August 2002 • Volume 8 • Number 8 |
Forget about tort reform. The only way to restore health to health care is to establish an entirely new system of medical justice, according to attorney Philip Howard. Author of The Death of Common Sense and The Collapse of the Common Good, Howard is chair of a new bipartisan coalition called Common Good -- and he'll keynote the 2002 AAFP Scientific Assembly in San Diego this fall (see related story).
Howard spoke June 17 to physicians gathered for the AMA House of Delegates annual meeting, during an educational session on the medical liability crisis. When he finished, he got something lawyers rarely get from doctors: a standing ovation.
Then later in the meeting, the AMA house voted to move liability reform to the top of the deck as AMA's priority number one.
Common Good is dedicated to overhauling America's "lawsuit culture." The coalition's board is almost shockingly diverse: George McGovern and Newt Gingrich, Alan Simpson and Paul Simon, plus leaders in health care, education, law, business, and public policy.
"Justice has become a kind of sporting contest, played at the intersection of personal tragedy and greed," Howard declared. Most people -- even reformers -- have tended to assume that the system of justice is immutable, like the Ten Commandments. "Prevailing orthodoxy is that patients, and indeed all Americans, have a virtually unlimited 'right' to sue," he said.
Accepting that frame of reference has determined the outcome, Howard said. "No long-term cure is in sight because we haven't let ourselves question the basic assumptions of who decides who can sue."
The result? Legal fear ripples throughout society, affecting not just physicians, but also teachers, ministers, Little League coaches -- everyone.
A PERFECT DISTRUST
Physicians' distrust of justice is perfect, Howard said. Common Good recently commissioned Louis Harris & Associates of New York City to do a nationwide survey of physicians and others in health care, and the chairman of Harris had never seen numbers so high, Howard said. "Ninety-six percent of physicians believe malpractice claims are brought because of adverse results, not medical errors. And when a claim is made, 83 percent said they did not generally trust the system of justice to achieve reasonable results."
The American patient is the biggest loser because physicians no longer feel free to follow their best judgments, Howard said. In the survey, a high percentage of physicians admitted to ordering unnecessary tests, prescribing unnecessary medication -- even altering humane choices at the end of life -- because of legal fear.
"Extrapolating a 1996 study of defensive medicine, the cost of defensive medicine is probably well over $100 billion a year," Howard said. "And this is a society where over 40 million Americans are uninsured. All that money could be spent to take care of people who are uninsured or who are really sick."
In addition, the current system fails to hold bad doctors accountable because "they invoke their so-called rights," he said. "The standard compromise, I am told, is to let the incompetent doctor leave quietly. There is a scandal in the making, just like the Catholic priests, as bad doctors are shown the side door and are allowed to go to the next hospital and practice on unsuspecting patients."
NO RIGHT TO SUE?
The Common Good coalition holds that there is no right to sue for whatever someone wants. "The rights our founders gave us were rights against state power," Howard said, but a lawsuit is the use of state power by one private citizen against another. "Any angry person can invoke state power against another citizen, and no one on behalf of society is making rulings of what's reasonable and what's not," he said.
Why? Back in the 1960s, judges awoke to abuses of authority and abandoned their responsibility to act as gatekeepers of who can sue for what, Howard said. "The role of law is not only to condemn what's unreasonable, but also to protect what's reasonable. We've forgotten the second half."
BATH WATER AND BABY
Common Good advocates an entirely new medical justice system, with special courts, perhaps like the patent courts, presided over by judges who have expertise in the field -- courts that patients and physicians would consider reliable. Getting there will require a revolution of sorts to make the public understand exactly what's happened, Howard said.
"To succeed in eliminating random jackpot justice, we must all get together and demand it," he said. "I hope we can work together to achieve it."
After extensive information-gathering and deliberation, the CDC's Advisory Committee on Immunization Practices on June 20 recommended limiting prophylactic smallpox vaccination to persons identified as initial responders in the event of a disease outbreak. ACIP also recommended that states be allowed to vaccinate staff at hospitals designated by state and local health authorities to treat smallpox victims.
The ACIP did not recommend mass vaccination. It reasoned that, in the absence of a known disease outbreak, the risks of universal vaccination outweighed the potential benefits.
Original estimates had placed the number of persons eligible for the limited vaccination scenario at about 15,000. But federal health officials now appear to be considering expanding that number to some 500,000 individuals. All vaccinations would be on a voluntary basis. Go to http://www.cdc.gov/nip/smallpox/supp_recs.htm for the full ACIP recommendation.
The committee's stance aligns with AAFP policy. In early June, the Academy recommended vaccination of "persons at the federal, state and local levels acting as smallpox response team members who would be called upon to investigate smallpox cases and contain outbreaks." Go to http://www.aafp.org/x10636.xml to read the AAFP statement.
