December 2000 • Volume 6 Number 12
Your input wanted
Proposal aims at health care coverage for all AmericansBY JANE STOEVER
Comment on AAFP's proposal by Feb. 28.
The Academy is igniting a nationwide dialogue on a proposal for all Americans to have access to care and coverage for it.
"We want input on our proposal from every AAFP member," says President Richard Roberts, M.D., J.D., of Madison, Wis. "Family doctors think about this stuff all the time. I'd like to tell each member, 'Read the proposal, digest it, be creative with your response.' Assuring coverage for everyone is crucial -- America needs the collective wisdom of each family doctor on this issue."
An AAFP task force analyzed the U.S. health care system for two years and gave a report to the Congress of Delegates this fall. Delegates decided, as the task force suggested, to ask members' views before adopting a plan.
The AAFP Board added financial charts to the task force report and put the resultant proposal online in late November. The proposed program would be funded by a payroll tax split between employers and employees and by revenues from the part of Medicaid covering basic services.
To spark response, the Board peppered the proposal with questions. For example:
Proposal: All people within U.S. borders, whether or not they are legal residents, would have coverage for basic health services without copayments or deductibles.
Questions: Should the plan cover everyone in the country? Would copayments discourage appropriate use of basic health services or simply discourage inappropriate use?
Proposal: Out-of-pocket costs for catastrophic illnesses should be capped. Services between basic and catastrophic levels could be bought directly by individuals, covered by employer-based insurance or individually purchased insurance, or paid for by medical savings accounts.
Questions: If you now offer your employees health insurance, how likely would you be to offer coverage for services outside the AAFP proposal? Should it be left to individuals to decide to seek coverage for this middle tier of benefits?
Reflecting on the state of the health care system, Roberts says, "Our country is already committed to universality. But when it kicks in, it's either late in the disease, when the person shows up in the ER, or early in the disease, when the person comes to the ER after hours with an upper respiratory infection that could have been handled more easily, less expensively and, frankly, more efficiently by the person's family doctor."
He adds, "Our country's been making all the wrong decisions consistently in terms of how to fund, structure and organize the health care system. The AAFP proposal is an attempt to begin to remedy that."
You can access the proposal at http://www.aafp.org/unicov/ or request it (item #R016) by calling (800) 944-0000. The Board will consider all responses, make revisions and submit a plan to the Congress of Delegates next October.
By Feb. 28, 2001, please e-mail your comments to unicov@aafp.org or write to AAFP -- Health Care Coverage, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672.
Did health care issues make headway?
VOTERS' TOP ISSUES
- The following percentages of voters considered these issues important* in votes for U.S. senators or representatives:
- 90% public education
- 85% crime, illegal drugs
- 85% Social Security
- 83% health care coverage for more families,
children- 83% medical decisions by doctors, not HMOs
- 80% the economy
- 79% seniors' prescription drug coverage
- 77% Medicare
- 76% health care system reform
- 74% tax relief for middle class
- 73% the environment
- 70% patient's bill of rights
- *A selection of issues from a Nov. 9 poll by the Mellman Group and Public Opinion Strategies
Even with the country embroiled in presidential vote-counting at press time, a few policy-watchers could still snatch some hope for health care from the elections.
"Two years ago, Democrats and Republicans didn't agree on much in health care," says Robert Crittenden, M.D., of Seattle. "But in this year's presidential campaigns, both parties made sweeping promises to America about the patient's bill of rights and pharmaceutical benefits for seniors."
Crittenden, a member of the AAFP Commission on Legislation and Governmental Affairs, teaches at the University of Washington medical school in Seattle and practices in a family medicine clinic. "One-third of our patients have commercial coverage, one-third have Medicaid and one-third have 'other,' including many with no coverage at all -- we have this in spades," says Crittenden.
He sees little chance of strong action on access-to-care initiatives from the incoming Congress. However, he holds out hope for strategies under discussion outside the halls of Congress.
For example, the Health Insurance Association of America (traditionally Republican) and Families USA (a coalition led by Democrats) are cosponsoring town forums to discuss coverage for low-income Americans. "These two groups are suggesting that Medicaid should cover more people and are promoting tax credits for employers who provide expanded benefits to employees under 200 percent of the poverty level," says Crittenden, a member of the board governing Families USA.
