While protecting confidentiality, states should notify partners of persons with HIV.
AAFP President Lanny Copeland, M.D., delivered that message Sept. 29 to a congressional panel.
"We believe there is a moral obligation to inform the partners of an HIV-infected patient that they have been exposed to the disease so they can get appropriate follow-up care and other support services as soon as possible," said Copeland.
"According to recent research in New York, 10 percent or fewer of people testing positive for HIV actually inform their partners," Copeland told the health and environment subcommittee of the House Commerce Committee.
Federal law already requires that spouses be notified. H.R. 4431, the HIV Partner Protection Act, would require all states to set up programs to contact others who may have been infected through sex or shared needles.
The bill, which probably will still be under consideration by Congress next year, contains these points:
- People with HIV would be asked to volunteer the names of their partners.
- Physicians and/or people with HIV could notify the partners.
- States would set up programs to contact and counsel the partners and offer referrals for HIV testing.
- Health professionals would suffer no penalties if, in good faith, they made errors in identifying partners.
- States could notify partners without the express consent of HIV-infected persons.
- State laws should prohibit insurers from discriminating against people tested for HIV. "HIV and AIDS do not distinguish between health plans," said Copeland. "Everyone should benefit from the same anti-discrimination protection."
Many states use name-based reporting, similar to that proposed in H.R. 4431. But some states allow anonymous testing, coding names by a unique identifier (such as a number). Copeland suggested changing the bill so it allowed states flexibility in protecting confidentiality.
HIV and AIDS have afflicted family physicians' patients since the epidemic began nearly 20 years ago, said Copeland, who practices in Albany, Ga. "This disease is affecting our patients who are newborns, school children, married adults, senior citizens, homosexual and bisexual, and illicit drug users. It knows no boundaries."
Results of human genome research will challenge, help family physicians
As you review the charts of two young asthmatic patients, you wonder why one of them has responded well to the albuterol bronchodilator you prescribed, while the other hasn't.
A 20-something white male patient tells you his lifestyle includes multiple sexual partners, both men and women, in a community rampant with HIV infection. He also abuses heroin. You're amazed he's HIV-free and don't know how long his good luck will last.
An adult female patient who's been suffering from fatigue and arthritis now has adult-onset diabetes. You recall that her late father, also your patient, had some of these problems, and you ponder the possibility of a genetic link.
A government project that's ahead of schedule and under budget will likely answer these and many other questions. It will substantially change the practice of medicine -- and the changes may begin within the next five years, according to Francis Collins, M.D., Ph.D., director of the National Human Genome Research Institute at the National Institutes of Health in Bethesda, Md.
This "next revolution in medicine" will fall on the shoulders of physicians who provide primary care, Collins said recently. The demands on family physicians will be significant as they gear up to provide information on genetic testing to their patients, help interpret test results for them and consider prescribing new genetic therapies that become available, he said.
The Human Genome Project is an international effort to map out the entire human genetic blueprint. Started in 1990, the project's goal is to construct detailed genetic and physical maps of the human genome, to determine the complete nucleotide sequence of human DNA, to localize the estimated 50,000-100,000 genes within the human genome and to perform similar analyses on the genomes of several other model organisms. The project also is charged with assessing the ethical, legal and social implications of its work.
The project has a yearly federal budget of $200 million, and it's currently 25 percent under budget, Collins said. The "finish date" of 2005 is being moved forward to 2003 because of rapid progress. More than half of all human genes have been mapped, with the information available on a web site.
Collins shared two principles explaining why genetics will play an increasingly important role in family practice:
Principle 1: Virtually all diseases except trauma have a genetic component. Even for conditions usually thought of as environmental, such as infectious diseases, genes dictate how the body will cope with the environmental challenge. For example, a recent study suggests that 1 percent of the Caucasian population lacks a specific cell-surface protein, rendering them completely resistant to HIV.
Principle 2: There are no perfect genetic specimens. People have an estimated five to 50 significant genetic flaws, some as subtle as one base pair gone awry in a chromosome, Collins said. While some mutations may be protective, many will place people at risk for something, especially as they age.
