up, you have the chance to make your voice heard on health care and other issues.

Some nuts and bolts to get you started:

Access the Web sites of candidates to learn their positions.

Contact local offices of parties, candidates or current lawmakers to see when they'll hold town meetings. Raise health-related questions at the meetings and share your views.

Remember, candidates often need the support of the medical community to get elected.

These ideas and others bubbled to the surface at AAFP's State Legislative Conference Nov. 12-14 in La Jolla. Additional advice and success stories shared at the meeting:

"The key to your relationship with your legislators is to have a relationship with your legislators. They'll think of you when things come up, and you'll be right there to help them," said AAFP President-elect Richard Roberts, M.D., J.D., of Madison, Wis., who admitted he's a political junkie.

"In any letter or contact you have with your legislator, make this point: 'This issue is going to affect your constituency; it will improve health care for our people.' You'll get your legislator's attention," said Rose Mary Hatem Bonsack, M.D., of Aberdeen, Md., a former member of the Mary-land Assembly and former AAFP director.

"The state senator or representative may later come to Washington," said AAFP Director James Martin, M.D., of San Antonio. "I'm not saying that they should be in our pocket, but that they should hear our concerns."

The Texas AFP honors legislators at dinners in their hometowns. The legislators meet area FPs, paving the way for future contacts.

Tennessee AFP Past President Jim King, M.D., of Selmer e-mails action alerts to physicians when key votes come up in the state legislature. "We e-mail our doctors, then have them call legislators," said King. "Recently, a big vote was coming up at 1 p.m., and I e-mailed 1,000 doctors in the state at 9 a.m. When I called my legislator's office at 10 a.m. and told the receptionist who I was, she said, 'Vote no!' I said, 'You got it.'"

Note: The next State Legislative Conference is Nov. 17-19 in New Orleans.

Thanks to AAFP effort, AMA will seek changes in pain relief act

BY PAULA BINDER
San Diego, Calif.

Relieving pain is good medicine. But to the Academy, the American Medical Association's support for the Pain Relief Promotion Act of 1999, H.R. 2260 and S. 1272, has been bad medicine.

Under the bill, federal law enforcement officials could look back at a patient's death and ­ using federally disseminated guidelines on palliative care - determine whether the physician provided appropriate care or assisted in a suicide.

While both AAFP and AMA oppose physician-assisted suicide, the AAFP "doesn't want the government in the role of defining good medical practice," explained AAFP President Bruce Bagley, M.D., of Albany, N.Y. "Such guidelines might not cover 'outliers' -- those patients who need more medication to control pain. This would create a 'chilling effect' -- exactly the opposite of what the bill's sponsors intend."

So the AAFP delegation went to the AMA House of Delegates Dec. 5-8 to try to change AMA's stance on the pain relief bill. The result: The AMA will seek improvements in the act by deletion of provisions that would establish federal protocols and/or regulations for pain management and palliative care. However, delegates did not adopt a second AAFP-sponsored resolve that would have instructed the AMA to withdraw its support for the pain relief act if those changes were not achieved.

Delegates adopted a third AAFP-sponsored resolve that instructs the AMA to "oppose any future legislation which gives the federal government the responsibility to define appropriate medical practice and regulate such practice through the use of criminal penalties."

Others opposing the pain relief bill in its current form include the American Society of Clinical Oncology, American Pain Society, AMA's Specialty and Service Society caucus and several state delegations.

The pain relief bill, H.R. 2260 and S. 1272, is intended to promote effective pain management while deterring the misuse of controlled substances for physician-assisted suicide. The House passed H.R. 2260 Oct. 27 by a bipartisan vote of 271-156.

Illiteracy: 'Hidden disability' creates health care confusion

BY SHARON DENT
Austin, Texas

Instructions printed on medication bottles are meaningless to almost half of your patients. More than half can’t understand a standard consent form. More than a quarter can’t read their appointment cards to know when they’re scheduled for another office visit.

In fact, only about 20 percent of adult Americans have the ability to read, understand and act on health care information, said Terry Davis, Ph.D., professor of medicine and pediatrics at the Louisiana State University Health Science Center in Shreveport, during the Conference on Patient Education Nov. 11-14 in Austin. Davis shared sobering statistics and offered suggestions for meeting the needs of illiterate patients.