In the near future, an end run around the U.S. Congress may be the best way to effect change.
"The gridlock, the paralysis in policy-making that we've seen in Congress for two years will get even worse with the parties so narrowly split in both chambers" as a result of the election, says David Mitchell, a partner in the strategic communications firm Greer, Margolis, Mitchell, Burns and Associates in Washington.
Mitchell discounts any chance for progress on a federal patient's bill of rights but says the states are taking steps to control managed care: "In the absence of federal control, when you have a problem that's producing pain, the states take it on."
Voters resonated with health care issues in the election, he adds (see box).
Some of the interest in the prescription drug issue, however, was stimulated by $80 million worth of campaign ads funded by pharmaceutical companies. The industry supported candidates who would vote against a Medicare prescription drug benefit but would favor, for example, prescription assistance for seniors via state-based, low-income programs and a moderate cap on out-of-pocket expenses.
How successful was the pharmaceutical industry's advertising? Twenty-two candidates backed by the industry won House seats, and only four lost.
"Double-digit health premium increases are predicted this year," says Mitchell, "and up to 40 percent of the increases can be attributed to prescription drug costs. Surveys indicate employers will pass the premium increases on to their employees.
"The prescription drug issue will not go away; it will continue to play out at the state level if not the federal level."
Heartbreak and hope
Physicians With Heart takes aid to AzerbaijanBY JANE STOEVER
The Physicians With Heart delegation, including 11 family physicians, trudged down broken stone steps and through a long tunnel to visit "internally displaced persons" in the basement of an unfinished building in Baku, Azerbaijan's capital.
Women cooked in the common kitchen in the hallway. About 20 families had a room apiece with damp floors, a few beds and an occasional table.
When the displaced persons fled in the early 1990s from a war-torn area now controlled by Armenia, each family tried to carry one valuable. Hanging in a dingy basement room was one family's prized possession: a crystal chandelier.
Daniel Van Durme, M.D., laughs with children in an orphanage near Baku about the pictures just taken by Physicians With Heart delegates.
Heave ho: Mary Lynass, M.D., of Tempe, Ariz., helps an airport worker unload medical supplies in Nakhchivan City.
"In all my involvement with international work, I've never had exposure to refugees or displaced persons," said Daniel Ostergaard, M.D., AAFP vice president for international and interprofessional activities. "In Azerbaijan, we had the opportunity to see their conditions."
A family of "internally displaced persons" meets a visitor in the kitchen of the Baku basement that serves as home for about 20 IDP families.
The Azerbaijan journey Oct. 6-15 marked the eighth annual airlift to a former Soviet republic by Physicians With Heart, a project of the AAFP, AAFP Foundation and Heart to Heart International, a humanitarian aid organization based in Olathe, Kan.
The IDP camp in Baku was one of many sites the delegates visited in Azerbaijan on the Caspian Sea in southwest Asia. Physicians With Heart distributed $1.9 million worth of medicine and supplies to Azeri clinics and health posts. The donations will benefit the needy, including displaced persons and refugees from other countries.
The delegates also brought an orphanage near Baku a washer, dryer, winter coats, and toys from AAFP resident and student members.
The delegation to Azerbaijan introduced Azeri physicians to family practice, a foreign concept to most of them. "We think family practice could help you meet your people's needs," AAFP Director Daniel Van Durme, M.D., of Tampa, Fla., said at sessions explaining the specialty in Baku and Nakhchivan City.
Next year, Physicians With Heart will visit Vietnam Feb. 16-26 and will conduct an airlift to a former Soviet republic in the fall. For details on the Vietnam airlift, check http://www.aafp.org/airlift/ or call Maya Singh at (405) 787-5200.
Strategic plan reflects world view
The Academy's strategic plan now includes a global focus, thanks to changes made by the Board of Directors and reviewed by the Congress of Delegates in September.
One element of the Academy's updated mission statement is "to advance and represent the specialty of family practice worldwide." One of 10 strategic directions is now "to facilitate and encourage activities of AAFP members toward meeting humanitarian needs worldwide and toward the global development of family practice."
The prior vision statement referred to all Americans. Now it says, "The AAFP will create quality, accessible health care ... dedicated to the health, dignity and well-being of all people."