Richard Clover, M.D., of Louisville, Ky., and Martin Mahoney, M.D., Ph.D., of Clarence, N.Y. -- both members of the Academy's Commission on Clinical Policies and Research -- serve as AAFP liaisons to the advisory committee.
The ACIP recommendation went to HHS Secretary Tommy Thompson for his review in conjunction with CDC officials. Still ahead: developing an implementation plan and establishing an oversight panel to monitor the safety and efficacy of the vaccine. Once the plan receives the final thumbs-up -- including sign-off from the White House -- vaccinations could begin early this fall.
A home page packed with a generous menu of AAFP resources, just a mouse-click away -- this is one of several new features of the Academy's redesigned Web site at http://www.aafp.org.
"The site is dramatically updated in terms of appearance, navigation and organization," says FP Jeffrey Weinfeld, M.D. "From the home page, you can go more directly to where you need to go."
Weinfeld, who practices at a community health center in Washington, D.C., serves on AAFP's Web Advisory Committee. Besides receiving regular input from the committee, the Academy has conducted focus groups with FPs on updating the site and has done user testing with FPs across the country.
"The majority of the Web site's content was there before," says Weinfeld, "but the organization and design are much improved."
AAFP members may now login to the "member side" of the Web site from the home page. Many member services are now collected under "My Academy," so it's easier for members to report their CME, check their CME records, subscribe to AAFP publications, create their practice Web sites, update their contact information, and use "Speak Out" to e-mail their lawmakers.
Visitors to aafp.org will also get better "search" results than before. Users have the option to search by phrase -- for example, requesting "diabetes mellitus" will give sources using the full phrase -- and the search request could include added words, such as "in childhood."
Questions and comments about the redesigned Web site may be e-mailed to online@aafp.org.
Remember when you were a kid and your dad assigned a chore so overwhelming that you didn't know where to start?
Some physicians are reliving that uncomfortable feeling as they face compliance with the Health Insurance Portability and Accountability Act. The deadline for complying with the HIPAA transactions and code sets standards is Oct. 16 -- unless you file for the one-year extension (see July FP Report). The deadline for complying with the privacy regulations is April 14, 2003.
Since physicians are all in this together, a little encouragement from colleagues is in order. FP Report checked in with some AAFP members who have made progress (some racing, some inching) toward HIPAA readiness. From updating forms and installing new software to physical changes in their offices, these docs are making headway.
DEVELOP A PLAN
Chip Bounds, M.D., of Moncks Corner, S.C., launched his compliance effort by forming a HIPAA team. The four-person team includes himself, plus representatives from the nursing, billing and front-office areas. "We've drawn up draft documents and had those approved at providers' meetings," said Bounds. "They're already in effect."
Early on, the team did a walk-through audit of the office, looking for areas that could compromise patient confidentiality. Common-sense actions like turning prescriptions facedown at the nurses' station were easy to address.
But some things needed a technological fix. All computers have been outfitted with locked screensavers, accessible only by password. The network is now password-protected as well.
Some physical improvements -- such as doors on the medical records room -- still await completion, but Bounds said he's on course: "We have a timeline; we want to be compliant by Oct. 1."
It's important to approach compliance in a businesslike way, said Bounds. "You need a plan and a timeline -- assign tasks and hold people accountable."
DELEGATE AUTHORITY
For Robert Patterson, M.D., of Sanford, N.C., the key word is "delegate."
"I'm force-feeding my HIPAA team right now, but eventually, they're going to be the experts. Then I can practice medicine, and they can tell me what I need to do," he said.
Patterson insists on a positive attitude. "I don't want my team to come to me with a compliance problem until they have two potential solutions to offer," he said. He looks to the Academy and the AMA for valid information and calming words. "Misinformation is rampant," said Patterson.
"We look to our software vendors to show us, from an accounting standpoint, what we need to do. They suggested filing for the extension and taking inventory of the current systems," Patterson said.
TAKE INCREMENTAL STEPS
Leonard Fromer, M.D., of Santa Monica, Calif., chair of the AAFP Commission on Heath Care Services, compared HIPAA to a skyscraper under construction -- and said his practice is hard at work laying the foundation. As he and his partners endure a management company change, their office is undergoing a total network and information system conversion.
"Everybody thinks about HIPAA compliance with every strategic decision we're making right now," said Fromer. A new emulator recently put on his computer hard drive is encrypted and HIPAA-compliant. "If it wasn't, we wouldn't have put it on. We don't want to solve problems only to have to re-solve them down the road," he said.
However slow and painful it may seem, take incremental steps as you inch toward HIPAA compliance, advised Fromer. "Hopefully, if this thing is done right, at the end of the day, physicians will be able to take care of their patients more effectively and efficiently."
