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FP Report

March 1999
News for members of the American Academy of Family Physicians

Company recalls one lot of DTaP vaccine

Check the AAFP Web site or AAFP Express for recommendations

Pasteur Mérieux Connaught USA has issued a voluntary recall of Tripedia™ DTaP vaccine, lot number 0916490, and will replace any remaining inventory that is returned. Routine stability testing has determined that the lot has fallen below specifications for potency prior to the product's expiration date, in regard to diphtheria.

Because many doses of the vaccine may have been administered, the CDC -- in conjunction with AAFP and the American Academy of Pediatrics -- prepared recommendations on what should be done for children who have received vaccine from the suboptimal lot.

The recommendations are available on the AAFP Web site at http://www.aafp.org/alert and on AAFP Express, the Academy's fax-on-demand system, at (800) 223-7397 (follow the voice prompts and request document #7002).

FY 2000 federal budget

Good news, bad news

The Academy alternately applauded and panned parts of the Clinton administration's fiscal year 2000 budget proposals last month.

Each year, the funding blueprint lays the groundwork for Congress' annual budget process, crucial to health care.

The upside. The Academy commended the administration for its proposal to escalate funding for the Agency for Health Care Policy and Research. The administration called for a 21 percent increase for AHCPR, from $171 million this year to $206 million in FY 2000.

"The Academy appreciates the administration directive that the budget will help 'to translate the findings of completed research into everyday medical practice,'" said the AAFP in its Feb. 10 news release.

The downside. In what the Academy called a "disappointing setback," the budget recommends zero funding for the Title VII cluster that includes family medicine training.

"In many areas of the country, there is a significant shortage of family physicians and other primary care physicians," said the AAFP release. "The nation's rural areas and inner cities are hardest hit. Cutting the funding for training is counterproductive."

(Note: Congress in the past has thwarted administration efforts to slash Title VII funds.)

The budget also calls for Medicare providers, including physicians, to be assessed $194.5 million in user fees to help cover the program's operating costs. User fees could include $1 for each paper claim (instead of electronic claim) filed for Medicare reimbursement.

The user fees "would impose additional burdens on practicing family physicians who are already struggling to comply with oppressive amounts of Medicare paperwork and regulation," said the Academy.

The Web site. AAFP's summary of the administration's health-related budget proposals can be accessed at http://www.aafp.org/x2401.xml on the AAFP Web site.


Action alert

Ask Congress to make GME technical corrections

In 1997, Congress set caps on numbers of residents to slow the influx of physicians into the nation's workforce. Inadvertently, the legislation created problems for family practice residencies.

So last year, family medicine organizations wrote model legislation to fix the glitches, and members of Congress introduced the bills. They were not passed last year but were expected to be reintroduced late last month.

Ask your senators and representatives to cosponsor the bills titled Graduate Medical Education Technical Amend-ments Act.

The bills target technical problems created by the Balanced Budget Act of 1997. For example, the bills would:

The bills made little progress last year partly because the Congressional Budget Office estimated unrealistically high costs for their implementation. The new bills would scale back one provision that deals with caps on residents in hospitals that have only one residency. Last year's bills called for single-residency hospitals to be completely exempt from caps; this year's revised bills would allow for growth of one position per year of residency, up to a total of three positions.

At press time, the GME Technical Amendments Act was expected to be reintroduced soon by Sens. Susan Collins, R-Maine, and Frank Murkowski, R-Alaska, and Reps. John Baldacci, D-Maine, and Tom Allen, D-Maine.

News from Headquarters


Buy a brick

Be a part of AAFP's new HQ

Your name will become part of the AAFP's new headquarters if you participate now in the Buy a Brick Campaign.

Through the campaign, a fundraiser for the AAFP Foundation, you can buy a 4"x 8" brick with your name engraved on it, which will become part of a circle walkway around the fountain at the new headquarters building's main entrance.

Larger 8"x 8" bricks also are available for purchase by medical practices, AAFP chapters and their foundations, and corporations. The larger bricks will become part of the walkway leading to the fountain.

Proceeds from the campaign will support all AAFP Foundation programs, including the Resident Repayment Program, student research externship program and research stimulation grants program.