She also showed video clips of patients with low reading levels, several of whom articulately discussed health issues with their physicians. Davis noted how easily patients can hide their illiteracy.

"You can’t tell by looking at those people, and, with many of them, you can’t tell by interviewing," she said. "Many patients of all literacy and socioeconomic levels won’t tell doctors when they don’t understand something."

In addition to not understanding the health information, many misunderstand it and therefore take inappropriate action.

Davis cited a study that found that one in four women who thought they knew what a mammogram was actually did not. "So, it isn’t effective to ask patients, ‘Have you had your mammogram?’ because many don’t know what you’re talking about," she said. "Some think a Pap test checks for all cancers."

Another study discovered that many patients don’t comprehend the basic terms they would hear during a discussion about colon cancer: colon, bowel, rectum, screening, blood in the stool, tumor and polyp, said Davis.

Illustrating the confusion that shrouds health care for many patients, Davis showed video clips of people with low literacy being interviewed about their medications and conditions. One man was taking 10 different medications but couldn’t read the instructions, so he just took one pill from each bottle every day. Another used his inhaler incorrectly. One patient thought "stool" meant "urine," and one very low-key patient thought his diagnosis of hypertension was strange because he wasn’t at all hyper.

Literacy impacts compliance, Davis said. One study found that 55 percent of patients reading at or below the sixth-grade level reported missing medications at least twice a week, compared with 8 percent for patients reading at or above the seventh-grade level. Patients with low literacy cited these reasons for missing medications: being confused, depressed or bothered by side effects, or wanting to cleanse their bodies.

Poor health literacy leads to longer hospital stays, ineffective use of prescriptions and misunderstanding of treatment plans, costing about $73 billion each year, said Davis.

"We need to tune in to patients’ concerns and address them to ensure compliance," she said. "Patients respond to practical advice and demonstrations."

For example, she cited a study of parents learning how to administer a liquid antibiotic. When the physician demonstrated how to draw the medicine into the syringe and then marked the syringe, 100 percent of parents administered the correct dosage, the study found.

Simplifying forms and materials alone won’t solve the problem, said Davis. You also have to simplify your spoken explanations and instructions. "People with low literacy need the most relevant and essential information without the unnecessary details," she said, offering these tips:

• Slow down.
• Simplify, limit the information you offer and repeat the instructions.
• Show patients pictures, models and demonstrations to illustrate what you want them to do.
• Listen and check for understanding by asking open-ended questions such as "How are you going to take this medication?"
• Be positive and hopeful. Emphasize the benefits of compliance, such as living longer or breathing more easily.
• Show respect for all patients.

"We need to understand how shameful low literacy can be," Davis said. "Many patients have never told anyone about it. It’s a hidden disability."

Don't miss chances to educate patients in your office

BY SHARON DENT
Austin, Texas

It’s one of the biggest challenges FPs face: effectively and inexpensively providing the information patients need to get and stay healthy.

Family physician Thomas Weida, M.D., medical director of the Hershey Medical Center in Hershey, Pa., offered tips for meeting this challenge in "Patient Education for Pennies: In Your Office" at the Conference on Patient Education Nov. 11-14 in Austin.

Pharmaceutical company representatives have said they usually have to visit a physician’s office five or six times before a new drug’s name and purpose become familiar, so Weida assumed that patients, too, understand and remember health care messages only after repeated exposure. "Develop the global strategy," he said. "Hit patients whenever you can in the office to teach them about a health topic."

Weida encouraged attendees to take a virtual walk through their offices, determining where patients spend the most time. "At each one of those points, you have the opportunity to put patient education to work," he said.

Start at the front door. A poster proclaiming the health benefits of beans greets patients visiting Weida’s office. Make it a quick and simple message, he said.

The reception window in Weida’s office is surrounded with posters, flyers and other educational items for patients to peruse. In the waiting room, they find a gold mine of materials on all types of health issues. "To me, ‘waiting room’ equals ‘education room,’" said Weida. "Your patients probably spend more time there than in any other room in your office. Take advantage of it."