Go to http://www.aafp.org/policy/1.html for a copy of the strategic plan, or call (800) 944-0000 and request #R412.
Use AAFP Reference Guide--
it's updated quarterlyWant information on a particular AAFP service, product or meeting but don't know whom to call? Need to talk to knowledgeable staff about an issue, whether it's computer software or emergency medicine?
Use the 2001 AAFP Reference Guide, which lists contact persons ready to assist you.
This year, the guide isn't published in FP Report. Instead, you can visit the members-only section of the AAFP Web site at http://www.aafp.org/ members/staff/resource.html to access the guide online. Key advantage of the online guide: It will be updated quarterly, so it will be more accurate throughout the coming year.
Members who are unable to access the online guide can get a faxed copy -- see the "Quick Fax" box. Or call (800) 274-2237, Ext. 4201, to request a mailed copy.
Don't forget Vaccine Information Statements
When it comes to certain vaccines, it's the law: Before you administer the shot, you must provide the patient with a Vaccine Information Statement. If you don't and the patient has a serious reaction, you could be accused of failing to obtain informed consent, says Richard Zimmerman, M.D., M.P.H., of Pittsburgh, AAFP's representative to the CDC Advisory Committee on Immunization Practices.
The vaccines covered under the National Childhood Vaccine Injury Act are: tetanus, pertussis, polio, measles, mumps, rubella, Haemophilus influenzae type B, hepatitis B, varicella and pneumococcal conjugate. For those vaccines, it's mandatory to provide the patient -- or the patient's parent or legal representative -- with the appropriate VIS.
The VISs are easily obtainable from the CDC or its Web site. Yet some studies have indicated that nearly a third of physicians may not provide VISs when they administer vaccines covered by the act.
"The National Vaccine Injury Compensation Program has provided physicians with excellent protection," Zimmerman says. "There are almost no lawsuits in regard to physicians who follow proper vaccination procedures."
VISs also exist for vaccines not covered by the law; physicians are strongly encouraged to use them. And VISs are available in languages other than English.
To ensure that you're using the most current VIS, Zimmerman suggests having your office staff download and print out all VISs early each January.
At http://www.immunize.org/vis/instr00.htm is more information on VIS use. Go to http://www.cdc.gov/nip or http://www.immunize.org and click on "Vaccine Information Statements" to download VISs and print them for use as camera-ready copies. You can order hard copies at http://www.cdc.gov/nip/publications/ or by calling (800) 232-2522.
Academy fellow to survey residents
Residents, keep an eye out for an e-mail from Matthew Lewis, M.D., the new fellow in AAFP's Medical Education Division. Or, better yet, beat him to the punch.
A recent graduate of the Swedish Family Practice Residency in Seattle, Lewis signed on for the staff fellowship with a mission: Bolster communications between family practice residents and the AAFP.
"We need to enhance the resident portion of the Web site," Lewis says. But he wants your input to know where to head with it.
"I've been trying to call about 10 residency coordinators a day to get e-mail addresses for residents in their programs," Lewis says. He's sent a similar request via e-mail to about 100 chief residents.
Lewis needs the e-mail addresses for a survey he plans to distribute to about 2,000 or 3,000 residents, asking them how the Academy's Web site can become more "resident-friendly."
"From the Committee on Resident and Student Affairs meetings I've attended, I've learned that resident leaders are concerned about communication between residents and the Academy," Lewis says. "They want to be sure residents know about resources available to them through the AAFP."
He notes that the Task Force on Student Interest considered the communication issue when developing strategies to attract and hold medical students' interest in family practice. One solution it came up with was Virtual FMIG -- the revised student section of the AAFP Web site designed in the spirit of a family medicine interest group.
To see that site, go to http://fmignet.aafp.org/.
While you're at your computer, send an e-mail to mlewis@aafp.org so Lewis can tap you for suggestions for better communications.
Stop direct-to-consumer TV ads
To the editor:
We physicians have a problem which is steadily growing -- prescription medication advertisements to the public on various TV networks.
While attending the AAFP convention in Dallas, I learned the FDA gave its approval of this practice. To change this approval would require considerable difficulties, such as obtaining a congressional mandate.