Prices in 1999 are: $50 for an individual supporter's name to be engraved on a 4"x 8" brick; $150 for the name of a medical practice, AAFP chapter or chapter foundation to be engraved on an 8"x 8" brick; and $250 for a corporation's name and logo to be engraved on an 8"x 8" brick. Send in your order by March 31 to have your brick included in the first phase of walkway construction.

For more information and order forms, contact Dwayne Rider in the AAFP Foundation at (800) 274-2237, Ext. 4452, or at drider@aafp.org by e-mail.


Two Web sites might be helpful

The National Guideline Clearinghouse is a public resource with a Web site intended to make evidence-based clinical practice guidelines and related abstract, summary and comparison materials widely available to health care professionals.

This new site is a comprehensive database of materials produced by the Agency for Health Care Policy and Research (AHCPR) in partnership with the American Medical Association (AMA) and the American Association of Health Plans (AAHP), and is updated weekly.

The NGC guidelines are not fixed protocols, but are intended for health care professionals and providers to consider. For each guideline included, NGC completes a guideline summary sheet that is submitted to the guideline developer(s) for initial and annual review.

The National Guideline Clearinghouse site is at http://www.guidelines.gov on the World Wide Web.

Available for both PC and Macintosh computers, the software is available to those who submit the sign-up sheet at http://cancertrials.nci.nih.gov/NCI_CANCER_TRIALS/zones/Forms/NciSignUp_3.html on the World Wide Web.


AAFP establishes listservs for special interest groups

The Academy's Committee on Special Constituencies has established an electronic mail service for five special interest groups addressing the concerns of women, minority and new physicians; international medical graduates (IMGs); and gay, lesbian, bisexual and transgender (GLBT) individuals.

To join the electronic mail (listserv) list or lists of your choice, send this message -- subscribe(space)name of list(space)your name (example: subscribe Women Jane Smith) -- to listserv@list.aafp.org, and you will be included. Listserv names are Minority, Women, IMG, GLBT and Newfp.

If you have questions about subscribing to the listserv, contact Academy staff at msutton@aafp.org.


AARP fights fraud

The American Association of Retired Persons began a campaign last month to turn its members into Medicare fraud busters.

At press time, the Academy learned the AARP would gather seniors in movie theaters Feb. 24 for a teleconference alerting them to fraud, for example, in charges for nursing home and home health care. Public service announcements were scheduled saying, "Who pays? You pay."

Seniors are being asked to talk with physicians about overcharges and call an 800 number to report suspected fraud and abuse to the Office of Inspector General.

The Academy asks you to inform your billing staff about a possible upsurge in patients' questions so your staff may respond politely, promptly and thoroughly.


Members get more diabetes information

The Academy's 1999 Annual Clinical Focus started the new year by supplying members with free information about the "Management and Prevention of the Complications of Diabetes."

In January, the ACF sent each member the Video CME syllabus "Strategies for the Prevention and Treatment of Macrovascular Complications of Type 2 Diabetes."

ACF Annual
Clinical
Focus

These ACF items will be mailed to all members in March: another Video CME syllabus titled "Guidelines and Barriers in the Treatment of Type 2 Diabetes" and a core American Family Physician monograph on "Management of Diabetes" with patient education materials.

"Diabetes is a very prevalent, chronic disease in our society," said LeAnn Carl, ACF manager. "We want to help our members give the best possible care to their patients with diabetes."

The ACF program began in 1998 as an educational initiative designed to bring members state-of-the-art information on a specific subject area each year.

For more information, contact Carl at (800) 274-2237, Ext. 5239.


Researchers: Senior Scholar program seeks applicants

Are you looking for opportunities to participate in federal primary care research activities, observe health policy development at the U.S. Department of Health and Human Services and learn about federal support for family medicine/primary care research? If so, consider applying for the AAFP Senior Scholar in Residence at the Agency for Health Care Policy and Research.

The Academy and AHCPR are seeking applicants for the six-month full-time (or equivalent period on a part-time basis) position based at the AHCPR's Center for Primary Care Research in Rockville, Md.