Your waiting room should have areas for adults and children with educational materials tailored to different age groups and placed at appropriate heights for the target audiences, he said. His waiting room also features a TV, VCR and bookshelf filled with health-related videos and other materials that patients can either look at while they wait or check out to take home. The videos are especially helpful for patients who can’t read well (see related story on page 1).

You won’t find neat stacks of brochures in Weida’s office. "Clutter is good when it comes to patient education," he said. "We used to have everything in nice, neat little piles, and no one wanted to mess up the nice, neat little piles. But when someone bumped them, and they got messy, people started picking them up." However neat or messy the area is, keep reminding patients to take any information that interests them.

Patients want a little privacy when reading up on sensitive topics such as domestic abuse, STDs, AIDS, prostate screening and erectile dysfunction, said Weida. When information on such topics sat untouched in the waiting area and exam rooms, "we put them in the bathroom, and now we can’t keep them stocked," he said.

In the hall, give patients something important to think about, Weida said. Place posters at eye level, both for children and adults. Consider the old Burma Shave approach, with a punchy message spelled out in a series of signs along the hallway. Line the walls next to the scale with posters about cholesterol, ideal body weight or other relevant topics.

Other places to focus educational efforts include the exam rooms, nurses’ station and exit, said Weida.

In addition to inundating patients with information, consider adopting a monthly theme for the most heavily trafficked areas. For example, focus on weight management in January, summer safety in July or back-to-school health issues in September.

Where do you find all these materials? Free stuff is widely available if you know where to look (see box at end of story), but Weida also encouraged physicians to view pharmaceutical representatives as a good resource. "Most doctors see a rep coming, and they look like this," he said, cowering and covering his face with his arms. "I see a rep coming, and I’m like this," he said, striking a vulture-like pose.

Pharmaceutical companies produce excellent patient education materials, including videos, booklets, brochures and posters, said Weida, who also takes advantage of the companies’ deep pockets. "We budget funds for patient education, but we also budget income," he explained. "Use the pharmaceutical reps’ marketing money to help fund your patient education program."

Many reps provide free lunches at monthly informational meetings for physicians, but Weida invites them to forego the food and instead post information on a bulletin board in the staff area of the office at a cost of $100 for two weeks. Reps can also sponsor "lunch and learn" sessions, where a volunteer physician makes a presentation on a health topic, and the rep gets a few minutes to plug his or her product. The rep pays an honorarium to the speaker, who donates it to the office’s patient education program.

You can often convince drug reps to underwrite informational mailings, sponsor classes for patients and pay for other educational initiatives in exchange for a little publicity, Weida noted.

Other ideas Weida recommended for patient education in the office:

• Create a grocery coupon exchange box, and place it next to educational brochures.
• Have young patients draw pictures or color posters about topics such as bike helmets, exercise or saying "no" to tobacco. Designate a special section of the waiting room to display the work.
• Offer office tours to school groups. You can take students’ vital signs, demonstrate some of the equipment, talk about health issues and give them materials to take home.
• Provide individual or group counseling to help prevent exacerbation of existing conditions such as diabetes, heart disease or migraines.
• Implement a telephone triage system for managed care patients who aren’t sure that their problems require an office visit.

Perhaps most importantly, Weida said each staff member must feel comfortable playing a role in patient education. "Get everybody in your office involved," he said. "It doesn’t matter who makes contact. What matters is that the education is happening."

Mark your calendar for the Conference on Patient Education Nov. 16-19 in Albuquerque, N.M.

Free (or cheap) stuff For a list of patient education resources, visit www.aafp.org/fpr/20000100/resources.html or, for a fax, call AAFP Express to request document #7009. see AAFP Express

AAFP establishes Public Advisory Board

The Academy has established a new avenue for gaining outside ideas and viewpoints as the specialty grows into the new century. Fifteen distinguished individuals have accepted the invitation to serve on the AAFP Public Advisory Board, which will hold its first meeting with the AAFP Executive Committee Feb. 15-16 in Washington, D.C.

"We believe this is the first time a national medical organization has established such an advisory board," said AAFP Executive Vice President Robert Graham, M.D. "The group will bring unique insights and perspectives to our deliberations on public policy and patient concerns."