Some developments Collins shared:
- Population-based genetic screening for hemochromatosis is being intensely discussed and may occur within the next five years. The screening test is straightforward, and the condition is easily treatable if diagnosed early, Collins said. Left untreated, it can lead to fatigue, arthritis, diabetes, cirrhosis and heart failure.
- Genetic tests eventually will make it possible to tailor drug therapy. For example, albuterol's effectiveness varies according to the patient's genetic makeup.
- Cystic fibrosis researchers now understand what's wrong at the molecular level and have come up with new drug therapies; as a result, three new CF drug trials are under way. In addition, research using plasmids to insert the properly working genes into upper airway cells has met with mixed success -- the strategy improved function, but the altered cells were soon wiped out by the immune system. In 1997, an NIH consensus conference recommended that a CF carrier test be offered to all adults considering having children, on a population-wide basis.
The National Coalition for Health Professional Education in Genetics was established in 1996 in response to the rapid pace and impact of human genetics research. More than 100 health care professional organizations are coalition members, including the AAFP. Collins said the coalition has developed a web-based genetics information center (see web site information below) and is working on core competencies in genetics for medical school curricula and for continuing medical education.
Collins presented "The Human Genome Project and the Future of Medicine" Sept. 19 at the AAFP Scientific Assembly in San Francisco. During his lecture, he shared the web addresses of these medical genetics web sites: http://www.medsitenavigator.com/NCHPEG -- National Coalition for Health Professional Education in Genetics; http://www.nhgri.nih.gov -- National Institutes of Health National Human Genome Research Institute; http://www.cdc.gov/genetics -- Centers for Disease Control and Prevention; http://www.er.doe.gov -- Department of Energy's Human Genome Program; http://www.ncgr.org -- National Center for Genome Resources; http://www3.ncbi.nlm.nih.gov/omim/ -- Online Mendelian Inheritance in Man; and http://www.hhmi.org/genetictrail -- Howard Hughes Medical Institute.
By Paula Binder, Editor
Techno-tools cover millennium bug, patient education, colposcopy, diseases
Help's here on the millennium bug, patient education and your CME-at-home needs. To order these items, call the AAFP order department at (800) 944-0000.
Quality Care Alerts
A collaborative program will soon begin sending you Quality Care Alerts -- information on areas where evidence strongly indicates medical practice should change.
The first alert, issued by the AAFP, AMA and other groups, will highlight scientific evidence in support of the use of beta-blockers in post-acute myocardial infarction. FP Lee Green, M.D., M.P.H., of Ann Arbor, Mich., served on the technical review committee on this topic.
- The document "Family Physicians and the Year 2000: Preventive Medicine for the Millennium Bug" covers technological problems expected to crop up on Jan. 1, 2000.
The bug might infect phone systems, lab equipment, biomedical devices and other time/date-dependent technologies.
- The revised CD-ROM "AAFP Patient Education Handouts" contains about 300 brochures, the Tar Wars coloring sheets and curriculum, teen-oriented brochures and "Let's Eat" nutrition sheets. The CD-ROM, with all materials in English and Spanish, costs $175 and is item #R1598.
- The new self-study CD-ROM program, "Colposcopy for the Family Physician," includes a syllabus, video and audio instruction, a photo atlas, searchable text documents and an interactive test. This program, item #R293, is approved for up to 11 hours of Prescribed credit and costs $110.
- Six new Video CME programs may each earn you one Prescribed hour of CME, and they cost $17.95 except for the last one. They are: "Alzheimer's Disease: A Family Practice Update," item #R1800; "An Update on Chronic Viral Hepatitis," item #R1806; "Seasonal Allergic Rhinitis: An Update," item #R1809; "Strategies for the Prevention and Treatment of Macrovas-cular Complications of Type 2 Diabetes," item #R1812; "Guidelines and Barriers in the Treatment of Type 2 Diabetes," item #R1815; and "Preventing the Microvas-cular Complications of Diabetes," item #R1818, now available for $10.
The last three items are part of AAFP's 1999 Annual Clinical Focus -- Management and Prevention of the Complications of Diabetes.