Besides the inconveniences to us as physicians that the patients ask for particular drugs, perhaps the most serious consequence is the added cost of medications due to expensive commercials. Most patients complain about the high price of prescriptions, which leads many to make periodic trips to Mexico to buy their medicines -- medicines made by the same companies but at a considerable reduction in price.
Having worked for a large pharmaceutical company in the past, I offer a simple solution to this growing practice. We should simply refuse to see the company's representatives ("detail men") until they stop this growing tendency (toward direct-to-consumer TV ads). We owe this to our patients, who are unaware of the negative effects of this menace.
John F. Smyth, M.D.
Mexico City
AAFP in 2000
The Pain Relief Promotion Act battle continues from January through November. AAFP and individual FPs fight the PRPA, saying it could put physicians at risk for penalties for prescribing needed pain medicine for dying patients. (At press time, it was uncertain whether the Senate would pass a bill with PRPA attached and whether the bill would become law.)
AAFP supports an AMA lawsuit against the Department of Health and Human Services, assailing unlawful undercompensation of physicians for Medicare services in 1998 and 1999. AAFP later signs an amicus brief supporting AMA's appeal of a judge's ruling in favor of HHS. Lobbying by AAFP and other groups throughout 2000 results in new methods for calculating the sustainable growth rate, raising physicians' payments.
The AAFP Public Advisory Board -- the first such panel for a national medical society -- holds its initial meeting in Washington.
AAFP's first electronic newsletter, AAFP This Week, debuts. All active members with e-mail addresses on file with AAFP become privy to the latest news of interest to FPs.
Once again, the Clinton administration "zeros out" family practice training funds in the 2001 budget proposal. AAFP begins effort to strengthen Title VII support for FPs' training. (At press time, Title VII appropriations had not passed, but increased funding was proposed.)
Grant money becomes available to state Tar Wars programs from the American Legacy Foundation and SmokeLess States National Tobacco Prevention and Control Program, funded by Robert Wood Johnson Foundation.
AAFP launches the Practice Quality Enhancement Program. Nearly 2,000 members request information about the pilot program. By year's end, 583 members are enrolled and are submitting information on quality improvement projects in their offices.
The AAFP Board votes to support the spirit of the 1999 Institute of Medicine report on medical errors and commits AAFP to studying steps to enhance safety in FPs' practices.
The AAFP National Network for Family Practice and Primary Care Research asks its members, primarily family physicians, to join its first study, focused on patient safety in FPs' offices.
Primary care match results are down overall, sparking discussion on why fewer medical students are selecting family practice and on ways to address the downward trend.
The White House convenes a meeting on children's mental health and psychotropic drugs. (Then) AAFP Board Chair Lanny Copeland, M.D., speaks about appropriate use of drugs as part of treatment for children.
American Family Physician celebrates 50 years of publishing.
The Academy organizes a dramatic show of support for patients' rights with a march on Capitol Hill. FPs, medical students and chapter reps take calculators and stethoscopes to lawmakers and ask, "Who do you want caring for your family -- an accountant or a physician?"
Forty-three FPs and 10 others rally on Capitol Hill to promote a patient's bill of rights.
AAFP, other medical societies receive a White House thank you for initiating a campaign to get unsafe consumer products off the market.
The Academy revamps its Web site, making http://www.aafp.org/ at once streamlined, yet chock-full of information. The site is sponsored in part by a grant from Bristol-Myers Squibb. One innovation: Members may create Web sites for their own practices by clicking on "My Academy." By November, more than 1,000 members had active sites.
(Then) AAFP President-elect Richard Roberts, M.D., J.D., panelist at a Washington debate, fires the first question at Gore and Bush health advisers: "What are the candidates going to do to promote primary care, preventive services and restorative care?"
AAFP, other national associations kick off a campaign, "Healthy School Nutrition Environments: Promoting Healthy Eating Behaviors."
The number of AAFP delegates to the AMA House of Delegates soars to 19, giving AAFP more AMA delegates than any other specialty society. The Academy helps pass a resolution for greater access to reproductive health care, including vasectomies and tubal ligations. "We serve patients with diverse views and beliefs, and patients who desire pregnancy prevention should be able to obtain these services," says (then) AAFP Director Deborah Haynes, M.D.
