March 2002 • Volume 8 • Number 3 |
 Raymond Weinstein, M.D., juggles a busy family practice in Dale City, Va., with his bioterrorism preparedness activities. |
Most days you'll find FP Raymond Weinstein, M.D., in his Potomac Family Health offices in Dale City, Va. As a member of a five-physician primary care group spread across three office locations, Weinstein spends the lion's share of his time seeing patients.
But on the first Tuesday of every month, you can pretty much count on finding him in a wholly different setting.
"I founded the Potomac Hospital/Greater Prince William County Chem-Bioterrorism Preparedness Committee in 1999 to help prepare Potomac Hospital for the possibility of a chemical or biological terrorist attack," explained Weinstein. "Although everyone thought this was an extremely remote possibility, and I initially had trouble getting doctors in the community to participate, I felt there was enough of a chance that it was worth the effort."
He started the committee with two other staff physicians from Potomac Hospital in Woodbridge; the hospital's infection control nurse; the local district director of the Virginia Department of Public Health; and Weinstein's son, a paramedic. But the committee now encompasses a far more diverse group. Representatives from HHS, CDC, FBI, Red Cross, local emergency response teams and others join community physicians and infection control and ER staff at the committee's monthly meetings at Potomac Hospital.
"We've grown to directly serve the two hospitals in the county, plus the local Kaiser outpatient facility and several hospitals in other counties," Weinstein said. "We also serve the medical community in the entire region with educational opportunities and materials."
Weinstein is an active member of the Metropolitan Washington Council of Governments Bioterrorism Task Force. Barely a fortnight before the Sept. 11 attacks, the task force completed a regional defense planning guide, an endeavor that had been in the works for two years.
"I believe all the preparation paid off, since this area was ground zero for the anthrax attacks, with seven of the 11 inhalational anthrax victims," said Weinstein. "Three of the victims were right from this community, and all were properly and quickly diagnosed, and all survived. I would like to think that our planning, preparations and educational efforts were at least partially responsible for our success."
Those efforts were apparent at the committee's Feb. 5 meeting, when Weinstein delivered a comprehensive overview of smallpox. In developing the presentation, he consulted with D.A. Henderson, M.D., a member of the World Health Organization team that successfully worked to eradicate the disease as of 1980, and now director of the HHS Office of Public Health Preparedness.
How bad would a bioterrorist attack with smallpox be? "It's the worst possible thing that could happen," said Weinstein. The extreme contagiousness of the disease, coupled with its multiple forms and the difficulty of treating those affected, have made it a focus of CDC's bioterrorism preparedness planning.
Weinstein's view is shared by others on the committee, notably Jared Florance, M.D., director of the Prince William Health District, based in Manassas, Va. Florance delivered the public health complement to Weinstein's address at the meeting.
INTERFACING WITH PUBLIC HEALTH
Understandably, said Florance, a primary concern of public health officials is disease surveillance by individual physicians, both in hospitals and out in the community. "Right now we rely on their intuitive surveillance. I get calls from docs all the time saying, 'This event is weird; it's something different,'" he said.
But other surveillance methods may be in the offing, Florance said, namely, using diagnostic codes to pinpoint suspicious disease outbreaks. "Everybody codes, right? Well, at some point we may be looking for ways to gather that information." Tracking certain codes could permit early identification of a potential disease cluster, allowing public health officials to interrupt the spread of disease.
"That's our end of it, which relies on information from the wider medical community, not just the ERs," said Florance. "What we're missing right now is a way to get that information from them to us in a way that doesn't add burden."
 FP Ray Weinstein, M.D., left, and Jared Florance, M.D., director of Virginia's Prince William Health District, discuss integrating the medical community with the public health system to respond to potential bioterrorist attacks. |
MAKING CONNECTIONS
Help is on the way, Florance added, citing HHS' recent announcement of major funding to shore up state public health systems and help create that critical liaison to the private medical community.
"That's exactly what we've been talking about," agreed Bowman Olds, a senior consultant and analyst with Science Applications International Corp. of McLean, Va. "How do we connect the local with the state with the federal system?"