Web watch: Check out these sites
Access these new online offerings.
- If you're looking for consultants or attorneys to help you with practice management issues, surf to http://www.aafp.org/fpassist on AAFP's web site. This free service conducts a search to find firms in your state that specialize in the medical field and have worked with FPs. Members without Internet access can use the service by calling Kristina Stricklin at the AAFP Socioeconomics Division at (800) 274-2237, Ext. 3448.
- Access http://www.aafp.org/airlift to check out the Siberian Airlift Journal, a story and photographs from last month's Physicians With Heart delegation. It's a humanitarian venture of the Academy, AAFP Foundation and Heart to Heart International.
- Click on http://www.aafp.org/congress to see what happened at the Sept. 15-17 AAFP Congress of Delegates in San Francisco.
- Visit http://www.medicare.gov/ for Medicare-related facts. The AAFP is an educational affiliate with the Health Care Financing Administration in the National Medicare Education Program, which operates the web page. In addition to statistics, public information campaigns and more, the page contains helpful links. For example, you can get HMO nonrenewal information at http://www.hcfa.gov, as well as details on Medicare benefits and the Medicare Medical Savings Accounts brochure at http://www.medicare.gov.
AAFP needs your numbers
The Academy has just brought its new membership database up to speed. Now, it needs your help.
On dues statements mailed in late October and early November, you are asked to indicate your home and office addresses, telephone numbers, e-mail addresses and fax numbers, and to say whether you prefer the AAFP to use your home or office address. All your AAFP mail, including journals, will go to your preferred address.
When the Academy enters your information into the new database, it will take advantage of U.S. Postal Service software to make addresses meet postal standards and qualify for discounts.
Addresses provided by some members could be changed to meet the standards imposed by the USPS, but any changes would allow the AAFP to send you mail as quickly and economically as possible.
Financial SummaryThis financial summary has been prepared to present an overall picture of AAFP's financial condition and operations.
Consolidated Statements of Financial Position
Assets
May 31, 1998
May 31, 1997
Cash and cash equivalents $ 11,363,479 $ 8,847,754 Receivables 5,909,966 4,228,098 Income tax refund receivable 1,895,547 1,895,547 Inventory of publication materials 96,251 112,150 Prepaid expenses and other assets 1,405,757 998,927 Marketable securities at fair value 39,138,830 31,313,700 Property and equipment: Land 495,000 495,000 Office buildings, improvements 2,793,757 2,571,909 Office equipment, furniture, fixtures 8,250,236 7,803,292 11,538,993 10,870,201 Less allowances for depreciation (5,953,357) ( 5,753,390) 5,585,636 5,116,811 Note receivable from 1740 Partners -- 1,925,000 Investments in deferred compensation plan 1,807,594 1,284,356 Total assets
$67,203,060
$55,722,343
Liabilities and Net Assets Liabilities and deferred revenue: Accounts payable $ 3,153,472 $ 2,619,767 Accrued expenses and other liabilities $ 3,573,728 $ 3,525,456 Unearned revenue 15,109,824 14,686,417 Liability for deferred compensation plan 1,807,594 1,284,356 Income taxes and related interest payable 2,051,358 2,024,176 Deferred rent concessions 933,788 1,325,997 Deferred gain -- 976,087 Deferred credit __-- 646,242 Total liabilities 26,629,764 27,088,498 Net assets: unrestricted 40,573,296 28,633,845 Total liabilities and net assets
$67,203,060
$55,722,343
Consolidated Statements of Activities Year Ended May 31 Revenues 1998 1997 Membership dues and fees $ 13,462,957 $ 12,479,915 Publications 18,912,931 19,498,113 Programs and miscellaneous 22,767,506 21,390,983 Investment income 5,252,020 2,168,892 60,395,414
55,537,903
Expenses Membership services and programs 28,643,208 25,163,819 Publications 10,985,565 10,255,839 General and administrative 10,311,372 11,353,642 Income taxes and related interest 1,902,182 2,496,885 51,842,327
49,270,185
Revenues in excess of expenses 8,553,087 6,267,718 Income tax refunds and related interest -- 4,433,080 Net unrealized gains on marketable securities 989,360 1,757,163 Gain on sale of partnership interest 2,397,004 __-- Change in net assets 11,939,451 12,457,961 Net assets at beginning of year 28,633,845 17,671,514 Restatement of prior period financial statements __-- (1,495,630) Net assets at beginning of year, as restated 28,633,845 16,175,884 Net assets at end of year
$40,573,296
$28,633,845
The above data are only a part of the complete financial statements examined by PricewaterhouseCoopers LLP, certified public accountants.