UTILIZE RESOURCES
Victor Ricker, M.D., of Toledo, Ohio, is modeling new provider documents after sample documents in the Academy's HIPAA Privacy Manual.
"I've got about half of them done," he said. Ricker and his partner Kenneth Bertka, M.D., have taken the "divide and conquer" approach -- Ricker tackled the privacy documents, while Bertka, more comfortable with technology, waded into billing and system compatibility issues.
Ricker feels a certain satisfaction in the progress he's made and encourages colleagues who have procrastinated to dig in. "It's like shoveling your driveway -- you know you need to do it, but you're just praying for a sunny day so you won't have to," he said.
AAFP Past President Bruce Bagley, M.D., of Albany, N.Y., also champions the Academy's HIPAA manual. He gave a copy to his in-house legal staff. "I basically did a handoff, and they were very appreciative," said Bagley. "The manual gives you a systematic approach and a concrete action plan." It also demystifies HIPAA, "which has been billed as the latest boogeyman," said Bagley.
RESIST PANIC
"We're not doing anything radically different, but we did apply for the extension," said William Soper, M.D., M.B.A, of Kansas City, Mo. "I think there is a danger of doing unnecessary work by getting too deeply involved in this thing too quickly."
When Soper moved into his current office space two years ago, he saw HIPAA coming -- and designed the space with patient confidentiality in mind. Some HIPAA-friendly features include private areas for the fax machine, for the inevitable stacks of paper messages and lab reports, and for telephone conversations.
Soper advised colleagues to stay informed by consulting expert sources. He regularly checks the Centers for Medicare & Medicaid Services Web site at http://www.cms.hhs.gov/hipaa/ for the latest HIPAA news.
Physicians can also check the Academy's HIPAA home page at http://www.aafp.org/hipaa.xml for reliable information and to order the HIPAA Privacy Manual.
"Don't panic," said Soper. But do educate yourself and tighten up your security, he added.
David Kibbe, M.D., director of health information technology in the AAFP Socioeconomics Division, has been on the front line disseminating information about the Health Insurance Portability and Accountability Act for many months. He has fielded questions from concerned physicians around the country. Here's a slice of what he's heard and, more important, the "good news" he wants FPs to consider.
FP Report: As you talk to physicians about HIPAA implementation, what are their top concerns?
Kibbe: I would say the major concern is HIPAA's size and scope. HIPAA seems difficult to grasp, partly because much of the early communication about it has come from lawyers and compliance officers. I see many physicians who despair of ever getting a handle on its provisions in any practical way. "Bring it down to the office level," and "Just tell me how to stay out of trouble," are requests I hear often. If I were in active practice today, trying to run a busy office, I would react the same way.
FP Report: Are these concerns warranted? Are physicians being asked to do the impossible?
Kibbe: Not really. I think HIPAA information standards are manageable, for the most part. What's been missing from most presentations that doctors hear are the benefits HIPAA will bring to their offices. When the standards for electronic transactions and code sets are implemented, it will really take the "crazy" out of the billing and payment hassles we currently endure.
FP Report: Can you spell out key areas where FPs could see significant positive changes -- that proverbial light at the end of the tunnel?
Kibbe: Certainly. The main benefits are these:
I also think that patient-physician relationships might improve if the office and the patient are able to access insurance and claims data at the time of service, clearing up any misunderstandings that may have arisen about the patient's coverage and health plan details.
 AAFP President Warren Jones, M.D.: "The AAFP believes strongly that the future viability of the AMA resides in a successful transition to an organization of organizations." |
The 155-year-old American Medical Association might metamorphose into the core element of an "organization of organizations," possibly with few or no individual members of its own -- if a business plan yet to be developed passes muster with the AMA House of Delegates next year.
At its annual meeting here, the AMA house voted June 19 that the AMA could transform itself in that manner. A committee representing the AMA, state medical societies, national medical specialty societies and other AMA federation components will develop the business plan.
The plan will address financial implications for the AMA and member organizations, as well as which AMA activities should continue and which should be cut.
The AMA's membership numbers have been dropping for years -- the organization currently represents only about 28 percent of all doctors. In the late 1990s and in 2000, several groups within the AMA, including its Commission on Unity, wrestled with the problem.
Most recently, the AMA's Special Advisory Group Extraordinaire reported its recommendations for change to the AMA Board of Trustees this February. The AMA board circulated the SAGE report to other federation groups, including the Academy, for comment before taking a stand on the report's recommendations.
In March, the AAFP Board of Directors endorsed the SAGE report, offered some refinements and strongly urged the AMA board to endorse the report as well.