The agency will pay half the scholar's salary during the assignment, but the scholar's home institution must maintain and pay for other benefits.

Candidates should possess an M.D. or D.O. degree, be board certified in family practice or have completed a family practice residency program and be a U.S. citizen. Research should be a part of the candidate's current career with the expectation that this research role will be enhanced upon return to the home institution. Training or experience in research (especially skills in the use of large data sets) is highly desirable. Experience in medical education and health policy is also desirable.

Applications received by May 3 will be given priority review by the AAFP Commission on Clinical Policies and Research in conjunction with AHCPR. Applications received after that date may be considered.

For more information or to obtain application information, contact Herbert Young, M.D., AAFP Scientific Activities Division director, or Carol Tierney, division coordinator, by e-mail at hyoung@aafp.org or by phone at (800) 274-2237, Ext. 5500.


Register online for spring meetings

The Academy's Annual Leadership Forum and the National Conference of Women, Minority and New Physicians will take place this spring in Kansas City, Mo.

These two meetings are geared to help AAFP leaders improve skills needed for leadership roles throughout the Academy.

ALF is set for April 30-May 1, while NCWMNP will take place April 29-May 1. For the third consecutive year, these two conferences are being held in conjunction with one another to offer attendees combined programming and networking opportunities. This year's theme is "Fostering AAFP Leadership: Strength-ening the Team."

Take note of two milestones in 1999: The NCWMNP will celebrate its 10th anniversary this year, and both meetings will offer on-line registration. To register online for either NCWMNP or ALF, visit http://www. aafp.org/meetings on the World Wide Web.

For more information, contact Donna Fletcher at (800) 274-2237, Ext. 3216, or at dfletche@aafp.org by e-mail.

Also on
the
WWW

If you're used to checking out the "What's New" page on the Academy's Web site, get ready for a lot more information. The page, at http://www.aafp.org/whatsnew.xml, now includes a more comprehensive collection of Web site additions and is updated daily.


New AAFP products and services

FP Report Special Section -- Hospitalists


Rural hospitalist gets nights, weekends free

FP Ross Ramey takes day shift in hospital for rural communities

Peterborough, NH

PETERBOROUGH, N.H. -- Can the idea of a hospitalist, an inpatient physician, work in a rural area? Yes, thought family physician Ross Ramey, M.D., of Jaffrey, N.H.

He already did utilization review at Monadnock Community Hospital in nearby Peterborough, N.H.; assisted at surgeries; and performed procedures for FPs and internists.

A few physicians wanted to drop their daytime rounds and admissions at the hospital, which draws patients from the towns and farms nestled among southwest New Hampshire's pine-covered hills and mountains.

So Ramey left his part-time office practice last June and does hospital-based work full time, wearing several hats.

Ramey checks the progress of Christine Vose after her third hip surgery.

"We agreed to do kind of a tradeoff," said family physician James Potter, M.D., of Jaffrey. "Ross already had a practice at the hospital, and he does hospital services during the day for me so I can open my practice earlier and add evening hours. My productivity has expanded. Besides, I always felt I was unfair to patients waiting to see me when I had to leave to admit someone during the day."

The equation has a plus for Ramey: His colleagues cover the off hours and OB care, so he has most nights and weekends free -- just what his wife and three children want.

"I needed a hospitalist after our kids hit their teen years, about three years ago," said his wife, family physician Lisa Ramey, M.D. "The kids were too old for a nanny but young enough so they shouldnÕt need to fix their own suppers and take care of each other."

Lacking a hospitalist, she turned over her OB cases and inpatient work to other physicians. "I always thought the kids would need us more when they were little, but they need us more now," she said.

Ross Ramey, M.D. (right), talks with the family of a patient who is dying in the ICU.

Eventually, Ross and Lisa Ramey and about 18 colleagues in Monadnock Health Services answered three questions:

Only four physicians and two nurse practitioners refer medical patients to Ramey as their hospitalist (his other colleagues still make admissions and rounds), and his pay as hospitalist comes from inpatient care and procedures. Through contracts with Monadnock Health Services, the hospital pays for two other hats Ramey wears: He is medical director of the emergency room and has transformed his utilization review work into a community-based continuum-of-care project that will encompass agencies, wellness activities, clinical guidelines, and inpatient and outpatient care.