Advisory Board members are: Drew Altman, president, Kaiser Family Foundation; Steven Beering, M.D., president, Purdue University; James Bentley, Ph.D., senior vice president, strategic policy planning, American Hospital Association; Daniel Callahan, Ph.D., director of international programs, Hastings Center; Jane Delgado, Ph.D., president, National Coalition of Hispanic Health and Human Services Organizations; Carol C. Diamond, M.D., president, U.S. Quality Algorithms, Aetna U.S. Healthcare; Mary Jane England, M.D., CEO, Washington Business Group on Health; David Hennage, Ph.D., M.B.A., executive director, American Nurses Association; Lee Newcomer, M.D., medical director, United Healthcare; Audrey Forbes Manley, M.D., president, Spelman College; Ed O'Neil, Ph.D., director, Center for Health Professions; Charles Peters, editor in chief, Washington Monthly; John Seffrin, Ph.D., CEO, American Cancer Society; Alvin Tarlov, M.D., executive director, Health Institute, New England Medical Center; and Karen Williams, president, National Pharmaceutical Council.

Immunization registries take mystery out of record-keeping

BY SHARON DENT

The Recommended Childhood Immunization Schedule has gotten increasingly complex. About 11,000 babies are born every day, and all of them need to receive 18-22 immunizations to protect them from vaccine-preventable diseases. With families moving more than ever, up to 25 percent of those children may visit two or more providers for immunizations before their third birthday.

Clearly, keeping track of which children have had which immunizations can get confusing.

That's why many communities and organizations are promoting immunization registries -- confidential, computerized databases that include immunization information on individual children and populations. Registries can range in size from those used by practices for their own patients to those including statewide information, according to Alan Hinman, M.D., M.P.H., senior consultant for public health programs for All Kids Count, a national network of demonstration projects working to implement community-based immunization registries.

"All states are working on developing registries," Hinman said. "Thirty-four have registries that are partially operational."

The American Medical Association, American Academy of Pediatrics and American Osteopathic Association support immunization registries and have encouraged physicians to participate in them. In August, the AAFP Board of Directors considered support but voted to further study the issue. One concern was that registries would create additional administrative burdens for physicians.

However, Hinman said registry developers are working to limit the paperwork and time required to participate, as well as to ensure that any administrative burden is offset by benefits. "One important benefit is that registries can generate reminder notices and recall notices, so physicians don't miss immunization opportunities," he said, adding that, according to the CDC, only about 25 percent of FPs use a reminder or recall system in their offices.

Hinman said resistance to registries also stems from the perception that immunization rates are already high enough. Although rates for young children are at the highest level ever, substantial resources have been poured into the effort over the last six years, and that's unlikely to continue, he said. When funding for those efforts diminishes, the country could see a rise in cases of preventable childhood diseases unless the immunization process is systemized.

Michigan AFP President Karen Mitchell, M.D., of Southfield has studied the issue of registries while serving on the Michigan Department of Community Health Advisory Committee on Immunization.A statewide registry is well under way in Michigan, and state law requires physicians who provide immunizations to participate in the registry, she said.

The Michigan system protects privacy by requiring health care professionals to enter at least two unique identifiers -- such as name and birthday -- into the registry to access information on a child. If two children with the same name and birthday are found, the system automatically requests a third identifier, such as a social security number.

Physicians can enter or retrieve information in real time through the computer system, and those without computers can use fax, phone or mail.

"It gives us all the information that is sometimes really hard to obtain," Mitchell said. "We can get more accurate information through the registry system than we can by calling other providers, waiting for records to come or even depending on parents to bring in the child's shot record. It can actually save time."

Anecdotal evidence of registries' success abounds. For example:

Registries helped control the size of a pertussis outbreak in a rural Minnesota community by identifying children at risk -- those who were nearly due for a DTP booster and those who hadn't been immunized because of medical or religious reasons -- so their parents could be informed of the disease threat.

The immunization rate for 700 low-income children at five Phoenix child care centers doubled to 90 percent this year when the organizations' nurse acquired access to the state's registry. Despite county-wide outbreaks of measles, pertussis and varicella during that time frame, cases of those diseases at the child care centers were reduced to zero.