Olds, a member of the team in charge of security for the 2002 Winter Olympics in Salt Lake City, said there is no one finger to be pointed for the confusion generated by last October's anthrax cases. "It's not just public health that was caught unprepared," he noted. "It was everybody.There've been some valuable lessons to be learned, and we're going to continue to learn -- as long as we can recognize that fact."
"This may be a time to reach out," said Florance. "It doesn't take very many people in a community to say, 'How can we help you if this happens?' You've got a lot of family physicians who've got M.P.H.s or who have other skills. I can't think of a place where they'd be more helpful."
"Doctors need to be able to recognize a bioterrorist attack, know how to react to it and not be afraid of it," Weinstein said, virtually echoing the description of the sentinel family physician given last fall by AAFP President Warren Jones, M.D., of Ridgeland, Miss. "We (the committee) are the only group I know of that's collecting information, creating and utilizing preparedness plans, providing education, and promoting communication between the private medical community and the public health community -- which is critically important when you're dealing with bioterrorism," said Weinstein.
Physicians' Medicare payments are stirring controversy, and you may already have received lower payments than last year.
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The Academy is continuing to fight a cut that took effect Jan. 1: the 5.4 percent cut in the Medicare conversion factor, a multiplier used to convert relative value units (for services) into payments for services.
The dramatic decrease has physicians, including FPs, up in arms. In December, Congress required the Medicare Payment Advisory Commission to report to Congress on the conversion factor problems by March 1. MedPAC already issued three recommendations expected to guide its report. One of the three: Hike the conversion factor by 2.5 percent for 2003.
Even though your Medicare payments may be slipping, it's likely you're not seeing a full 5.4 percent drop in your Medicare reimbursement. Why? At least in part because the Academy championed resource-based practice expenses, a Medicare payment element that reached its full effect Jan. 1.
"The changes related to practice expenses reflect previous congressional action to correct long-standing inequities in physician payment in moving to a resource-based approach, and the Academy helped spur that action," says AAFP President Warren Jones, M.D., of Ridgeland, Miss.
Your lawmakers will soon study MedPAC's report and wrestle with suggestions for the conversion factor. "Our contacts with Congress now will increase our chances for ending the conversion factor chaos," says Jones.
Bottom lines. The Centers for Medicare and Medicaid Services projected a 3 percent drop in family practice payments because of the 5.4 percent cut in the conversion factor (see Table 1). The average change forecasted for all physicians was a 5 percent drop. Because Medicare payments are adjusted geographically, the pay rate differs across the country.
Table 2 shows payment changes for family physicians' three most commonly used codes, with the most-often-used code listed first. "The relative frequency of the use of these three codes, as well as other codes, will dictate the impact of the 2002 payment rates on the average family physician," says Jerome Connolly, senior government relations representative in the AAFP Government Relations Division. "I believe the net effect of changes for these three codes will be a reimbursement rate that's pretty close to the one family physicians received in 2001 for these codes."
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AAFP efforts this year. The Academy is taking a lead role in a coalition of health professional groups seeking to correct the conversion factor problems. Coalition activities include:
Sustainable growth rate. The formula for annually updating the conversion factor is governed by the sustainable growth rate, a mechanism intended to control spending on Part B services. The SGR is tied to changes in the gross domestic product: When the economy slumps, Medicare payments to physicians are decreased. The SGR also requires payments for a coming year to take into account past errors in GDP estimates.
MedPAC's advice. MedPAC is asking Congress to:
Your input. A summary of some of the above information is available at http://capitol.aafp.org -- AAFP's Speak Out: Legislative Action Center -- by clicking on "Action Alert!" To e-mail your lawmakers and ask for a congressional remedy to the conversion factor problems, go to the site's "Take Action Now" box, enter your ZIP code, and click on "GO!" Select the letter "Medicare Physician Fee Update," and add your own comments.
"Explain how a reduction in the conversion factor and Medicare payment rates is affecting your practice," Jones suggests. "Tell what difficult financial and business decisions you may feel compelled to make as a result. If you have stopped accepting new Medicare patients or expect to do so, be sure to let your lawmakers know that."
He adds, "Your help is important. Given the deficit budget proposed by the administration, getting Congress to enact MedPAC's recommendations will represent a difficult challenge."