Ramey and James Bennett, M.D., study the X-rays of a hospitalized patient and confer about treatment.

"I can shift from one role to another without disturbing the structure of an office practice," said Ramey. He's reduced the length of stay for his patients to 2.89 days, compared to other medical patients' four-day average. "I'm familiar with community services and have time to contact them right away to set up assistance after hospitalization," he said.

Ramey has worked in the area 12 years. "Everybody knows Ross. This is a rural area, and everybody knows everybody," said his wife. "He isn't a locum tenens from California."

His advice to hospitalist wannabes: "Some years of service in a practice can prepare you to be a hospitalist. There's a certain amount of seasoning that's helpful."



Hospitalists


Physicians nudge HMO to allow full-time or part-time hospitalists

Kaiser-Permanente of Northern California gave its generalist physicians a choice almost three years ago: Be a hospitalist or a clinic physician.

Family physician James Cotter, M.D., and 19 other FPs and internists ducked the choice.

They picked a third route: rotator.

Cotter
Cotter

"I'm too young not to do hospital work," said Cotter, 46, of Napa. "I don't want to give up my hospital skills. I like the intensity of hospital work. I like working with specialists. I like helping sick people get better."

But Cotter didn't want to dump his clinic practice. "I like the long-term relationships with the clinic patients and working with the same staff and doctors," he said. "At the hospital, the staff tend to come and go."

The rotators practice in a clinic for four weeks and then take a seven-day shift at Kaiser's hospital in Vallejo.

Types of inpatient care management FPs use*
Types of management Percentage
(average)

Primary care physicians
manage virtually all their
own inpatient care
(with consultations, referrals)

59.9

Primary care physicians
organize into groups
and take turns caring for inpatients

21.1

Hospitalists are in place;
using them is optional

14.6

Hospitalists are in place;
using them is mandatory

4.5
*Based on a June 1998 AAFP survey of 2,052 family physicians concerning the types of inpatient care management they use for adult medicine patients. Respondents could indicate more than one type of management. The four types are adapted from a model developed by internist Robert Wachter, M.D., of San Francisco.

In addition, seven hospitalists work day shifts full time, and three hospitalists cover night shifts. With the rotators, they manage inpatient medical care for some 110 patients at a time. And almost 100 generalists work in Kaiser's four clinics full time.

"This hybrid system, using rotators, is not in the Kaiser design for adult primary care," said Cotter. "Regional administrators favor a pure system, with physicians in the clinic full time so they're not distracted with hospital visits. However, the administration hasn't forced the issue. Our doctors prefer this system, so that's fine. Besides, we've not seen any problems with the efficiency of rotators vs. full-time hospitalists."

Cotter, a member of the AAFP Task Force on Hospitalists (see story below), is the physician in charge of Kaiser's Napa medical offices and assistant physician-in-chief at the Vallejo hospital, responsible for utilization and outside services.

In 1997, the first year for hospitalists for Kaiser-Permanente of Northern California, the length of stay for patients with hospitalists was 15 percent lower than for other medical patients. In 1998, length of stay was about 3.5 days, a bit longer than in 1997. It's likely the patients were sicker last year, said Cotter.

A patient survey indicated high satisfaction with hospitalists, but the survey did not ask whether the patients would have preferred care from their own physician instead of a hospitalist.

Cotter finds a day in the hospital easier than a day in the clinic.

"In the hospital, you run your own schedule. You can control how much time you spend with each patient and can come back," he said. "In the clinic, you have more patients, it's always busy, there's someone you have to work in, you work late, and you deal with the phone calls and everything else. But I wouldn't want to be a hospitalist full time. I like variety."


Task force finds variety of views about hospitalists

AAFP President-elect Bruce Bagley, M.D., chaired the 1998 Task Force on Hospitalists.

bagley
Bagley

"We found we couldn't be for the hospitalist idea or against it," said Bagley, of Albany, N.Y.