How can you get involved in an immunization registry? Hinman suggests physicians contact their local health departments to find out whether a registry is available.

"All registries are anxious to recruit private providers," he said. "Most registries are housed in health departments, but health departments provide a minority of the immunizations in this country. More than two-thirds of immunizations are provided in private practice offices. So the utility of a registry is directly proportional to the level of participation."

New immunization schedule gets approval Want the latest advice on immunizing your young patients? The 2000 Recommended Childhood Immunization Schedule has been approved by the AAFP, American Academy of Pediatrics, and the Center for Disease Control and Prevention's Advisory Committee on Immunization Practices. "The year 2000 may go down as the year vaccine safety was much improved," said Richard Zimmerman, M.D., M.P.H., of Pittsburgh, Pa., a member of the AAFP Commission on Clinical Policies and Research. The new schedule features several changes, he says, including three resulting from safety concerns: The rotavirus vaccine was removed from the schedule in response to several studies that suggest a possible increased rate of intussusception among infants who have received rotavirus immunization. Whole-cell pertussis vaccine is no longer identified as an acceptable alternative to acellular pertussis vaccine. Acellular pertussis vaccines offer superior safety profiles for both local and systemic reactions, compared to whole-cell pertussis vaccine. An all-inactivated polio vaccine is recommended in place of the IPV/oral vaccine series previously included in the schedule. The change is intended to eliminate the risk of vaccine-associated paralytic polio. Other additions to the 2000 immunization schedule are recommendations that children be immunized against hepatitis A in certain states or regions, and a footnote explaining that additional vaccines may be licensed and recommended throughout the year. "About every year or two for a while, there's going to be a new vaccine," Zimmerman said, adding that a conjugate pneumococcal vaccine for infants and children likely will be licensed in the spring. You can get a copy of the new immunization schedule by visiting the AAFP's Web site at www.aafp.org/x7666.xml, using the AAFP Express document-by-fax system, or calling the AAFP order department at (800) 944-0000 and requesting item #R974.

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• 21st Century Issues •

Managed care backlash may boost patient care

Megamergers, stricter regulations, rising costs, course corrections and better care -- managed care can look forward to all that in the early 2000s.

"The backlash from physicians, patients and the media; state laws; and court rulings are pushing in on managed care," says Lee Sacks, M.D., of Oak Brook, Ill., chair of AAFP's Commission on Health Care Services.

Sacks foresees more consolidation, with regional plans in financial difficulty becoming the acquisition targets. "The large plans will come into a market and cookie-cutter it out," he says. "They use one claim system. It doesn't acknowledge differences among Chicago, Kansas City and New York, or among areas with large physician groups and those without."

The U.S. Congress is at loggerheads over its managed care legislation, with divergent House and Senate bills and slight chance Congress will send President Bill Clinton legislation he is willing to sign.

But states are clamping down on managed care (see chart).

States tighten reins on managed care ISSUE ADDRESSED VIA LAWS OR REGULATIONS Bans on gag clauses Inpatient care after childbirth Emergency care service mandate Direct access to OB/Gyn - or - OB/Gyn as primary care provider Prompt payment to providers Any willing provider accepted in health plans Definition of medical necessity Standing referrals Licensing of medical directors Insurer liability NUMBER OF STATES 48 42 38 37 35 22 22 22 19 3 Source: Health Policy Tracking Service, National Conference of State Legislatures, December 1999

"We can't stand by and wait for the bipartisan bickering in Washington to end," says Mary Frank, M.D., of Rohnert Park, Calif., chair of the AAFP Commission on Legislation and Governmental Affairs. "Our governor signed legislation in 1999 that accomplishes a lot of reforms the AAFP has been working for at the federal level. The law requires HMOs to cover breast exams, breast cancer treatment and treatment for some mental illnesses and to cover contraceptives as prescription drugs. Maybe states can set the model for federal legislation."

HMOs have begun dropping Medicare patients in areas of lower reimbursement. "Some of that's politics," says Sacks. "They sent a message to Congress." 1999 adjustments to the Balanced Budget Act of 1997 included an upswing in HMO Medicare reimbursements in areas not covered by Medicare+Choice.