The SAGE called for substantial changes in the AMA structure -- the most radical of which was transition to an organization of organizations. But the AMA Board of Trustees rejected the concept, recommending instead that the voluntary individual membership model somehow be strengthened.
AAFP President Warren Jones, M.D., of Ridgeland, Miss., chided the AMA board in reference committee testimony, calling the recommendation "a reaffirmation of the status quo that is woefully inadequate."
"The AAFP believes strongly that the future viability of the AMA resides in a successful transition to an organization of organizations," he said.
After hearing extensive, diverse testimony, the reference committee went against the board and recommended the organization of organizations model. After hours of debate, the AMA house called for an "implementable" business plan first. "If the business plan is adopted by the AMA House of Delegates, the AMA will transition to an organization of organizations," the house declared.
The call for a business plan was prudent, said Daniel Ostergaard, M.D., AAFP vice president for international and interprofessional activities. "The SAGE report also called for other changes that would have reduced costs, such as elimination of the AMA house's interim meeting and a reduction in delegation sizes. Delegates didn't vote for those changes, so those expenses are still in place. All stakeholders need to know the additional costs of moving to an organization of organizations before making a decision."
If the AMA were to change into the core element of an "organization of organizations" (see story above), how would it affect you? Here are some ways:
If you currently belong to the AMA, you might not be able to continue your direct membership -- unless the AMA somehow kept an individual membership channel open. But currently, less than 30 percent of all doctors are members, the key reason the AMA has been looking for ways to change.
In cases in which the AMA -- or another member organization -- took the lead in lobbying on an issue that the entire group agreed on, the lobbying effort could be more powerful than ever. That's because the lead organization could say it spoke on behalf of a vastly larger number of doctors -- physicians represented by the member organizations of the larger group. (Professional liability reform, anyone?)
The Academy would be expected to pay dues to be a member of the organization of organizations. Therefore, in a sense, some of your AAFP dues dollars would go to the AMA. How much would the AAFP pay for its membership? No one knows -- which is why the AMA House of Delegates decided to look at a business plan next year before committing to the change. The concept has to be doable for all the groups involved.
The AMA would downsize, dropping some activities, products and services. But it would continue its key role in areas such as medical ethics, advocacy, standards and publishing. Member organizations might market their products and services together, so you could compare and select what's right for your practice.
It's easy to switch from receiving the printed FP Report by mail to receiving the e-mailed table of contents with links to the online issue. Just visit http://www.aafp.org/myacademy/, login and click on "My Subscriptions." Follow the instructions to select or change your delivery option for each publication shown.
Several contributors have pledged a total of $799,190 to support the discipline's effort to transform and renew itself -- the Future of Family Medicine project.
The initiative, launched in January, aims to enhance family physicians' quality of practice -- yielding benefits for patients across the country.
Seven family medicine organizations (listed below) earlier pledged organizational and financial support for the project. The external contributors and the amounts they recently committed to the project are: Eli Lilly Foundation ($125,000), Pharmacia Corp. and Pharmacia Foundation ($350,000), Robert Wood Johnson Foundation ($299,190), and Schering Laboratories/Key Pharmaceuticals ($25,000).
The project will build on market research conducted this spring on the specific wants and needs of various groups: patients, physicians, medical students and residents, payers, government and consumer advocacy groups.
The project leadership committee will meet Aug. 23 24 in Vancouver, British Columbia, to review the market research.
The Future of Family Medicine project is a joint effort of the Academy and the 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 Society of Teachers of Family Medicine.
Plan now to attend the 2002 AAFP Annual Assembly. It begins with the Congress of Delegates Oct. 14 16 in Marriott Hall at the San Diego Marriott Hotel and Marina. The Scientific Assembly, with almost all of its CME sessions at the San Diego Convention Center, will be held Oct. 16 20. This year's Assembly keynote speaker will be attorney Philip Howard, chair of Common Good, a bipartisan coalition that advocates an entirely new medical justice system (see related story). For more information on the Scientific Assembly, go to http://www.aafp.org/assembly.xml.
Speak your mind at the reference committee hearings of the Congress of Delegates, AAFP's policy-making body, and listen to the debate during the general sessions of the Congress. Along with considering resolutions and recommendations, the Congress usually takes action on proposed Bylaws amendments. This year, no amendments were proposed, so there will be no need for a Reference Committee on Bylaws hearing.
The Congress will elect new Board members and officers Oct. 16. To see who's in the running, go to http://www.aafp.org/congress, click on "2002 Candidates" and supply your AAFP ID number. You'll find the candidates' personal statements and résumés plus a new service for members: You can ask candidates your questions -- and get their responses -- at the Web site.
The top CME meeting for family physicians is the AAFP Scientific Assembly -- and if you'd like to make a presentation to your peers at next year's Assembly, now's the time to prepare your proposal.