 FP resident Casey Dutton-Triplett, M.D., addresses patient Emily Cunningham's concerns during her exam after a group visit. |
Poverty. Drug use. Depression. Physical abuse. STDs. Mix any of these conditions with teen pregnancy, and you have a recipe for disaster. The patients coming to Providence St. Peter Family Practice Residency Program are no exception to the risk.
What is exceptional about these patients of the Olympia, Wash., residency program is the method for their treatment: group visits. The sessions bring together eight to 10 pregnant teens and any friends or family members who wish to accompany them. The group visits were organized 11 years ago when physicians at the practice became frustrated in their efforts to care for teen-age mothers whose psychosocial problems are inadequately addressed by traditional care, says FP Devin Sawyer, M.D.
PRACTICE 2010 CONCEPT
This may seem like a futuristic way of practicing medicine, but it doesn't have to be. The AAFP promotes group visits through Practice 2010, a quality initiative to help FPs accelerate change in their office practices. In the group sessions, several patients receive an educational message and then can discuss their unique concerns during a one-on-one exam. The process allows physicians to make effective use of their time.
In Olympia, every two weeks teen-age patients -- sometimes as young as 13 -- come in for a group session that begins with an interactive lesson on a salient topic such as nutrition, usually delivered by a third-year family practice resident. The patients then have an examination and may also be seen by a nutritionist or social worker.
"This is a fun way of practicing medicine," says Sawyer, who precepts three third-year residents who report back to him on their patients' status at the end of each session.
Many of the patients are enthusiastic about the sessions as well. "I'm learning new stuff all the time," says Julie Murray, 18. "It's helped me open up, and I've made some friends." Is she scared? "A little bit," she says. "A new baby is going to pop out, and I'm going to have to take care of it."
But if the staff at Providence St. Peter can help it, patients such as Murray will be better prepared.
IT STARTS WITH EDUCATION
One recent session began with social worker Suzanne Woodsum-Reed discussing child-proofing a home, a topic probably given little thought by teen-agers who might have come from broken homes or dropped out of school.
In fact, some don't know where they'll be living when their baby is born. And many of the pregnancies are complicated by physical or sexual abuse.
Although some might think the situation is hopeless, Sawyer says the prospect of having a child forces some of the teens to get their lives together.
The teens are quick to accept snacks such as muffins, yogurt, milk and juice, provided by the clinic to help increase awareness of good nutrition and to give the patients incentive to come in.
The clinic also encourages compliance by keeping a running appointment on Tuesday afternoons for the visits.
"It's really fun," said Rebecca Keen, 19, "and it's so much easier because you don't have to set the appointment -- the appointment's already made."
Another benefit apparent at a recent session was that of peer interaction. Two new mothers -- now veterans of the program -- returned with their newborns in tow to tell their friends what to expect from labor, night feedings and sleep schedules.
 New parents return to the group with their infants: At left is April Kelly; at right are David and Lisa Sanford. |
"Twenty-seven hours of labor!" new mother Lisa Sanford told the group.
Her husband, David, offered tips for potential labor coaches: "During the labor, get involved. I was holding her leg up and was right there, and it was really cool."
OTHER GROUPS, OTHER PATIENTS
Sawyer's practice also provides well-child care in group visits, sometimes transitioning mothers from the adolescent maternity care program. The patient benefit is twofold, says Sawyer: The inexperienced mothers receive additional peer support from more seasoned mothers, and the visits facilitate parent-to-parent learning.
Sawyer says they've learned along the way how to best structure the well-child visits. For instance, it's best not to take vital signs during the sessions -- unless you don't mind a room full of crying infants. A resident physician facilitates the teaching session, and each patient has a brief one-on-one interaction with the primary care physician. Immunizations are given at the end of the visit.
Sawyer's practice also treats patients with diabetes in group visits. Again, a resident physician delivers a teaching session based on the needs expressed by the group. Initially Sawyer said he was concerned about residents' ability to lead the sessions, but his worries were put to rest by the creative approaches they took. In one session, the diabetes group visited a supermarket and selected groceries so the physicians could educate patients on interpreting food labels.
In the teen mothers' group, the residents organized a game of "Baby Jeopardy" for eager participants who earned prizes by correctly supplying the questions.