You asked for it, you got it
HCFA team tackles regulatory burden
Responding in part to AAFP pressure, the Health Care Financing Administration re-cently announced the formation of an internal team to study physicians' regulatory burden.
A little background: The 1997 Congress of Delegates urged the Academy to work with appropriate government agencies and other organizations to develop reasonable and simplified paperwork for nursing home care, durable medical equipment and other areas.
Subsequently, at the recommendation of the Commission on Health Care Services, the AAFP Board chair issued an appeal to HCFA for some relief. "Family physicians are being overwhelmed by the paperwork and procedural hassles associated with coordinating the care of their patients in various settings outside the office," said then-Chair Patrick Harr, M.D., of Maryville, Mo.
At the Academy's urging, HCFA put the issue on the Sept. 28 meeting agenda of its Practicing Physicians Advisory Council, which advises Health and Human Services Secretary Donna Shalala, Ph.D., on the impact of proposed regulations and implemented policies.
Physicians at the meeting expressed support for a study of their regulatory burden and said they hoped to be part of the process.
HCFA's new team will be led by family physician Steve Gleason, D.O., of Des Moines, Iowa, who serves on the HCFA administrator's executive council of advisors. Gleason welcomes input from the Academy, so AAFP committees and commissions will work with staff to develop a list of burdensome, duplicative or otherwise unnecessary regulatory requirements to be shared with Gleason's team.
The team ultimately hopes to produce a compliance manual or another method to reduce the regulatory burden.
Work resumes on E/M guidelines that should help family physicians
The Health Care Financing Administra- tion and medical organizations are resuming work on a new framework for evaluation and management documentation guidelines.
"The new framework addresses many problems family physicians have had under the old E/M guidelines," said Rosemarie Sweeney, AAFP vice president for socioeconomic affairs and policy analysis. "We were concerned HCFA might simply revert to the old guidelines, but it's now making progress on the new framework."
Work on the new framework halted when the AMA stopped physicians' review of HCFA's revisions, objecting to any numeric counting of organ systems for reimbursement. The AMA and HCFA reached agreement Sept. 22 that some counting would be acceptable. It's expected the new framework will help family physicians code their services for better reimbursement, in less time than is now required, and with fewer hassles.
AAFP, coalition help fend off legislation on 'lethal' drugs
In letter to New York Times
AAFP rebukes Congress
In a letter in the Oct. 19 New York Times, AAFP President Lanny Copeland, M.D., of Albany, Ga., attacked Congress's failure to pass tobacco control and managed care bills.
"This Congress voted down legislation that could have been a powerful tool in reducing tobacco use," said Copeland, citing a 73 percent increase in teen-age smoking since 1988.
Copeland also criticized Congress for failing to pass a proposal defining the standard covering emergency care, a requirement for internal/external appeals processes for beneficiaries and a mandate for full benefits disclosure to beneficiaries.
"Doctors take an oath to do no harm," said Copeland. "Perhaps Congress should do the same."
The Academy helped prevent congressional action last month on the Lethal Drug Abuse Prevention Act, H.R. 4006 and S. 2151.
The bills would have allowed the Drug Enforcement Agency to suspend the dispensing license of any physician who prescribed drugs for use in a suicide.
"The Academy is concerned that family physicians could be made liable for criminal penalties ... for prescribing needed pain medication to their terminally ill patients," said a letter from AAFP leaders to all members of Congress. The Academy called the bills "unacceptable intrusion" by the government into patient care.