Next year's Scientific Assembly will be held Oct. 1 5 in New Orleans. Speakers' proposals, which for the first time must be submitted electronically, are due Oct. 28.
Go to http://www.aafp.org/assembly/cmeproposal/ to submit your application. Warning: Once you start submitting it, you must finish the process. Here's help: To preview the application form, scroll down to the bottom of the Web page and click on "This PDF File." If you don't have the free Adobe® Acrobat® Reader needed to open the file, click on "More About PDF Files."
Mark your calendar for the deadlines listed below. For more information, see the Web pages or call (800) 274-2237 and the extensions noted.
Student health policy scholarship. Medical students interested in fostering public health and shaping health policies are prime candidates for attending the American Medical Student Association Political Leadership Institute in Reston, Va., Jan. 30 Feb. 2, 2003. The AAFP Foundation has a program allowing a student to do just that -- through the James G. Jones, M.D., Student Health Policy Scholarship. Each chapter foundation may submit a nomination; the nomination deadline is Sept. 13. Call Ext. 4457 for details.
Fundamentals of Management. The FOM program provides management and leadership training and is approved for Prescribed CME credit. A brochure including the FOM application is available at http://www.aafp.org/fom.xml. If you apply by Sept. 30, you'll be eligible for a $100 discount on your tuition. The final deadline for applying is Oct. 31.
Resident Repayment Program. First- and second-year residents may apply for this debt-reduction program for candidates going into rural practice, inner-city practice or full-time family medicine teaching. The winners, chosen by lottery in December, may receive as much as $2,500 per year for up to four years. For more information, go to http://www.aafpfoundation.org. Apply by Oct. 15.
Resident scholar awards. If you are or recently were the lead author for a research project or scholarly activity as a resident, consider joining the Resident Scholars Competition. The author of the first-place paper will receive $300; the second-place award is $200; the third-place prize is $100; and seven "honorable mention" citations will be given. Visit http://www.aafp.org/resident/scholars.html for an application, or call Ext. 3160. Apply by Nov. 15.
Joint grants for research. You can now request up to $30,000 in support for your research project, compared with the former ceiling of $20,000. The council overseeing the joint grants program for the AAFP Foundation and the Academy is seeking applications for projects "using rigorous design and appropriate analyses" and also for simpler studies.
Submit your proposal electronically by Dec. 1. For information on the joint grants and several other AAFP Foundation research grant programs, go to http://www.aafpfoundation.org.
Talk about your inflammatory issues! Did you hear about the June 19 fire sparked in a Salem, Va., medical clinic? The culprit: a bag of tortilla chips left too close to the warmer for the refried beans -- all part of a staff lunch courtesy of a drug company. The lunch was to serve as the backdrop for a sales pitch by a sales rep from the company, Pharmacia Corp.
Technically, the rep wasn't at fault. For you Clue® fans, it was the caterer with a can of Sterno® in the upstairs meeting room.
The point is, the consequences of interactions between pharmaceutical representatives and physicians or physicians-in-training are often unpredictable.
Few physicians, for example, would predict that a marketing spiel delivered over lunch with a drug rep might alter their prescribing behavior. Or that accepting a speaker's fee from a drug company could be associated with a subsequent request to add that company's drug to the hospital formulary -- despite the fact that equally effective and less costly drugs already appeared there. Yet solid research evidence shows these types of things occur. (See study citations.)
To its credit, organized medicine has over the past decade defined what constitutes ethical behavior by physicians and pharmaceutical interests, starting with the AMA's 1990 "Guidelines on Gifts to Physicians From Industry," and including the AAFP's "Principles for Cooperation" that 16 pharmaceutical firms signed onto last fall (see below).
Now, industry has addressed the gifts issue with the April release of the Pharmaceutical Research and Manufacturers of America's "Code of Interactions with Healthcare Professionals," a document that reads much like the AMA guidelines.
Visit http://www.phrma.org/press/newsreleases/2002-04-19.390.phtml for more information on the PhRMA code, including a link to the code itself.
AAFP President Warren Jones, M.D., of Ridgeland, Miss., applauded PhRMA's action, saying it's heartening to see the group of some 80 pharmaceutical and biotechnology companies promoting industry responsibility.
"As a physician," Jones said, "my primary responsibility is to patients. I monitor my interactions with pharmaceutical companies with this in mind." The PhRMA code, he added, demonstrates industry's intent to partner with physicians to see that interactions between the two groups are ethically appropriate and provide true patient benefits.
Some, however, are underwhelmed by the PhRMA document.
Christopher Ryan, M.D., of the Wilson Family Practice Residency, Johnson City, N.Y., is among the skeptics. Noting few differences between the code's precepts and the status quo, he questions the motivation behind PhRMA's action.