He said about 20 percent of AAFP members use hospitalists, about 55 percent are neutral on the hospitalist concept and about 25 percent believe going to the hospital is part of being a complete family physician. The latter group, said Bagley, wonders, "How could the AAFP consider letting anyone be a hospitalist?!"

In Bagley's practice, physicians take weekly turns doing hospital rounds in the morning and then -- usually over lunch -- update other physicians on the patients. "We've done this for 22 years," said Bagley. "I don't know why, all of a sudden, it needs a label."

Even though the percentage of family physicians with hospital admitting privileges sank from 91.1 percent in 1988 to 85.8 percent in 1998, only about 4 percent of physicians throughout those 11 years felt their privileges were unduly restricted.

"Most family physicians who dropped their privileges did so voluntarily, and they're not upset about it," said Bagley.

He acknowledged, however, "The potential is there for a managed care organization to say, ÔWe'll take care of your hospitalized patients.' People are afraid of involuntary exclusion from the hospital. We all should be concerned about that."

The AAFP Congress of Delegates approved several task force policy recommendations, including:

Many physicians who talked with task force members stressed the importance of communication between the hospitalist and the primary care physician. "The concern has always been lack of continuity," said Bagley.

So the task force developed "Guidelines for Interaction in 'Hospitalist' Models."

The guidelines are attached to a report to the Congress of Delegates, "Hospitalist Models for Inpatient Care."

The report and guidelines are available at http://www.aafp.org/x19805.xml or may be ordered free as item #R708 from the AAFP order department at (800) 944-0000. They are also available as document #8001 on the AAFP Express fax service (see page 2).

AAFP commissions are continuing to monitor the hospitalist trend.


New breed at Boston University: Family Physicians on inpatient service

Last year, Boston University Medical Center's new family medicine department opened an inpatient service staffed mainly by family physicians.

They are a new type of hospitalist for the center, and they're eager for the help of residents who'll begin staffing the service this summer.

"We've become the leaders of the inpatient teams for the most difficult patients."
-- Larry Culpepper, M.D.

"In a large academic health center, primary care is often devalued," said Larry Culpepper, M.D., department chair. "Our primary care-based hospitalist system allows us to demonstrate the strengths of family practice in addressing the inpatient needs of our patients."

Department faculty, community FPs and a few internists take turns as hospitalists on seven-day shifts, managing the care for 40-50 patients. With close community connections, they've cut the average length of stay by about 1.5 days, to 4.25 days.

"Other specialists often look to us for help with a particularly difficult case, one with serious psychosocial aspects," said Culpepper. "Also, we're often the arbiter and interpreter and final decision-maker when multiple specialists have differences concerning what's best for the patient. We've become the leaders of the inpatient teams for the most difficult patients."


If you get out of hospital care, what do you lose?

Cauthen
Cauthen

"A lot of doctors nationally are giving up hospital care," said family physician Don Cauthen, M.D., of Scott and White Clinic, the largest group practice in Texas. "We think that's a political mistake."

Cauthen, of Temple, Texas, is Scott and White Clinic's family practice chair, coordinating the work of 95 FPs in the central clinic in Temple and 18 regional clinics.

All the FPs do hospital work. Some take one-week stints as short-term hospitalists and some make traditional hospital rounds.

Cauthen listed what family physicians lose if they give up hospital care:

"If you get out of hospital care, you even lose the language a little," said Cauthen. "It seems foreign to you, and you tend to view in-hospital care in a magical way. But if you're in the midst of it, you know it's just medicine."


Inpatient physicians' association pushes voluntary (not mandatory) use of hospitalists

Nelson
Nelson

Two years ago, generalists worried they'd be forced to leave their patients at the hospital door, surrendering them to a hospitalist's care.

By now, the paranoia has pretty much subsided.

Why? Perhaps because the number of hospitalists hasn't surged. And perhaps because several groups insist hospitalist systems should not be mandated.

"The National Association of Inpatient Physicians supports voluntary implementation of hospitalist programs," said internist John Nelson, M.D., of Gainesville, Fla., a cofounder of the NAIP. "Patients and physicians should be able to choose hospitalist systems or not."

