May 1999
News for members of the American Academy of Family Physicians
Rep. Greg Ganske, M.D. (center), and his wife, family physician Corrine Ganske, M.D., talk with AAFP Board Chair Neil Brooks, M.D., before reporters arrive at the press conference on AAFP's support for Ganske's bill.Patient rights bill gains AAFP support
It was a "first," and it featured the unlikely pairing of a plastic surgeon and a family physician.
But there they were: Rep. Greg Ganske, M.D., R-Iowa, a plastic and reconstructive surgeon, and AAFP Board Chair Neil Brooks, M.D., of Rockville, Conn., on Capitol Hill March 24, announcing AAFP support for Ganske's Managed Care Reform Act of 1999.
"I think the relationship between a doctor and a patient is very, very important," Ganske told a room full of reporters. "And what we're talking about is open communications -- the ability to maintain trust between a physician and a patient. Aspects of my bill deal with that."
Ganske sounded pleased, and he probably was. The bill he'd crafted, H.R. 719, was going to be introduced in the House just a few hours later, and it suddenly had the weight of 88,000-plus Academy members behind it. The Academy was pleased, too: The Ganske bill was the first patient rights legislation it had ever supported.
Reasons? As Brooks told reporters, Ganske's legislation "achieves a good balance of protection for the patient and freedom for doctors to practice good medicine. The bill has all the points important to improving health care quality for American families, which, taken together, provide the basics of good, comprehensive reform."
More specifically, Brooks said, the bill includes such elements as a prohibition of gag clauses, compromise on HMO liability, and formation of internal and external review processes.
Ganske's bill also includes a physician-centered definition of "medical necessity." As an example of the need for such a definition, Brooks told reporters about a patient suffering from a herniated disk. The health plan called for a month of bedrest and analgesics, but the problem and the patient's pain were severe. It took Brooks two weeks to convince the health plan to allow surgery.
The reporters were listening and scribbling. Their stories appeared in publications such as Physician's Weekly, National Journal's Congress Daily, Des Moines Register, Hartford Courant and the Bureau of National Affairs' Health Care Policy Report.
By Todd Simchuk, associate editor
FP perspective focuses guidelines on improving patient outcomes
Research shows that lowering glucose concentration to as close to normal as possible reduces the risk of complications in patients with diabetes. Does that mean you should aggressively strive to lower the glucose levels of all your diabetic patients?
"FPs get bombarded with half a zillion guidelines, and most of them come from people with questionable perspectives, if not questionable motives."
-- William Phillips, M.D.
A new clinical practice guideline in development by the AAFP and the American Diabetes Association will provide an up-to-date review of evidence and recommendations on the balance between harms and benefits of tight glycemic control in patients with type 2 diabetes mellitus. The draft guideline concludes that all patients benefit to some degree from glycemic control depending on their individual risk profiles.
William Phillips, M.D., a practicing family physician in Seattle and a member of the AAFP's Commission on Clinical Policies and Research, said the guideline will offer practical advice.
"There have been other guidelines and many studies over the years that tried to dictate the care of our patients, and many of them went far beyond the available evidence to make recommendations that were nearly impossible to implement in real-world practice," Phillips said. "This guideline will maintain a reasonable perspective while bringing us up to date on the best evidence."
Resources
- Be among the first to receive the new diabetes guideline, The Benefits and Risks of Controlling Blood Glucose Levels in Patients with Type 2 Diabetes Mellitus, by calling the AAFP at (800) 944-0000. The guideline (item #R928) is free with a $3 shipping and handling charge and should be released this summer.
- The AAFP Clinical Policy Review Form can help you evaluate clinical guidelines to determine whether a guideline is evidence-based and relevant to your practice. Get it at the AAFP Web site at http://www.aafp.org/clinical/polreview or order it from AAFP Express.
- If you're looking for a particular guideline, want to compare recommendations from various guidelines or need advice on a specific disease, check out http://www.guideline.gov for a guideline clearinghouse maintained by the Agency for Health Care Policy and Research.
The guideline reflects a trend of collaboration between the Academy and other organizations committed to distributing evidence-based clinical guidelines.
"The approach that the Academy has championed for a decade has become the norm, so now we can participate with others on developing guidelines, which is a refreshing change," said Herbert Young, M.D., AAFP Scientific Activities Division director.