"I think the most dangerous part of the code is the preamble," Ryan said. "An excerpt: 'This Code is to reinforce our intention that our interactions with healthcare professionals are to benefit patients and to enhance the practice of medicine.'"
Such claims are misleading, Ryan said. "I would have had much more respect for the document and its authors if it read, 'The purpose of interactions between our salespeople and physicians is to increase sales of our products.' Honesty goes a long way."
ALLEGATIONS OF ABUSE
Admittedly, there are grounds for concern. One striking example can be seen in newly unsealed court documents alleging that a pharmaceutical company committed a number of unethical acts in the mid- to late 1990s. Among those allegations against Warner-Lambert:
Pfizer acquired Warner-Lambert in 2000 -- after the alleged abuses were said to have taken place. Pfizer has denied many of the allegations contained in the suit, brought by a former Warner-Lambert employee. The case is now being investigated by the Boston U.S. attorney's office.
TODAY'S ETHICAL CLIMATE
Such over-the-top allegations illustrate the potential seriousness of the gifts issue. No doubt most transgressions -- on each side of the physician/industry equation -- are far more innocent. Yet recent study results and increased media scrutiny have helped prompt, among other things, an ongoing investigation by the HHS Office of Inspector General into the extent of the gifts problem.
Physicians -- and politicians -- are seeking answers at various levels, although some "fixes" seem to beg the question of whether the cure is worse than the disease.
At one Seattle multispecialty practice, Polyclinic, drug reps are now charged a minimum of $30 to set foot in the door. Last month, Vermont Gov. Howard Dean, M.D., signed into law a pharmaceutical bill that included a provision requiring full reporting of industry gifts to physicians totaling more than $25.
Similar legislative measures are in play in other states. For Massachusetts gubernatorial hopeful Steve Grossman, the issue is one of several underpinning his campaign platform. His rival in the Democratic race, Robert Reich, a former U.S. labor secretary, proposes an outright ban on gifts.
Norman Kahn, M.D., AAFP vice president for science and education, while congratulating PhRMA on its new code, cited some differences between it and the AMA guidelines that could affect certain aspects of national CME meeting planning. Those differences, he said, would be discussed during upcoming meetings of the Accreditation Council for Continuing Medical Education, AMA and the Academy's Commission on Continuing Medical Education.
For the individual physician, Kahn noted, it's always wise to subject each interaction with industry to the "sunshine test."
"SUNSHINE TEST"
"You have to look at your own motives," said Kahn. If you're seduced by the thought of whatever perk is being offered by a company in exchange for a few minutes of your time, "Don't talk yourself into believing that you 'just won't listen to the pharmaceutical information being presented,'" he warned. "Look at it from your patients' perspective."
"I think it's no coincidence that www.nofreelunch.org (a Web site devoted to this issue) uses a CAGE questionnaire," said Daniel Sontheimer, M.D., of the Spartanburg (S.C.) Family Practice Residency, referring to a standard addictions screening tool. "Like the alcoholic who uses denial, I think I -- we -- have done the same. Asked why I shun reps, I won't tell you they're evil. My response is, 'They're that good.'"
The AMA's 1990 adoption of the "Guidelines on Gifts to Physicians From Industry" was arguably the principal move in organized medicine's effort to define what constitutes ethically acceptable behavior by physicians dealing with industry. Those guidelines are at http://www.ama-assn.org/ama/pub/article/4001-4236.html on the AMA Web site.
The AAFP long ago threw its support behind the AMA guidelines and periodically revisits the issue to keep it fresh in the minds of physicians and industry alike.
Last fall, the Academy took an additional step when it issued its "Principles for Cooperation." The principles reaffirm AAFP's position on the AMA guidelines and its endorsement of standards for commercial support of CME created by the Accreditation Council for Continuing Medical Education -- all while seeking industry buy-in to putting patients' interests first. Sixteen pharmaceutical firms signed onto those principles, available at http://www.aafp.org/cooperation/ on AAFP's Web site.
Also last year, the AMA launched a major initiative to educate physicians about the gifts guidelines. Go to http://www.ama-assn.org/sci-pubs/amnews/pick_01/prsa0917.htm for more about that initiative.
The issue resurfaced this past June at the AMA House of Delegates annual meeting in Chicago, with delegates adopting a resolution calling for stepped-up efforts to educate medical students and residents about the importance of the gifts issue.
 Lenexa, Kan., resident Garry Porter, 52, ponders the results of his recent self-ordered full-body scan. |
You've heard the expression "the customer is always right." This notion is being tested in the world of health care, where consumers can now order a battery of health tests without a doctor's consultation.