In the end, the success of the group visit program is measured by its ability to educate patients. Therein lies the beauty, Sawyer says: "The seasoned patients model the behaviors" the physicians try to teach. "This is why the group visit works."
Want to read FP Report online as soon as it's available? Or do you prefer the printed version you're holding in your hands? Now, you can choose either one -- with a click of your mouse. Just visit http://www.aafp.org/mysubscriptions and scroll down to FP Report. Click on "E-mail," and you'll get the e-mailed table of contents, with links to the online issue, beginning with the next available issue. Change your mind? Just click on "Mail" to start receiving the printed version again.
Choosing the electronic version is a win-win situation for you and the Academy: You can read it days before you'd get the printed version, fewer trees will be used for FP Report paper stock, and the AAFP will be able to reallocate some of FP Report's printing and postage budget to other programs that benefit you and your patients.
There's an added benefit when you visit http://www.aafp.org/mysubscriptions: You can also choose to receive AAFP Direct (formerly Directors' Newsletter), the biweekly source of "insider" news for Academy members, by e-mail, fax or mail -- and you can choose to receive the e-mailed AAFP This Week, your best source for the latest news for family physicians.
Physicians with experience conducting group visits and team visits took part in a meeting on the topic at the annual Conference on Patient Education Nov. 15 18 in Seattle. Here are the insights and methods of two of the participants.
GROUP VISITS FOR DEPRESSION
The group visit works best when the physician uses it in an area that he or she is enthusiastic about, says Rupal Patel, M.D., of the Florida Hospital Family Practice Residency in Orlando, Fla. For her, this area is treatment of depression.
Working with a behavioralist, Patel runs eight-week clinics that include six to 12 patients with mild to moderate depression. The clinic's patients have at least one other chronic illness. Patients who have personality disorders, severe depression or suicidal tendencies, or are psychotic, bipolar or substance abusers are excluded. Such patients are best referred to a psychologist or psychiatrist, Patel says. But FPs can fill a niche, Patel says, noting that psychologists are often ill-equipped to deal with the coexisting condition in patients who have another chronic illness such as gastroesophageal reflux disease.
Residents help to facilitate the group. Also, a behavioralist is involved in initial coaching and skills building and as an integrative training tool for the residents.
The 90-minute sessions are tightly structured: 10 minutes with the nurse to take vital signs, 5 minutes for warm-up/socializing, 30 minutes for the doctor to perform one-on-one checkups, 10 minutes for group instruction on a didactic topic, 30 minutes for patient interaction and so forth.
TEAM VISITS FOR DIABETES
Gregory Bartel, M.D., used to think he had a good record caring for patients with diabetes. Then he built a registry of his patients and was surprised to learn that only about half of his diabetic patients came in regularly for checkups.
This pushed him to engage in a "team approach" to management of the disease, says Bartel, of the Mayo Clinic in Rochester, Minn. The team consists of a registered nurse, a diabetes educator and the primary care physician. Before each visit, the patient has A1c tests done so the results are available for the appointment, as well as results of home glucose monitoring. While waiting for the appointment, the patient completes a self-management form to identify problem areas.
Then the team goes to work, each member taking turns visiting the patient. The nurse takes vital signs, reviews goals, and asks about progress and concerns. The educator follows and addresses the concerns brought out during the nurse's visit. The physician is reserved for the last 15 minutes, during which the patient's feet are examined and goals are discussed.
The team approach differs from the traditional approach to diabetes management in that the focus is on having the patient set the goal, says Bartel. Before, he would blame poor outcomes on noncompliance. "But the fact is, noncompliance merely means the doctor's goals don't match the patient's," says Bartel. That's why he focuses on having patients take ownership of their goals. "If a patient eats five Big Macs, smokes two packs of cigarettes a day, is disabled and sits on a couch all day, and his goal is to walk to the mailbox three times a week, by golly, that's his goal," says Bartel.
"My role is to reinforce the patient's goal," says Bartel. "I tell my patients, 'Diabetes is serious, and you are the most important person in managing it'."
•Chapters lobby for change•
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Nationwide, rising medical liability insurance premiums and costlier jury awards in malpractice cases are forcing some family physicians to move their practices or close their doors.