Despite straight talk from (then) AAFP President Bruce Bagley, M.D., about fair Medicare reimbursement, the AMA House of Delegates adopts the "Halt 2000" resolution. Backed by more than 40 hospital-based groups, the resolution calls for a partial halt in the 1998-2002 transition to resource-based practice expenses. At year's end, the U.S. Congress is no longer considering "Halt 2000" -- a win for primary care.
"America's children are caught in the cross fire," says Bagley in a news release on AAFP's new policy against media violence.
The annual member attitude survey indicates 81 percent of members view AAFP positively, compared with other organizations; 61 percent say AAFP has improved; 72 percent feel the Academy is doing a good job representing the specialty to the public, patients and organized medicine.
The Board renames AAFP's Washington policy center The Robert Graham Center: Policy Studies in Family Practice and Primary Care, in honor of departing Executive Vice President Robert Graham, M.D.
The torch is passed from Graham to Douglas Henley, M.D., AAFP's new EVP. Henley, who was in private practice for 20 years, is the first past president and Board chair of the Academy to assume the EVP post.
"No health insurance? It's enough to make you sick," say ads in the National Journal at the Democratic and Republican national conventions. The AAFP cosponsors the ads for health care coverage for all Americans.
The AAFP Congress of Delegates:
-- pledges AAFP to a leadership role in making sure at least one journal exists for original clinical research in family practice;
-- calls for phasing in new criteria for evaluating and categorizing clinical content of CME, encouraging incorporation of evidence-based content;
-- welcomes announcement of a multimillion-dollar publicity effort for the specialty, including grass-roots projects and February ads in USA Today and The Washington Post and National Public Radio sponsorships;
-- chooses Warren Jones, M.D., as president-elect, the first African-American tapped to lead AAFP; and
-- asks for amendments allowing new physicians to have a Board seat and international medical graduates to have delegate status. The AAFP Congress will vote on the amendments Oct. 1-3, 2001, in Atlanta.Members choose from the most extensive selection of CME offerings ever at the Scientific Assembly in Dallas. Surgeon General David Satcher, M.D., Ph.D., an FP, commends AAFP for the 2001 Annual Clinical Focus: Asthma, Allergy and Respiratory Infections.
"The AAFP is missing the perspective of over 30 percent of its active members -- new physicians," says Julie Wood, M.D., at the Congress of Delegates.
Bharat Patel, M.D., left,listens at an April meeting as Ben Oteyza, M.D., calls for international medical graduates to have delegate seats in the AAFP Congress.
President-elect designate Warren Jones, M.D., left, and Surgeon General David Satcher, M.D., Ph.D., confer after Satcher's talk at the Scientific Assembly.
The Keystone III think tank outside Colorado Springs, Colo., debates the specialty's future. Some 82 attendees are on hand; many more take part through AAFP's Web site.
R. Michael Miller, J.D., 57, AAFP's deputy executive vice president since 1992, dies of a heart attack. Miller joined the Academy staff in 1968 and received Honorary Membership in AAFP in 1998.
Academy leaders express concerns about FDA's possible development of more stringent criteria for waived laboratory tests under the Clinical Laboratory Improvement Amendments.
Flu vaccines come late, some not till December. AAFP and CDC advise vaccinating high-risk patients first, when supplies arrive, and assuring patients that late vaccinations are still worthwhile.
President Richard Roberts, M.D., J.D., gives feedback to CEOs of about 20 large health plans concerning their initiatives to develop a common formulary database and simplify physician credentialing and the determination of covered benefits.
It seems likely federal lawmakers will fail to pass a comprehensive bill for patients' rights. Roberts brands the 106th Congress "the Congress of missed opportunities and misplaced priorities."
The AAFP draft paper on health care coverage for all Americans jump-starts a nationwide dialogue (see story).
Teamwork essential to control this chronic problem
BY CINDY McCANSE
A Big, Bold and Beautiful class exercises at St. Joseph Health Center in Kansas City, Mo.
You can't walk into a bookstore these days without seeing shelf upon shelf of books touting the latest "sure-fire" weight-loss diet.
With more than half of all American adults defined as overweight and nearly a quarter as clinically obese, it's easy to see why consumers spend upwards of $30 billion each year on commercial weight-loss products.
The results are often disappointing.