Nelson acknowledged doctors' misgivings about giving up hospital care to hospitalists. "I understand how that may be a concern for AAFP members, when, about 30 years ago, they were struggling to get hospital admitting privileges," he said.

He added, "Some may believe the NAIP is a union of hospitalists out to kick other doctors out of the hospital. That's wrong. We just want to rub elbows with people who do the same kind of work we do."

The NAIP, affiliated with the American College of Physicians-American Society of Internal Medicine, began taking dues-paying members last April and counts about 750 in its ranks, including family physicians.

Nelson estimated about 5 percent of the country's 3,000 or so hospitalists are family physicians. Ads in medical journals indicate demand for more hospitalists.

NAIP's position on voluntary use of hospitalist systems is similar to policies of the AMA and AAFP. (For AAFP's position, see story on task force, page 4.)

All of which hasn't stopped some HMOs from requiring the use of hospitalists. For example, Group Health Cooperative, based in Seattle, Wash., said in an AAFP survey last year that its only type of inpatient care management was the mandatory use of hospitalists.

Group Health was the only one of the 15 HMO survey respondents with mandatory use of hospitalists as its sole option for managing inpatient care. But almost half of the respondents had or were considering having at least one site where primary care physicians must use hospitalists.

Note: Information on the NAIP and its April 21 meeting in New Orleans is available at http://www.naiponline.org or (800) 843-3360.


Family Physician: 'I'm a pro with hospitalists'

Burke
Burke

Family physician Theresa Burke, M.D., of Gainesville, Fla., has used hospitalists for 10 years -- internist John Nelson, M.D., (see story) and his partners.

Burke has a full-time family practice but works only about 40 hours a week, in contrast to FPs' national average of 53.2 hours.

How does she do it? "John's a big help!" she said.

For most adult patients needing hospitalization, Burke contacts the hospitalist on call to admit the patient and manage the case. She gets discharge summaries and does follow-up.

There are exceptions. "Some of my patients have psychosocial problems and are attached to me," said Burke. "If they want me to handle their care, I do."

For example, a college student had suffered a gang rape several years earlier, was still in therapy and had a kidney or pelvic disease requiring hospitalization. "She still relayed fears about men, and the hospitalists were all men, so I handled her care," said Burke.

She also pays social calls on older patients who are nervous about being hospitalized. She doesn't bill for those calls. "I'm willing to put in the extra effort for my patients who need my support," she said.

She's not alone in that. In many hospitalist systems, primary care physicians pay social calls.

Burke opted for hospitalists in order to have more time at home with her husband and two children, now 11 and 16. "Ask children of an older doctor Ñ almost always a man Ñ if they saw their dad much," said Burke. "The children were raised by the mom; the dad wasn't around much. Doctors just gave up their families and their lives for their patients."

That's not her style. "I don't want to be the missing doctor-parent," she said. "I'm a pro with hospitalists."

Physicians With Heart


Next stop: Uzbekistan

September 25 - October 5, 1999

Physicians With Heart's annual mission to former Soviet republics heads for Uzbekistan this fall.

Want to come along?

You'd get to:

The Academy, the AAFP Foundation and Heart to Heart International (an humanitarian aid organization) sponsor the annual airlift.

"The hospitals and physicians have great need for such essentials as drugs, stethoscopes and crutches," said Daniel Ostergaard, M.D., co-chair of Physicians With Heart and AAFP vice president for education and scientific affairs. "The physicians in the delegation describe family practice as it exists in America, a new and intriguing concept to health professionals in most of the former Soviet republics."

The delegation, including family physicians and guests, will make the capital city of Tashkent its home base. The delegation will visit rural areas and other cities, such as those in the Ferghana Valley east of Tashkent.

Last year, Uzbekistan observed the Year of the Family, focusing on health issues for children, young adults and mothers. About 40 percent of the Ferghana Valley population is under age 15. Uzbek physicians combat problems including iron deficiency, anemia, goiters, worm infestation, tuberculosis and hepatitis.