AAFP constituent chapter officers in many states are hearing members' concerns about:
In some states, where medical liability issues have reached crisis levels, chapters have been working for years for tort reform. Other states are just entering the fray by collecting data from physicians and insurers, and a few chapters are using their data to formulate plans to push state lawmakers to introduce liability-related legislation.
MISSISSIPPI
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The Mississippi AFP has been advocating tort reform for several years, "and we will be involved forevermore with this whole issue," said MAFP President Timothy Alford, M.D., of Kosciusko.
"We got involved because we began observing FPs leaving the state for friendlier legal climates," he said. "A well-trained physician in southern Mississippi left after he was sued. The insurance company would not renew his policy, and no other company would write one."
That doctor moved to a nearby state and now teaches at a university and practices, said Alford. "He moved from an underserved area to a relatively adequately served area -- compounding the maldistribution problem."
Working closely with the Mississippi State Medical Association and lobbyists, the chapter has helped get several pieces of legislation introduced in the state legislature. The measures, if passed, would:
Alford said he's hopeful the proposals will see action this session, but "one senator told me, basically, 'You guys are right. The fact is, if I vote for you on this issue, I will not be alive in the next election.'"
NEW YORK
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New York lawmakers are no different, said Vito Grasso, executive vice president of the New York State AFP. The state's physicians pay some of the highest medical liability insurance premiums in the country because of escalating jury awards and a shrinking marketplace for insurance.
However, lobbying efforts by the chapter and other groups have resulted in legislation that limits the annual increase of premiums paid by physicians for the state's Excess Medical Malpractice Program policies. The policies provide coverage beyond the basic "primary" malpractice insurance. Starting in April, premiums for the excess coverage can't exceed the prior year's premiums by more than 9 percent.
The state's required primary liability coverage limits have increased from $1 million/$3 million (economic/noneconomic damages) in 2001 to $1.3 million/$3.9 million in 2002. According to data from Jury Verdict Research, 48 percent of the medical malpractice awards in the state in 1999, combining economic and noneconomic damages each exceeded $1 million. Without tort reform in New York, analysts say some awards could reach nearly $7 million by 2004.
"We're supportive of the excess coverage system," Grasso said. "But the real issue hasn't changed. The cost of exposure has increased, jury awards are increasing, and there's continuing pressure to increase premiums for primary policies.
"The solution is to reform the tort system."
Working with the Medical Society of New York State and other medical organizations, the chapter is lobbying for a reform measure including:
CONNECTICUT
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Citing concerns from members, the Connecticut AFP board has embarked on a fact-finding mission about the state of medical liability insurance, said President Paul Edelen, M.D., of East Hartford.
In December, the state's largest insurer -- Connecticut Medical Insurance Co., a physician-owned company -- notified policyholders that premiums were increasing by an average of 30 percent. Edelen said the board then "moved the issue to the top of the list" for action.
Rates have been climbing steadily, he said. From 1988 to 2001, his CMIC premiums increased 81 percent, for an average increase of 6 percent annually. This year's increase is 58 percent.
"The rate jump this year was an order of magnitude above previous increases!" Edelen said.
In his renewal notice, the insurer stated "higher court settlements" are to blame. "But we want to know why primary care has been hit so hard. Is this going to inhibit some physicians from practicing?" Edelen asked.
Those answers could come when the board meets with company representatives. At press time, a meeting was slated for late February.
"This outcome (increased insurance rates) is something that needs to be more visible," Edelen said, "and the consequences of high jury awards need to be visible to the public."
TENNESSEE
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No one agrees more than Timothy Linder, M.D., of Selmer, Tenn., president-elect of the Tennessee AFP and chair of the chapter's legislative committee.
One thing the public doesn't know, Linder said, is that juries in medical malpractice cases see the plaintiff's total medical bills -- not the ones with health insurance company adjustments. These lower, adjusted costs reflect the plaintiff's "actual" bill. "So they are working off the wrong numbers to begin with," said Linder.
His committee plans to study the issue this year with the intent of seeking some tort reform legislation in 2003.
"We can look to other chapters for some guidelines on how to go about getting legislative reform," said Linder.