Successful strategies to lose weight and maintain weight loss require a comprehensive, often multidisciplinary approach that combines patient lifestyle modifications with skillful and sensitive medical care, says Sharon Stubbs, M.D., of the family medicine department at the University Hospitals of Cleveland. Stubbs works with overweight and obese patients in the primary care setting.
"Most obese patients want to lose weight," says Stubbs. "If they have a doctor who wants to help them, they're very excited."
Other team members may include a nutritionist or dietitian to provide dietary counseling; mental health professionals who can deal with associated psychosocial problems, if present; and knowledgeable nursing and office staff to track patients and ensure follow-up.
Take a weight history
Management begins with a thorough history. A childhood weight history is essential, as are questions regarding current food consumption and physical activity patterns.
It's also important to ask patients about weight-loss methods they've used and to review all prescription and over-the-counter medications they are taking.
Don't forget to ask about alternative agents, too, says Stubbs. Some of these compounds exacerbate weight problems and can interfere with any pharmacologic therapy instituted.
Weight-loss Drugs
- Appetite suppressants
- Noradrenergic
- Dextroamphetamine
- Phenylpropanolamine*
(Acutrim, Dexatrim)- Phentermine (Ionamin)
- Serotonergic
- Fenfluramine/
dexfenfluramine
(Redux; withdrawn, 1997)- Sibutramine (Meridia)
- Thermogenic agents
- Ephedrine
- Digestive inhibitors
- *Orlistat (Xenical)
- Hormonal manipulation
- Cholecystokinin
- Neuropeptide Y
- Leptin
*On Nov. 6, the FDA said it would seek removal of phenylpropanolamine from all prescription and over-the-counter products containing the drug, based on study results showing that PPA was associated with an increased risk of hemorrhagic stroke in women ages 18 to 49.
Along with a complete physical exam, laboratory testing should focus on determining serum levels of cholesterol and other lipids and assessing blood glucose and insulin levels.
Design a treatment plan based on the results of these investigations, Stubbs advises. Goals of treatment should be to lose more than 2 kg the first month and more than 5 percent of baseline over three to six months. That loss, she adds, should be maintainable.
Dietary and physical activity modifications are the mainstays of therapy. Obese patients should limit fat intake to no more than 20 percent to 25 percent of total calories consumed. Providing specific education about preparing healthy, good-tasting foods goes a long way toward encouraging compliance.
"I don't recommend cutting out any particular food group because it makes it hard to stick to and, nutritionally, it's not sound," says Angela Miller, M.D., also with the family medicine department at the University Hospitals of Cleveland, where she teams up with Stubbs in providing obesity care.
Kick the couch
Becoming more physically active is the toughest part of treatment for many patients, says Miller.
"I find that for my patients, the hardest thing to do is to get them to move," she warns. "They'll change their eating habits, but they just don't want to get up off the couch."
The key, she adds, is to set realistic exercise goals and give positive feedback for even modest gains in physical activity.
Some patients may require pharmacologic therapy to achieve basic weight-loss goals. Typically, clinically obese patients who fail to lose weight despite adherence to dietary and exercise recommendations and those with certain health problems may be started on a drug regimen in concert with behavioral measures.
Drugs to treat obesity fall into four categories. (See box at left.)
When all else fails
What about surgery? Consider it only for morbidly obese patients -- and only if all else fails, advises Miller. Morbidly obese patients are those whose body mass index (weight [kg] divided by height [m] squared) is greater than 40, or those with a BMI greater than 35 and other health risks.
Procedures now recommended include vertical banded gastroplasty and Roux-en-Y gastric bypass. These newer procedures have advantages over the traditional jejunoileal bypass. Other procedures, including laparascopic techniques, are being studied and show promise for the future.
Today's obese child -- tomorrow's diabetic patient?
BY CINDY McCANSE
It's bad enough that clinical obesity's on the rise among all Americans, jumping from about 15 percent to nearly 23 percent in the past two decades.
But even more alarming, according to researchers, is its growing prevalence among U.S. children and adolescents. During that same period, the prevalence of obesity in kids and teens nearly doubled -- prompting concern that rates of associated co-morbidities such as hypertension, hyperlipidemia and type 2 diabetes would also rise among these groups as they have among adults.
Fears borne out
Raul Zimmerman, M.D.