The gain to patients is dubious. Cholesterol tests, computerized tomography scans, prostate-specific antigen tests and STD screens are all available -- at a price -- regardless of whether a person would benefit from such testing. One pharmacy chain even offers coupons in its store flyers for discounted osteoporosis screening.
Family physicians are taking notice.
"Sometimes knowing more is doing worse," said AAFP Board Chair Richard Roberts, M.D., J.D., of Madison, Wis., who has taken the lead for the Academy in responding to inquiries about these tests. "What people really need is the ongoing relationship with a physician they trust who can help them put the pieces of the health care puzzle together."
Do the tests empower patients? Do they cause unnecessary concern? Do they falsely reassure patients? Do they drive up costs?
"Yes," said Roberts. "All of the above."
PLAYING ON FEARS
Roberts said he approves of the tests "to the extent that the tests prompt people to engage the system. But that's not how they are being used." The way he sees it, consumers are being given a false promise that submitting to testing somehow confers good health on the person tested.
Of course, some tests are useful, Roberts said.
"There are clearly some tests that have been helpful -- home glucose testing, for instance. That said, there are lots of instances where tests are being used inappropriately and are not proved to improve people's health," he said.
On a recent weekday, Alan Klaus, 53, arrived at his local pharmacy in Kansas City, Mo., to get his cholesterol screened. The convenience appealed to him. Within five minutes, he was seated with a tube in his arm to have blood drawn for a cholesterol test. "My wife is a nurse, and she told me I should do this," he said. At the suggestion of the pharmacy representative, Klaus also agreed to have a PSA test.
The problem, said Roberts, is that cholesterol levels are only a minute factor in assessing a person's risk for heart disease. "Total cholesterol is only one small piece of the puzzle. For a pharmacist to say, 'Oh, your cholesterol is normal,' may give the patient false reassurance," he said.
Then there's the PSA test that Klaus was offered. Roberts contends that the PSA test is one example of a test that has not been shown to improve people's health. Furthermore, suspicious findings may come back that warrant further, more invasive tests.
STRIKING A BALANCE
Other family physicians worry about the profit motive in making the tests available.
"Anytime you market directly to consumers -- whether diagnostic tests or medications -- you have to strike a balance between the positive values of giving patients more information about their health options and empowering them to request or even demand some health services that might benefit them, versus the negative values of driving up costs, misinforming the public so that private industry can make a profit, and so forth," said Howard Brody, M.D., Ph.D., professor of family practice and philosophy and former director of the Center for Ethics in the Humanities at Michigan State University, Lansing.
But Emily Essex, director of advertising and sales promotion for InterFit Health, a national health screening group based in Houston, said the direct testing is giving patients ownership of their health. InterFit is an outfit that provides the medical staff -- phlebotomists and medical assistants -- who administer screenings at chain stores.
Max Bouja, M.D., dean of the medical school at the University of Texas, Houston, is InterFit's corporate medical director. The organization has a medical advisory board, and there's a medical director in each state in which InterFit provides testing at corporations or in retail venues. Laurie Lee, president of InterFit, said, "We're not functioning in a vacuum. We're functioning under medical directors."
Essex said, "Our main objective is to help people take charge of their health. We give them the ability to take care of themselves in a more appropriate way and read their own results."
Physicians should not feel threatened by patients' direct access to the tests, she said. "Because we provide this service, they can have more time with their patients."
SEE YOUR DOCTOR?
Patients whose test results indicate intervention is imperative are contacted directly by an InterFit nurse or doctor and encouraged to see their own physician, said Essex. With slightly or significantly out-of-range results, patients' reports are stamped with an advisory note to consult their personal physician. However, there is no mechanism to ensure that patients follow through, she conceded.
What Theodore Ganiats, M.D., of La Jolla, Calif., finds worrisome is the accuracy of these tests. "All direct-to-consumer tests will have a certain number of false-positive results," said Ganiats, immediate past chair of the Commission on Clinical Policies and Research. "What are the patient and physician to do if the consumer test is positive? Retest in the doctor's office? What if the two results disagree? What is the appropriate management strategy?
"Unfortunately, this is rarely worked out in advance, so both the patient and physician move forward guessing what is the best management path."
But false-positive and false-negative results are only part of the problem, said Roberts. "The real danger is that these tests undermine and erode the doctor-patient relationship."
FULL-BODY SCANS
At the extreme end of the direct-to-consumer health test trend is the availability of body scans -- ranging from scans of specific organ systems to full-body scans.
Scare tactics abound. The brochure of one imaging center warned, "Heart attacks happen every day, even in apparently healthy people," and went on to list those who were at risk: men over age 35, women over age 40. A fairly broad range.