•Chapters lobby for change•
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You treat a patient for depression. But your diagnosis reads "fatigue," "back pain," "abdominal pain" or a combination of these symptoms. Your billing code goes nowhere near mental health.
Sound familiar? Exasperating?
"Family physicians want to be able to call it like it is," says Bradley Fedderly, M.D., of Fox Point, Wis. "We want to diagnose depression and bill it that way."
In Wisconsin, says Fedderly, the legislature minimally requires insurers to cover outpatient mental health care provided by psychiatrists, psychologists, hospitals and state-certified outpatient clinics. Not by family physicians.
Similar "carve-outs" apply in most states.
The Wisconsin AFP is taking steps now toward a legislative attack on the carve-out next year.
In written comments submitted Feb. 12, the chapter asked lawmakers to amend the Mental Health Parity bill, S.B. 157, to include FPs as reimbursable for mental health care.
"Wisconsin sets its budget biennially, and this is a budget year," says Fedderly, the chair of WAFP's Legislative Committee. The Sept. 11 terrorist attacks intensified the slump in the economy, causing tax revenue to plummet. "We thought we put the budget to bed last fall. After Sept. 11, lawmakers recalculated and came up with a $1.2 billion deficit," says Fedderly. "Our legislative session ends March 12, and all the legislators will get passed by then will be the budget."
The next session, though, starting this fall, won't wrestle with the budget. "We should be able to get the mental health bill moved in the next session," says Fedderly. "We'll have the same cast of characters this fall, with the newly elected lawmakers not taking office until January."
WAFP members are emphasizing cost-effectiveness in contacts with their legislators. "Family physicians can and do provide the lion's share of mental health care, at least at the gatekeeping level," says Fedderly. "We control costs by providing the care we're trained to offer instead of referring the patient to a subspecialist. We'd like to bill for what we do."
•Chapters lobby for change•
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Sometimes a few well-placed jabs wield a lot of clout. Such was the case with New Jersey AFP member and self-proclaimed motorcycle jock Jeffrey Zlotnick, M.D., of Phillipsburg when he spoke out in December against a bill that would have repealed the state's motorcycle helmet law.
Zlotnick made his case as a physician and taxpayer when his quotes, written for an NJAFP press release, were picked up by two statewide daily newspapers just before the issue came up for a legislative vote. Zlotnick's comments also appeared in a letter that was delivered by fax, e-mail or in some cases by hand to every New Jersey legislator.
Zlotnick wrote, in part:
"As a physician, I understand the danger of riding without a helmet. I've seen serious injury and death result in bike accidents from what would be a routine fender-bender in a car. As a taxpayer, I am appalled that our lawmakers would repeal helmet laws and cause us to pick up the tab for the 'consenting adult' who chooses to ride without a helmet and ends up with a massive head trauma."
NJAFP Executive Vice President Ray Saputelli said that the bill, which initially hinged on two or three votes either way, was defeated by a vote of 60 14. "It wasn't even close when we were done," he said. "We mobilized and got this done in two days ... sometimes you just need to stop the madness, and I think that's what Jeff's quotes did."
NJAFP's political clout started at a slow simmer about a decade ago when the chapter organized a government affairs committee. Its potential to effect change mushroomed after members voted to raise their own dues to hire a part-time lobbyist to enable the chapter to get more involved in governmental affairs, said Saputelli. Since then, "we've certainly grown in name recognition. We're being invited to the table a lot more than we used to be," said Saputelli.
The chapter's Web site at http://www.njafp.org lists dozens of health-related bills pending in the state legislature. But Saputelli said there is the danger of overload. "Family physicians are generalists by nature and want to be involved in a lot of things that go through the legislature." He said it makes sense to focus limited chapter resources on key issues that can really make a difference.
"There are times when it's OK to let someone else fight the battle and we say 'us too, we agree.' And there are times we should lead the charge," he said.
As for Zlotnick, he spends up to three hours a week gathering information about those key issues because what happens in his state legislature affects him personally. "This is my future, this is my career. Proposals will come up that, unchecked, will negatively impact my ability to practice and take care of my patients," he said. "It's my job to say, 'If you pass this law, this will be the result.'"