Faced with widespread managed care backlash, the industry apologized in late November. The American Association of Health Plans sent a memo to health plan executives saying industry practices helped precipitate the criticism and some practices may need to be changed.

A few weeks earlier, UnitedHealth Group freed providers from needing prior approvals for many tests and hospitalizations.

"There'll be a swing back to a greater focus on patients," says Sacks. "And besides, most physicians acknowledge managed care has improved health care tremendously. For example, nobody did any review in my office until managed care started auditing, and our documentation has improved, as well as our cancer screening."

Even with improvements in operations, though, pressure on physicians is likely to increase because of hikes in health care costs. "Employers will look to managed care to help lower the rate of increase in health care costs. Once again, physicians will be caught in the middle," says Sacks.

• 21st Century Issues •

Bruce Bagley, M.D.: 'Patients will expect better customer service from us'

AAFP President Bruce Bagley, M.D., of Albany, N.Y., has adopted quality issues as the focus of his term. He believes that family physicians will be expected to provide more and better services in the future. To prepare for that, Bagley would like to see the AAFP and its members look at the efficiency of their systems and how to improve them, including the implementation of electronic medical records. He discusses quality in this Q&A.

What are the important quality issues facing family physicians?

Quality of care means not only practicing consistent evidence-based medicine, but also being able to document that care and monitor outcomes of care.

Family physicians are well trained to provide quality care, but most of us need to work on monitoring and improving outcomes of care. In the future, we will need systems such as electronic medical records to help manage and document patient care, yet we will still provide the quality of care patients have come to expect from their family physicians.

Probably the biggest quality issue facing all of medicine is customer service. We must do something about poor telephone service, office waiting times, messages and call backs. People have begun to expect great service in all other things they do. Why not at the doctor's office?

How can FPs tackle these issues?

One way will be to move toward full implementation of electronic medical records to help resolve both quality-of-care and customer service issues.

Implementing office systems that are paperless, efficient and capable of "e-medicine" is essential. For instance, with current electronic medical systems, patients can contact their family physicians for personalized health advice 24 hours a day, seven days a week, 365 days a year and can expect a reply within 24 hours. Also, patients can provide their family physicians with information regarding their chronic diseases such as diabetes or hypertension by entering data directly into their own medical records. And family physicians can share patient data and test results among physicians who are treating the same patient to reduce duplication and waste.

Another way to improve customer service is to instill a culture of continuous quality improvement into office functions and routines. CQI has a proven track record for effecting organizational change.

How do office design and layout affect quality?

Our current office systems are designed to bring the patient to the doctor, face to face, for the purpose of diagnosing and treating disease. With managed care, family physicians are expected to take on the responsibility of caring for a population of people whether they need to come to the office or not. New systems of ongoing care and the ability to communicate personalized health advice will be essential.

Electronic medical records can help with this. For example, implementing electronic medical records would allow a patient to get lab results and health tips online. Patients could make appointments through the computer as well.

How can FPs improve teamwork in the office to facilitate patient care?

Teamwork results from an office culture of empowerment. All office staff -- from front desk receptionists to back office nursing staff -- must be given responsibility for the product of not only their own work but also the work of the team. Having a common mission and core values developed by your team of workers helps define the work environment. Rewards and constant positive feedback for a job well done will foster a sense of teamwork. And teamwork is required to have a consistent quality product and excellent customer service. No one can do it all alone.

How will electronic medical records affect family medicine in the future?

The explosion of information technology will leave no part of our society untouched. The business of medicine will have to leap into the information age soon. Electronic medical records will be the platform for the care of patients in the future. Web medicine and shared medical records among all who treat the patient will be the norm. It's important for family physicians to be part of this revolution, and electronic records will provide better support for the increasingly complex task of management we are expected to do.

• 21st Century Issues •

Researchers at final ASPN convocation welcome new era for practice-based research

BY SHARON DENT
Colorado Springs, Colo

A pair of FPs -- father and son -- served as symbols of the business under way at the final Ambulatory Sentinel Practice Network annual convocation Dec. 1-4 in Colorado Springs, Colo.