"Kids don't do their own cooking. You have to be working with the entire family."On one front, at least, those fears appear to have been borne out. Although data are limited, there is growing evidence that cases of type 2 diabetes (traditionally known as "adult-onset diabetes") are on the rise among patients ages 10 to 19.
Not surprisingly, this trend is most marked in patient groups that have an abnormally high prevalence of diabetes across all ages. Members of the Pima Tribe of Arizona represent such a group.
Three decades of research by the National Institute of Diabetes and Digestive and Kidney Diseases helped establish the link between obesity and diabetes in this population. Fully 50 percent of adult tribe members have diabetes; of those with the disease, 95 percent are overweight or obese.
More to the point, a 1992-1996 analysis of this ethnic group found the prevalence of type 2 diabetes to be 22.3 per 1,000 persons among 10- to 14-year-olds and 50.9 per 1,000 among 15- to 19-year-olds.
In addition, a retrospective study of 10- to 19-year-old patients in Cincinnati found that among African-Americans and whites, the incidence of type 2 diabetes leapt from 0.7 per 100,000 in 1982 to 7.2 per 100,000 in 1994. That's a huge increase for a disease that until very recently represented only 1 percent or 2 percent of all cases of diabetes in this age group. Researchers now estimate that between 8 percent and 45 percent of all youths newly diagnosed with diabetes have type 2 diabetes.
Screen youngsters
Obesity is a common thread throughout these diabetes case studies, making careful screening of overweight youngsters a priority, says FP Raul Zimmerman, M.D., co-director of the weight management program at Halifax Medical Center in Daytona Beach, Fla.
Even so, he says, diabetes may not manifest itself early on. "If you check obese patients for certain metabolic features like insulin sensitivity early enough in life, you'll probably find that they're normal. But if you continue to follow them over time, comparing their levels with those in non-obese people, you're more likely to see development of diabetes."
Part of the problem in detecting and managing diabetes in children and teens has been the lack of widely accepted diagnostic criteria.
Another obstacle is finding ways to treat the disease once it's found, Zimmerman says. For adults, that often means losing the weight -- even modest losses can translate into significant gains in glycemic control. But for kids, special problems can intrude.
"The group effort in weight management seems to be very important," he says. "You put obese adults together who are 30 or 40 years apart in age, and they do quite well. But you put a bunch of kids together -- even if they're only three or four years apart -- and they look at each other and say, 'You're not at all like me.' That's not a support group."
Encouraging increased physical activity can be a big challenge if the kids would rather watch TV or play computer games. Another hurdle: promoting healthy eating. "Kids don't do their own cooking," Zimmerman points out. "So from that perspective, you have to be working with the entire family" -- a situation often complicated by the fact that most heavy kids have heavy parents.
Add to that the paucity of antidiabetic medications available for young patients, and it's small wonder that policy-makers the world over are envisioning spiraling health care costs associated with obesity and its complications.
Clearly, early intervention is the key, says Zimmerman. Children at risk for obesity and its attendant health risks must be identified at a young age, and measures must be taken to head off potential complications. Early detection, patient education, caring intervention -- they're all tasks tailor-made for the family physician.
Reimbursement remains an obstacle
BY SHERI PORTER
The murky waters of physician reimbursement for diagnosis and treatment of obesity cause frustration for family physicians, says Cynthia Romero, M.D., of Virginia Beach, Va.
"Despite the growing number of obese patients, reimbursement for office visits and treatment is still quite poor," says Romero, who submitted the "Obesity as a Disease" resolution to the 1998 AAFP Congress of Delegates on behalf of the new physicians' constituency.
The Congress adopted the resolution, prompting a September 1999 letter from the Academy to the Health Care Financing Administration. The letter pointed out that obesity is an established diagnosis within the International Classification of Diseases and questioned HFCA officials about the Medicare regulation, "Program payment may not be made for the treatment of obesity, no matter what form the treatment may take."
"We fail to understand the rationale for HCFA's refusal to pay for the treatment of obesity," said the AAFP.
More than a year later, the number of obese Americans continues to escalate -- and Medicare payment methods remain unchanged.
A primary diagnosis of morbid obesity will be reimbursed, says HFCA spokesperson David Clark. "It's the treatment of obesity that's not a covered service."
And therein lies the dilemma: What's the logic behind reimbursing physicians for diagnosing obesity but then tying their hands in the treatment phase?