•Chapters lobby for change•
•Chapters lobby for change•
A pregnant mom came to the group family practice of Barry Sundland, M.D, in Aurora, Colo., a few years ago for prenatal care and delivered a healthy baby. Recently, the same mom lost insurance, became pregnant and didn't make it to the office for care. She ended up in the emergency room with a kidney infection and was hospitalized for three days.
"If she'd been seen in the office earlier, a simple urinalysis and a $10 prescription could have eliminated the three-day hospital stay," Sundland said at a hearing of the Colorado Senate Committee on Health, Environment, Children and Families Jan. 24.
He was illustrating the need for maternity care to be covered under Colorado's CHP+ program, the State Children's Health Insurance Program. Colorado already covers prenatal care under Medicaid. The new bill Sundland was backing would expand that coverage so families eligible for CHP+ could have maternity care, namely, families with incomes between 133 percent and 185 percent of the federal poverty level, adjusted for family size. The bill would authorize Colorado to seek an easily obtainable waiver from the federal government to cover maternity care under CHP+.
"If women don't get coverage and don't have good prenatal care, kids get a bad start," said Sundland.
During the hearing, senators asked pointed questions, such as, "You estimate the new coverage would cost $6.5 million in state funds, and federal matching funds would be twice that. How do we know the $6.5 million per year won't go up greatly after the program's in full swing?"
Sundland, the only physician in private practice to testify, is familiar with maternity care coverage from insurers such as Cigna, Aetna and PacifiCare. "In the private sector, physicians receive from $2,000 to $2,500 for global OB care," he said, referring to prenatal care, delivery and postpartum care for an uncomplicated pregnancy. "Physicians' payments have been stable over the past decade. Despite inflation, insurers have done a good job of not paying us more."
The expanded CHP+ would provide $300 per month for physician reimbursement per patient. "Since most pregnant women receive care over an eight-month span, that works out to about $2,400," said Sundland.
Coalition building may save the bill, even in a time of budget crunch. All testimony at the hearing favored the measure. Staff from the Colorado Department of Health Care Policy and Financing, for example, said the 500 most expensive Medicaid births over the past few years cost an average of $195,000 each.
The budget battle looms. After the hearing, Colorado AFP lobbyist Pat Steadman of Denver said, "We're having major shortfalls. Most Medicaid providers will have their fees frozen, and there's a bill to cut pharmacists' dispensing fees dramatically, for a savings of $32 million."
Steadman added, "The idea that we'd expand coverage but cut pharmacists' reimbursement is a hard pill for some legislators to swallow. It's a tough year to argue for the CHP+ maternity care, but that's what we're doing. We know prenatal care is cost-effective."
As for the patient Sundland told the senate committee about, she was supposed to return to Sundland's office for further care. That hasn't happened. "We tried to get hold of her and can't," said Sundland. "We probably won't see her again until she has another major health problem or goes into labor."
•Chapters lobby for change•
Sometimes health care issues surface in tandem in state legislatures and the U.S. Congress. A federal bill the AAFP supports -- Start Healthy, Stay Healthy -- would encourage states to provide what the Colorado AFP (see story "Colorado AFP speaks up - Children's insurance program should cover maternity care") is seeking: maternity care coverage under the State Children's Health Insurance Program.
Start Healthy, Stay Healthy, S. 1016, would also avoid the question of redefining child in eligibility criteria for federal benefits. The bill, instead, would let states cover income-eligible pregnant women under SCHIP and automatically enroll their newborns in SCHIP. The federal government would supply about two-thirds of the funds for the coverage, and the states would provide one-third.
S. 1016 and the Colorado bill differ from the administration's approach. On Jan. 31, HHS issued a press release on its plan to redefine child so that states could, if they wished, extend SCHIP eligibility to children from conception to age 19. The plan may take effect after a 60-day comment period and analysis of responses. For the press release on the plan, see http://www.hhs.gov/news/press/2002pres/20020131.html.
With its kickoff in January, the Future of Family Medicine project gained ground toward its goal of developing a strategy to transform and renew the specialty of family practice.
AAFP President-elect James Martin, M.D., of San Antonio, chair of the project leadership committee, said he is pleased with the groundwork that's been laid. "This is a very exciting time for our specialty," he said. "There is tremendous support from all of the organizations within family medicine, and we have extremely qualified leaders staffing our five task forces. This project will result in a new outlook for family practice."