AAFP key contacts -- members who lobby their lawmakers at AAFP's request -- and Academy staff and leaders asked Congress to defeat the bills. In addition, the Academy joined the Coalition to Improve Pain Management, opposing the bills.
"The House and Senate were surprised at the outpouring of consternation from the 58 groups in the coalition," said Michele Johnson, government relations representative in AAFP's Washington Office. Rep. Henry Hyde, R-Ill., and Sen. Don Nickles, R-Okla., introduced the bills. Nickles boiled down S. 2151 to a one-sentence amendment, tried to have it attached to a spending bill, but gave up as Congress neared adjournment last month.
Specialty wins contract for primary care faculty development in genetics
As knowledge of human genetics explodes, family medicine will play a key role in ensuring state-of-the-art genetics education for faculty in several medical disciplines.
The Bureau of Maternal and Child Health has awarded family medicine a $1.6 million contract for faculty development in genetics for specialties including family medicine, pediatrics and internal medicine. The three-year contract was awarded Sept. 24 to the Society of Teachers of Family Medicine on behalf of the Primary Care Organizations Consortium, a national oversight coalition with representatives from those three specialties. Norman Kahn, M.D., director of the AAFP Education Division, is the family medicine representative on PCOC's executive committee and the contract's initial project director.
According to Kahn, the project will focus on educating three types of faculty: community-based physicians who teach residents and students, full-time faculty, and leaders including residency directors, department chairs and others.
What's up
in primary care education?
No more ivory towers. No more silos for separate disciplines.
Primary care education should be community-based and multidisciplinary. That will help students and communities the most.
This was the consensus of educators and administrators at the meeting on "Primary Care Education for the 21st Century: Lessons From National Initiatives" Sept. 24-26 in Baltimore.
Katie DiMasi does her first check of a patient's nose. George Spitzer saw DiMasi and FP Bill Minier, M.D., in Omaha.About 400 representatives of six initiatives, involving 98 health education institutions, shared what they've learned since the early nineties. They've spawned programs to educate medical students, nurses, midwives and physician's assistants in underserved areas. They've often trampled barriers between disciplines.
Rebecca Henry, Ph.D., of Michigan State University in East Lansing reported the view of students evaluating an interdisciplinary service project: "Some faculty get it, some just don't." Students saw academic-based faculty as more territorial about their roles. But community-based physicians focused on the case or the problem.
"Suddenly, when things were patient-centered, everything fell into place," said Henry. "We realized how much we undermine when we do projects in the academic setting instead of the community."
IGC Project
The AAFP and the Society of Teachers of Family Medicine helped create the five-year, 10-school Interdisci-plinary Generalist Curriculum Project, which convened the Baltimore meeting. The IGC gives community-based experiences to first- and second-year medical students."The first year of med school is books, books, books," said Katie DiMasi, a first-year student at the University of Nebraska in Omaha, one of the IGC sites. "Sometimes it's hard to remember what you're in med school for."
The IGC zaps that problem. "I love working here," DiMasi said last month at the Social Settlement, which offers senior services, daycare for kids and a one-room clinic where IGC students help physicians provide care.
In the IGC, family physicians, general pediatricians and general internists create generalist courses and line up preceptors. "All of us were concerned about losing our identities," said FP Jeffrey Susman, M.D., IGC codirector at the university. "People didn't want us to sell out or dilute family medicine. That concern hasn't played out."
Susman said it helps to have first- and second-year students spend more time in physicians' practices and a bit less in class: "You have to ask, 'What's the end product?' We're training compassionate, competent physicians, not biochemists or anatomists or histologists."
Crediting the IGC, a microbiology teacher quoted in last year's IGC annual report said, "The students have been more engaged in the course than in any of the preceding 30 years I've been doing it. ... They're asking questions that are to the point of clinical situations."
Community partnership
The Baltimore meeting focused on community partnership, which means putting citizens at the table, said pediatrician-psychologist Don Weston, M.D., vice chancellor of health sciences for West Virginia's university system.Since the early 1990s, the state has created a network of 13 rural health education consortiums, with 130 health centers and departments. Each consortium has a citizen board. "The rural citizens have to approve what we do in their communities," said Weston. At the state level, rural citizens sit at the table with deans of the health science schools to decide how the health education program will operate.