"Every physician who's practicing and providing continuity of care is doing research -- he or she is studying what the patients' problems are and how the interventions are working." -- Gene Farley, M.D.

Gene Farley, M.D., of Madison, Wis., was one of ASPN's founders in 1981. His son, Tillman Farley, M.D., of Fort Lupton, Colo., followed in his footsteps as a family practice researcher. Together, they reflected both the traditions and future possibilities of practice-based research as ASPN passed the torch to the Academy.

ASPN announced last year that financial burdens were forcing its closure, and the Academy responded by launching plans for a national network for family practice and primary care research based on the ASPN model.

"We had real concern about what was happening to ASPN as an organization and what would happen to the research that ASPN was directing, but now it looks like the research will continue. It's all coming together," said Gene Farley.

Larry Green, M.D., worked with Farley to start ASPN and nurture its growth over the years. Now director of the Academy's Center for Policy Studies in Family Practice and Primary Care in Washington, D.C., Green said convocation attendees were both saddened by ASPN's demise and enthusiastic about the Academy's new network. "At the front end of the meeting, there was apprehension and some mourning," he said. "By the back end of the meeting, the apprehension had been assuaged, and people were interested in doing research and getting on with it."

In a speech to attendees, AAFP President Bruce Bagley, M.D., of Albany, N.Y., told researchers that the key elements of ASPN would remain as main components of the Academy's new network:

• research generated by health care professionals and conducted in the practice setting,
• an annual convocation of practices for sharing ideas and enthusiasm for practice-based research,
• an advisory committee composed of stakeholders and
• continued support for the Federation of Practice-Based Research Networks.

"I wanted to assure the ASPN folks that we have the same mission and vision," Bagley said. More than 100 ASPN clinicians from the United States and Canada have expressed interest in participating in the Academy's research network, he noted.

Brainstorming sessions at the meeting focused on topics such as quality of care, the value of the doctor-patient relationship, diabetic patients with other problems, the use of antibiotics in treating bronchitis and the decision-making process regarding use of hormone replacement therapy.

Gene Farley predicts a bright future for practice-based research. "Every physician who's practicing and providing continuity of care is doing research because he or she is studying what the patients' problems are and how the interventions are working," he said.

• 21st Century Issues •

Spend the money on what the fight was about: no smoking

BY JANE STOEVER
La Jolla, Calif

Mississippi Attorney General Mike Moore: "Guess what? You guys are all we have."

States are playing havoc with the $246 billion from the tobacco settlement.

"We agreed the states should keep all the tobacco settlement money as long as they improved public health and kept kids from getting addicted," Mississippi Attorney General Michael Moore said at the AAFP State Legislative Conference Nov. 14 in La Jolla. He sought and fought for the 46-state compromise.

"If a state gets $1 billion, how does spending half of that on a highway reduce smoking?" asked Moore. "One state's building a morgue -- I guess they could call it the Philip Morris Memorial Morgue."

Moore warned that the U.S. Congress might intercept the flow of dollars to the states if they keep siphoning the money toward construction and tax cuts.

In 1994, when Moore filed the first state lawsuit against tobacco companies, he thought people would run to his defense. Wrong. His mother hated it, and his governor sued him. "Who stood by me?" he asked. "Doctors."

And now, many attorneys general who pressed for the settlement are out of office. "Guess what? You guys are all we have," he told about 125 family physicians, chapter executives and lobbyists.

"When you testify, make it real. Talk about arteriosclerosis and amputation. But also make it dollars and cents," said Moore. "Say, 'Here's the payoff in 10 years if we can stop 20 to 30 percent of kids in our state from smoking.' And get real kids to help you, the ones with blue hair and tattoos and pierced noses. They're the ones most likely to smoke, not the class presidents."

Moore urged family physicians to protect the settlement money by establishing nonprofit corporations in their states to dispense it.

He added, "You've got a huge fight ahead of you. Do it as family doctors. You deal with kids. People will listen to you."

• 21st Century Issues •

Help patients sift wheat from chaff on World Wide Web

BY TODD SIMCHUK

You might be an old hand at using the Internet, but some of your patients are not. You already know to remind them to treat e-mail like a postcard -- something that could be read by others. Also keep in mind the learning curve for using the World Wide Web.