1999 details. Family physicians and their guests heading for Uzbekistan will leave New York City Saturday, Sept. 25, and return Tuesday, Oct. 5. In addition to airfare to and from New York City, costs for transportation, housing and meals will be about $3,000.

If you're interested in international family medicine and want to join the delegation, call Kirsten Harrison of Physicians With Heart at (619) 687-0343.

1998 wrap-up. The 1998 airlift had two phases. First, the delegation brought more than 12 tons of medical supplies and pharmaceuticals to the Siberian region of Russia in October. Russian customs officials released the aid to health care facilities in December. Second, Physicians With Heart sent more than five tons of medical materials to Uzbekistan late last year.

Readers' Forum


C-section privileges

To the editor:

I'm writing in response to the article, "What's it take to get C-section privileges?!" (FP Report, February 1999)

As a fourth-year medical student pursuing a career in family medicine, I have heard, on numerous occasions, of graduates of accredited family practice residency programs finding it difficult to obtain hospital privileges for certain procedures. I've heard the difficulty is more common in the urban setting. I'm offended that a graduate of "ABC" residency program with 70 "widget" procedures (as primary) is somehow more experienced than a graduate of "XYZ" residency program with 70 "widget" procedures (as primary) regardless of specialty training. It is my opinion that the Sonora Community Hospital and the OB-Gyns mentioned in the article are not only violating the antitrust laws, but also discriminating against the outsiders (FPs).

I realize that OB-Gyns and other specialties feel threatened by the competition family physicians create, but that's what the capitalist system in the United States is based on. I believe expectant mothers should be able to choose between an OB-Gyn who not only will take care of their pregnancy and delivery, but may take care of the newborn as well. I'm sure there is no debate about one OB-Gyn versus another receiving privileges, as long as they have achieved adequate numbers and experience to support their request.

I have a feeling that as the population of specialists reaches saturation levels, more and more primary care physicians, especially family physicians, will have increasing difficulty obtaining privileges. Family physicians need to band together now and not take a back seat, to prevent this from happening in the future.

STEVEN M. KOERTH, MSIV
UT-Houston Medical School

News from Washington


AAFP encourages Janet Reno to sue tobacco companies

A month before President Bill Clinton said the federal government should sue tobacco companies to recoup Medicare costs, the Academy and other groups asked Attorney General Janet Reno to do just that.

"We urge you to file suit on behalf of the federal government to recover the Medicare costs associated with tobacco-related disease," said AAFP Board Chair Neil Brooks, M.D., of Rockville, Conn., and others in a letter to Reno.

"The costs to Medicare for providing health care for tobacco-related disease are staggering," said Brooks and nine other leaders in a public health coalition. "The tobacco industry should not be allowed to profit by transferring to the taxpayers the cost of medical care to treat diseases which its products cause."

Clinton suggested a federal lawsuit in his State of the Union address Jan. 19 and included about $20 million in the proposed fiscal year 2000 budget for the Justice Department to explore the lawsuit's feasibility. Brooks and leaders of other groups in the Effective National Action to Control Tobacco coalition wrote Reno Dec. 8.


April 5 is deadline for Y2K compliance on Medicare claims

The Health Care Financing Administration has set April 5, 1999, as the date Medicare carriers should begin returning claims not filed in accord with requirements for the year 2000.

Whether you file electronically or on a paper, you need to use the full eight-digit code for the date: two digits for the month, two for the day, and four for the year.

To find "Appendix E: HCFA Y2K Requirements," a new attachment to Family Physicians and the Year 2000, obtain Appendix E from the AAFP order department at (800) 944-0000 (ask for item #709) or from AAFP Express (request document #8003).


HCFA: Internet OK to transmit Medicare data

The Health Care Financing Administration recently reversed its prohibition on using the Internet to transmit Medicare information, including claims and other sensitive HCFA data.

Medicare contractors and others can transmit this information via the Internet as long as specific security methods are used. Methods are outlined on the agency's site at http://www.hcfa.gov/security/isecplcy.htm on the World Wide Web.

Otherwise, HCFA's Internet policy is essentially the same as a draft policy circulated last fall.