Roberts took issue with a June 24 Wall Street Journal article titled "Don't Let Your Doctor Keep You From Getting a Body Scan," in which the writer asserted, "the medical establishment has a vested interest in keeping patients out of scanning centers."
"That's laughable," said Roberts. "These tests generate more visits to the doctor.
"If you're doing the tests to avoid the doctor, you're going to need to see the doctor (to confirm the results) eventually anyway. Either me or the undertaker."
The Academy and an individual family physician brought Congress this message recently: Tort reform is crucial, especially for rural patients and their physicians.
Written testimony. "When confronted with substantially higher costs for liability coverage, family physicians are often forced to stop delivering babies." The Academy sent this message in June to the House Judiciary Committee's Commercial and Administrative Law Subcommittee and in July to the House Energy and Commerce Committee.
"With fewer physicians providing maternity and prenatal care, women's access is restricted, depriving them of the proven benefits of early intervention," wrote the Academy.The AAFP testimony accented the dependence of rural communities on family physicians for routine maternity care.
The Academy endorsed the Help Efficient, Accessible, Low-Cost, Timely Health Care (HEALTH) Act, H.R. 4600. It should be passed, said the AAFP, because it would:
Florida field forum. George Harris, M.D., of St. Petersburg, Fla., spoke at a field forum of the U.S. House Energy and Commerce Committee in Clearwater, Fla., June 22.
"I am concerned about the continued access to care for Florida patients, especially rural women who may have worsened pregnancy outcomes than if they had regular access to a physician for their maternity care," said Harris.
Sharing information from the Florida AFP, Harris said:
"The crisis that Florida is facing is real and deserves the attention of Congress," said Harris.
The House of Representatives passed provisions to fix the flawed Medicare payment formula June 27. However, the payment fix is mired in a controversial bill offering prescription drug benefits. At press time, senators were expected to introduce bills that would differ sharply from the House bill on drug benefits but would probably reflect House provisions on Medicare payments.
With the divergent views in the congressional chambers, enactment of prescription drug benefits this year is up for grabs. But AAFP staff in Washington have high hopes for the payment fix.
"We do expect Congress this year to pass a measure addressing the Medicare payment problems," says Kevin Burke, director of the AAFP Government Relations Division. "We're asking Academy members to keep up the pressure on Congress -- for patients' sake -- to revise the Medicare payment formula."
By early last month, 1,353 AAFP members had written their lawmakers, seeking relief from this year's Medicare payment cut and the prospect of cuts totaling about 14 percent over the next three years. The messages underscored the relationship between fair Medicare payments and physicians' ability to keep caring for Medicare patients.
The House, in its June 27 vote, agreed to increase physician payments by roughly 6 percent over the next three years and to explore ways to restructure the payment formula.
Also, in early July, the Centers for Medicare & Medicaid Services proposed adding more than $1 billion to Medicare payments from 2003 to 2005.
The Academy has been such a dominant force in seeking payment reform that The New York Times, in May, mentioned AAFP's influence. The Times named the AAFP and the American College of Surgeons as participants in an AMA-led coalition.
To send your senators an e-mail supporting Medicare payment reform, open http://capitol.aafp.org/. At "Action Alert," click under "Update on the Medicare Physician Payment Crisis," and follow the instructions provided.
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Use the new cultural competency training package -- "Quality Care for Diverse Populations" -- to examine ethnic and sociocultural issues routinely encountered in a medical setting. The training program features video vignettes and is available in two formats: videotape/manual (#R723, $150) or CD-ROM (#R724, $100). Order the program online at https://secure.aafp.org/cgi-bin/catalog.pl?uid=cat100955 or call the above number. |
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As part of the AAFP Annual Clinical Focus 2002: Cancer, a free copy of the American Family Physician monograph Family Physicians and Cancer will be mailed to all active members this month. The monograph is also available at http://www.aafp.org/afp/monograph/. You may go to http://www.aafp.org/acf.xml to print out 12 new patient education handouts on cancer. |
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Proven value: The 2002 2003 Tar Wars® program curriculum is now available online. Use these free materials to present the AAFP's tobacco-free program for kids in your community. Visit http://www.tarwars.org to order classroom tools and promotional items. Call (800) TAR-WARS for more information. |
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Proven value: Preregister now for the 2002 Scientific Assembly. The meeting Oct. 16 20 in San Diego features about 300 different courses, lectures and workshops. Register online at http://www.aafp.org/assembly.xml or by fax or mail according to the information in your Official Program. After the Sept. 10 preregistration deadline, participants must register on-site. Important note: Pack your Official Program; you'll receive an addendum with late changes in San Diego. |
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A shipping fee may apply; Kansas residents pay a 7.275 percent tax. |
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FP Report is published by the
AAFP News Department.
Copyright © 2002 by
American Academy of Family Physicians.