And the growth of health information on the Web is explosive, with major players such as former Surgeon General C. Everett Koop, M.D., and the American Medical Association getting into the Web site business. Helping patients sort the wheat from the chaff is a growing challenge for family physicians.

"Everybody talks about whether the content on the Web is good or not, and the thing is, some content is terrible," says John Bachman, M.D., of South Rochester, Minn., a family physician at the Mayo Clinic and lecturer on computer use and the Internet.

Here are some ideas for helping patients when it comes to health Web sites:

Consider the source. "When people are learning about the Web, they have to think about credibility," says Bachman. "Are you going to believe just anyone who puts stuff up there, or sources like the Mayo Clinic and Johns Hopkins?" Bachman notes that content mentioning brand names may be sponsored by companies selling the products.

Use major "search engines." Bachman encourages patients to look for health information with search engines such as www.healthfinder.com.

Visit Web sites together. When patients bring in incorrect information, Bachman uses the opportunity to visit the Web site with them -- to investigate the source and its credibility.

Check the ratings. FPs and patients can also check out sites such as www.healthscout.com, run by family physician John Renner, M.D., of Independence, Mo. Renner is part of a national group evaluating medical Web sites. Healthscout, in its "stars and stinkers" page, each week lists sites to trust, as well as stinkers to avoid.

Encourage patients to use the Web. The Academy offers patient education material at www.familydoctor.org, which might be a good starting point for patients.

"When patients use the Web intelligently, it empowers them," says Bachman. "When they're involved in gathering the information and sifting through it, they tend to make better choices and do the right things."

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NLRB gives go-ahead to resident unions in private institutions

BY JANE STOEVER

The National Labor Relations Board opened the floodgates Nov. 26 for residents in private hospitals to unionize.

But family practice residents may not rush through the gates.

"Family practice residents will be one of the least likely groups to need collective bargaining," says Jennifer Aloff, M.D., of Midland, Mich. She chairs the AAFP National Congress of Family Practice Residents.

"Most family practice residents are pretty happy with their working conditions, their pay, their learning opportunities, the patient care they provide," says Aloff. "I haven't heard a lot of rumbling."

In 1976, the NLRB said residents in private hospitals were primarily students rather than employees, and could not come under the protection of the National Labor Relations Act. The NLRA prohibits unfair retaliation for collective bargaining activities. Residents in public hospitals in many states have unionized.

In 1996, Boston City Hospital merged with a private hospital to create Boston Medical Center, a private facility that allowed residents to continue the union begun at the city hospital. In case later mergers with private institutions threatened the union, the residents asked the NLRB to change its 1976 ruling and grant residents in private hospitals protection under the NLRA. On Nov. 26, the NLRB voted 3-2 in favor of the residents.

In 1998, the National Congress of Family Practice Residents asked the AAFP Board of Directors to endorse residents' right to form associations. The Board did that last July, noting it does not support strikes or withholding services.

"As learners, residents deserve quality education and supervision. As employees, we have the right to safe working conditions," says David Meyers, M.D., of Washington, D.C., resident member of the AAFP Board. "Some family practice residents are concerned about lack of supervision, which is not good for education or patient care. If organizing gets these residents the supervision they need, it helps residents and patients."

Order from AAFP at (800) 944-0000 unless otherwise noted. A shipping fee may apply; Kansas residents pay a 6.875 percent tax.

	"Early Detection of Mental Illness," Video CME program, will be available this month as part of AAFP's Annual Clinical Focus, Mental Health 2000. All AAFP members will soon receive a free syllabus and a coupon to buy the program, #R870, at the reduced rate of $10.
AAFP Family Health Facts patient education brochures include these new topics: drug abuse, heart disease, prostate cancer, hormone replacement, pain relievers. Free sample package, #R1500; package of 100 brochures costs $22.
	Proven value: The MOM Care (Management of Maternity Care) Program Guide is free online at www.aafp.org/momcare or available with chart documentation forms as #R703 for $149. Call (800) 274-2237, Ext. 4166, for a sample documentation form.

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FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.

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