Other News

Your practice and advances in human genetics

We want your input on family practice and the impact of advances in human genetics for a special section in the June FP Report. Please complete these questions, then fax to (816) 822-8857 or e-mail to pbinder@aafp.org by April 1. Thank you!

  1. Regarding progress in human genetics, what benefits do you see for you and your patients, and what concerns do you have? (Use separate sheet if needed.)





  2. How prepared are you to discuss issues related to genetic testing, including ethical issues, with your patients? (Check one.)

    boxwell prepared
    boxsomewhat prepared
    boxill-prepared

  3. If you checked "somewhat prepared" or "ill-prepared" in question 2, what additional information would help you be better prepared? (Check all that apply.)

    boxMore information about advances in genetic testing
    boxMore information on ethical dilemmas of genetic testing
    boxMore skills training in helpful approaches to counseling in this area
    boxOther (Please specify; use separate sheet if needed.)

Name (optional):



FPR3/99


Study reflects skills in identifying, treating depression

An ongoing study reflects the skills and perceptions of family physicians, general internists and OB-Gyns in diagnosing and treating depression.

Managing patients with depression

Characteristic* FPs
General
internists		 OB-
Gyns
Feel responsible for treating depression 88% 73% 41%
Confident in diagnosis 95% 92% 80%
Confident in overall management 83% 64% 34%
Confident in treating depression
-- with counseling 36% 25% 19%
-- with medication 91% 75% 44%
Know diagnostic criteria well 84% 81% 56%
Assess for sexual or physical abuse 24% 25% 49%
Assess for suicide by direct questions 65% 52% 48%
*Self-assessments reported in January/February Archives of Family Medicine.

Family physicians shine in most elements of the report in the January/February Archives of Family Medicine (see table).

"Family physicians practice a high standard of medical care, compatible with experts' guidelines on depression," said family physician Allen Dietrich, M.D., of the community and family medicine department of Dartmouth Medical School in Hanover, N.H.

Dietrich, a co-author, said, "The study speaks well for our specialty. It's to the credit of the people who founded family practice that they stressed the centrality of behavioral and psychosocial issues. We're 10 years ahead of internists and OB-Gyns in this area."

Dietrich, however, noted that FPs, internists and OB-Gyns lack confidence in treating depression with counseling, suggesting the importance of mental health referrals or more training in counseling.

Dietrich also said all three groups of physicians need to improve in assessing depressed patients for sexual or physical abuse and asking them direct questions about suicide.

The report -- analyzing a survey of 621 FPs, 474 general internists and 255 OB-Gyns -- is "Primary Care Physicians' Approach to Depressive Disorders: Effects of Physician Specialty and Practice Structure."


AAFP now has nine delegates to the AMA

Thanks to members who have voted for the AAFP as "my voice, my choice" within the AMA, the Academy now has nine AMA delegates, three more than any other national medical society (see chart at right).

Society** Number
of delegates
Largest AMA
specialty society
delegations*		 AAFP
ACOG
ACP-ASIM
ACR
ASA		 9
6
5
5
5

* Other specialty society delegations have 3 members or fewer.

** Societies other than AAFP: American College of Obstetricians and Gynecologists, American College of Physicians-American Society of Internal Medicine, American College of Radiologists and American Society of Anesthesiologists.

The Academy won one new delegate through AMA's fall 1998 vote.

Since 1996, every 2,000 votes have gained a society another delegate. This fall, however, the ante goes up. For every 1,000 votes, the society will gain a delegate.

Confused?

To clarify: Societies within the AMA automatically have one delegate. The annual ballot process, begun in 1996, maximizes the clout of societies with high votes. Once members vote, they don't need to vote again. So the final tallies are cumulative.

By now, the Academy has won 16,217 votes, accounting for eight AAFP delegates besides the one each group in AMA has.

If AAFP's cumulative tally remained about the same this fall as in 1998, the Academy would have 17 delegates. In comparison with state medical societies, only six states would have more delegates than the AAFP.

The total number of AMA delegates fluctuates. At its December 1998 interim meeting, the AMA house had 478 delegates, including 68 AAFP members (representing either state medical societies or the AAFP).

FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.


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