The project is a joint effort of the Academy and AAFP Foundation, American Board of Family Practice, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group and the Society of Teachers of Family Medicine.
At a planning session Jan. 25 26 in Santa Barbara, Calif., members for the project's five task forces were identified.
In addition, the project has contracted with Siegelgale, a strategic brand consulting firm based in New York City, to coordinate market research and develop a future strategy for family practice. National qualitative and quantitative research will explore the specific wants and needs of various groups -- patients, physicians, medical students and residents, payers, government and consumer advocacy groups -- as they relate to family practice. Focus groups are currently under way in Boston, Minneapolis and Los Angeles. "Ultimately, this research will help guide the development of a powerful marketing strategy for the specialty," said Martin. This research will be completed in time for the project leadership committee meeting Aug. 23 24.
The task force roles and leaders are as follows:
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March 2002 • Volume 8 • Number 3 |
President George W. Bush, in his proposed budget for fiscal year 2003, slates $0 for training in family practice. However, the budget summary says inner cities and rural areas have too few physicians.
That's a disconnect, according to the Academy.
"We appreciate Bush's recognition that significant areas of the country do not have enough doctors," says AAFP President Warren Jones, M.D., of Ridgeland, Miss. "However, eliminating the only federal programs specifically designed to support family medicine training is the wrong response to the problem."
Jones objects that, for the second straight year, Bush has proposed $0 for the Public Health Service Act's Title VII, Section 747 -- the primary care cluster, including funds for training FPs.
Family physicians are the most likely medical specialists to serve underserved rural and urban populations, Jones says.
Last year, despite Bush's recommendation of zero funds, Congress appropriated $93.05 million for Section 747, a major victory for family practice.
Jones says the specialty can't rest on last year's success: "Congress is working with a budget deficit this year; the whole game plan is changed from last year, when there was a surplus. We have a hard fight ahead of us to preserve support for Section 747."
More bad news from the budget plan: It requests $251.7 million for the Agency for Healthcare Research and Quality, a 15.7 percent decrease from the funds appropriated for AHRQ for fiscal year 2002. The Academy lobbies aggressively each year for funds for AHRQ; it is the only federal agency charged with supporting primary care research.
On the up side: The proposed budget would increase funds for the National Health Service Corps from the $148 million appropriated for 2002 to $192 million for 2003.
To the editor:
I read with interest the letter of Maury Greenberg, M.D., in the December FP Report.
I am in total agreement with his concern that in time nurse practitioners and physician assistants will be licensed in various states to provide primary care. We in family practice shouldn't be too upset about it, for we have, for a variety of reasons, done it to ourselves. Many family physicians have been actively involved in the training of nurse practitioners, and they are widely used in many offices. In some remote areas of Texas, nurse practitioners practice medicine under the guise of physician supervision that in some cases is so superfluous, it is close to being a sham.
Four years of medical school and a three-year family practice residency develops in the physician the diagnostic acumen, the procedure ability and the therapeutic expertise that cannot be matched by nurse practitioners or physician assistants. We must educate the public -- our patients -- about the difference. Otherwise, in the future, government and private insurers will direct those covered to the lesser-trained in the guise of cost saving. It's up to us; let's do it.
Bruce Jacobson, M.D.
Fort Worth,
Texas
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To the editor:
I'm writing regarding Dr. Maury Greenberg's comments in the December FP Report in which he stated we need to stop worrying about collaborating with other groups that may be usurping us and start worrying about our own members.
He happened to mention colonoscopy and OB-Gyn privileges. I recently returned from job interviews in Florida, where I was informed I would not be doing any colonoscopies or obstetrics, even though I am credentialed in these areas in Indiana.
We need to start ensuring that our members are able to become proficient and gain credentials in various skills or we will continue the downward spiral of the scope of practice that many family physicians are experiencing, while nurse practitioners' and physician assistants' scope of practice continues to grow.
John Chomer, M.D.
Noblesville, Ind.
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FP Report is published by the
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Copyright © 2002 by
American Academy of Family Physicians.