Romero says insurance providers have been slow to realize the cost benefits of treating obesity. If a patient is obese, that's not only the primary problem, says Romero, but also an underlying problem that worsens other disease states. "There's a misperception that obesity is a 100 percent self-induced problem -- the insurance companies presumably don't want to reimburse for diagnoses that could be changed if the patient had self-motivation," she says.
The good news is that a few organizations are getting it right. One example: HealthPartners Central Minnesota Clinics in St. Cloud, Minn. Family physician A. Clinton MacKinney, M.D., M.S., is medical director for the not-for-profit health care system, which employs 500 physicians and owns both a hospital and an HMO insurance product. HealthPartners stresses preventive health measures, including proper weight maintenance. "We are compensated for obesity counseling time," says MacKinney, adding that physicians there must adhere to strict documentation rules.
MacKinney, a member of the AAFP Commission on Health Care Services, also sits on a HealthPartners committee that reviews new and promising obesity therapies. Weight-loss medications are not covered, says MacKinney, "but I'm not in favor of them anyway. I don't think that's a good place for us to spend our patients' resources when other interventions have demonstrated greater long-term success and safety."
Richard Coorsh, assistant vice president of communications at the Health Insurance Association of America, says his organization doesn't compile statistics on how its members reimburse physicians for obesity visits. But he suggests that in most cases, "there will be reimbursement for conditions associated with morbid obesity."
This "ring around the rosy" logic from insurers and HCFA frustrates Romero. "HCFA may say it's reimbursing, but I'm getting claims denied," she says. Sometimes physicians select another primary diagnosis -- a cold, hypertension, cardiovascular disease, sleep apnea -- relegating the patient's obesity to the second or third diagnosis on the chart.
The unintended consequence? Skewed statistics. The number of doctor visits for obesity are grossly underestimated, says Romero. Other physicians agree that underreporting of obesity will mean fewer research dollars down the line to help fight America's growing health problem.
Get credit in 2000 for all your 2000 CME activities
If you're due for re-election to AAFP membership at the end of this year, circle Dec. 31 with red ink. You must accrue the required CME hours by that date, and all credits earned should be reported to the AAFP as soon as possible.
Members in the Active and Supporting (FP) categories must accrue at least 150 hours of AAFP Prescribed and Elective credit within each three-year re-election period.
A tip: Responses on the American Family Physician and Family Practice Management quiz cards are posted to the year in which they are postmarked, so cards received in 2001 are posted to your 2001 CME record.
If you have questions about CME requirements for continuing AAFP membership, need help identifying CME opportunities or would like a copy of your personal CME record, call a CME records representative at (800) 274-8043. Request a new CME reporting form if you need one.
You may submit your CME information by mail to CME Records, American Academy of Family Physicians, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; by fax to (913) 906-6087; or online at http://www.aafp.org/cme/.
See "Quick Fax" for information on requesting a fax of the CME reporting form.
A shipping fee may apply; Kansas residents pay a 7 percent tax.
Order from AAFP at (800) 944-0000 unless otherwise noted.
Check your mail in the next two weeks for two items from the Annual Clinical Focus on Mental Health: The American Family Physician monograph Diagnosis and Management of Depression and the Video CME syllabus Generalized Anxiety Disorder. You may order the companions to the syllabus -- a videotape and post-test (#R805) -- for $17.95. In addition, the AFP monograph is online at http://www.aafp.org/afp/monograph/.
There's now an online option for subscribers to the AAFP Home Study program. Subscribers can go to http://www.aafp.org/hssa/quiz/ to submit their answers to CME quizzes in the monthly monograph and audiotape series at no extra charge. For information about subscribing to Home Study, visit http://www.aafp.org/hssa/ or call (800) 274-2237, Ext. 5298.
The 2001 AAFP Catalog you recently received (#R493, free) highlights tools for your quality improvement efforts, sports a new section for family practice residents, and offers resources to maximize your use of the Internet in patient education and your own CME. You can order online at http://www.aafp.org/catalog/.
Proven value: Another AAFP resource for you and your patients is http://www.familydoctor.org/ -- a patient education site that recently won the World Wide Web Health Award from the Health Information Research Center.
FP Report is published by the AAFP News Department.
Copyright © 2000 by American Academy of Family Physicians.
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