The network is working: The number of health professionals in rural West Virginia has increased by 11 percent.
Far to go
At the meeting's close, Harvard internist Thomas Inui, M.D., Sc.M., of Boston pointed to issues noticeable by their absence in the discourse: "Primary care folks never talk much about the biomedical revolution. There's little reference to genetics in primary care."Inui also charged, "We do our best job with arthritis, myocardial infarction, depression or name-your-favorite-chronic-condition when we collaborate, generalist and specialist. We don't talk much about that in primary care. We need to."
By Jane Stoever, Managing Editor
Ambulatory care training data reveal pros, cons
Research on ambulatory care training swings from upbeat to "oops!"
On the up side, the scale and scope of ambulatory training are greater than expected.
Hospital-related and community-based ambulatory teaching sites train an average of three types of professionals, not just one. And training encompasses community-oriented primary care, self-directed learning, service projects, lectures, supervised patient care and rounds.
"The community impact of ambulatory care has been beneficial. It's increased staffing, resources and economic benefits at many sites," medical educator Sarena Seifer, M.D., of Seattle said at the Sept. 24-26 national initiatives meeting in Baltimore. "Besides, being able to teach is a retention tool."
On the down side, teaching sites have higher costs than other sites, and teachers have less time for patients. One study indicates nonteaching physicians see 12 1/2 patients per half-day, and teaching physicians see 11 1/2 patients on the half-day they teach. However, teachers' weekly productivity exceeds that of nonteachers.
Joseph Scherger, M.D., M.P. H., suggested, "Students can assist the office staff and the doctor. Students can save the doctor time that can be traded for teaching time."
Scherger is associate dean for clinical affairs at the University of California, Irvine's medical school; professor and chair of the family medicine department; and former AAFP director. He puts students to work. They bring the patient to an exam room, take the patient's history, and often do parts of the exam and present patients in the exam room. "The patients love hearing themselves presented," said Scherger. "I tell them, 'If Eileen misses anything, jump in.'"
He added, "If students aren't looked at as an asset to managed care, the problem isn't managed care, it's us."
Equation out of whack
More minorities in America, fewer offering care
Over time, the health care workforce will look less and less like the people it serves.
"Twenty-five percent of the population is from minority groups, 10 percent are in the health professions, and the gap is widening," said Claude Earl Fox III, M.D., M.P.H., administrator of the Health Resources and Services Adminis-tration, Sept. 24 at the national initiatives meeting in Baltimore.
Several of the initiatives received HRSA funding. "Our data show, thank God, that our (HRSA-supported) graduates are four times more likely to practice in underserved areas than others," said Fox.
AAFP Education Division Director Norman Kahn, M.D., asked, "How do you see the federal government partnering with the states about minority issues when the states seem to be moving away from affirmative action?"
Fox answered, "We can provide models that work for recruiting minority kids. We can provide data to states, to policy-makers, so they know their state's health status. We can look at the catalytic role the feds can play -- we can fund some projects, but we at HRSA have a drop in the bucket compared to what's needed."
And he cautioned, "What we do can't be heavy-handed."
FP Report * November 1998 * Volume 4/Number 11
The official news publication of the American Academy of Family Physicians. Published monthly by the News Department, Communications Division, for distribution to all AAFP members. Opinions expressed in the FP Report do not necessarily reflect the policies of the AAFP.
Paula Haas Binder, Editor, News Department
Todd Simchuk, Managing Editor
Sharon Dickinson Dent, Associate Editor
Jane Stoever, Associate Editor
Leigh Anne Bathke, Associate Editor
Renee Campbell, Production/CirculationAddress comments and inquiries to FP Report, 8880 Ward Parkway, Kansas City, MO 64114-2797; fax them to (816) 822-8857; call (800) 274-2237, Ext. 4230; or send them to pbinder@aafp.org via electronic mail.
Copyright © 1998 American Academy of Family Physicians. All rights reserved.