Young noted that the Academy also has taken the lead in suggesting topics and helping to shape evidence reports with the Agency for Health Care Policy and Research. Those evidence reports will serve as springboards for future clinical guidelines. Family physicians representing the Academy have been involved in developing evidence reports on topics such as new onset of atrial fibrillation in the elderly, acne, attention deficit/hyperactivity disorder, cancer pain, pre-term labor, depression and acute bacterial rhinosinusitis.
Phillips said the AAFP's involvement lends credibility to a guideline. "FPs get bombarded with half a zillion guidelines, and most of them come from people with questionable perspectives, if not questionable motives," he said. "It's good to know that a guideline has been influenced by the Academy -- it speaks to its relevance."
Family physicians working on guidelines want to improve patient care through an evidence-based approach to treatment and prevention, said Phillips. Although guidelines can be an important tool in achieving that goal, they aren't always developed by other organizations with such a purpose in mind.
"The involvement of family physicians in the guidelines process helps maintain perspective on patient needs and relevant outcomes," said Phillips. "Instead of allowing subspecialists to dictate what they think we should do, which is mostly refer patients to them, an appropriate guideline can help family doctors use the best current medical evidence to improve the care of patients with the conditions we treat. We've got so much data -- and so little of it addresses the bottom-line concerns of our patients -- that you need an expert at the table to ask the right questions and insist on the appropriate answers. It turns out that expert is often the family doctor."
By Sharon Dickinson Dent, associate editor
News from Headquarters
AAFP supports renewed interest in National Primary Care Week
A new initiative by the American Medical Student Association hopes to revitalize National Primary Care Week and increase student interest in primary care professions.
U.S. Surgeon General David Satcher, M.D., Ph.D., has announced that AMSA and the Health Resources and Services Administration are revitalizing the observance, which will take place this year from Sept. 27 to Oct. 2.
The effort will focus on increasing the number of primary care doctors, as well as encouraging them to practice in America's underserved communities, improve health care by using an interdisciplinary approach, and build partnerships between communities and health professional students.
Travis Harker, a medical student on hiatus to work as AMSA's legislative affairs director for a year, will direct National Primary Care Week. Harker, who is between his second and third year at the Ohio State University College of Medicine and Public Health in Columbus, plans to pursue a career in family practice.
What does he hope to accomplish with National Primary Care Week? "I'd like to see a better understanding of primary care and for people to realize its value," he said. "It's not simply the delivery of services to patients who walk through your office door, but it involves community outreach, public health and health policy."
The Academy served on the National Primary Care Day Steering Committee for several years until the program was discontinued in December 1997.
"Primary care is still counterculture in America," said Norman Kahn, M.D., AAFP vice president for education and science. "There are more subspecialty physicians, practicing outstanding medicine, than at any time in history. But there are more health professions shortage areas, more underserved communities and more families without a physician, in both rural and urban areas."
Within the next month, AMSA will have a National Primary Care Week planner's kit with information to help students coordinate the effort at their schools. It will include tips on fund-raising, dealing with the media and promoting primary care. To order the kit, contact Harker by e-mail at lad@www.amsa.org or by phone at (703) 620-6600, Ext. 211.
Applications available for patient education conference awards, scholarships
The 21st annual Conference on Patient Education will be Nov. 11-14 in Austin, Texas, and organizers are accepting applications for the following:
- The Excellence in Education Awards -- presented by Patient Care magazine, AAFP and the Society of Teachers of Family Medicine -- recognize patient education efforts in the categories of physician or practice group, family practice residency program and health professional.
Applicants are also sought for the H. Winter Griffith Award for Excellence in Patient Education Materials. The application deadline is June 18. For more information, contact Ray Rosetta at STFM by e-mail at program@stfm.org or by phone at (800) 274-2237, Ext. 4512.
- The Resident Scholarships and Grants Program provides funds for family practice residents to attend the meeting. The application deadline is July 15. For more information, visit http://www.aafp.org/pec/ or contact Pamela Rodriguez at AAFP by e-mail at prodrig@aafp.org or by phone at (800) 274-2237, Ext. 5534. You can also get an application from AAFP Express, the Academy's document-by-fax system.
Legislation
Chapters seek help addressing midlevel providers' scope-of-practice legislation
Midlevel health professionals are expanding their practices through state legislation, and an AAFP commission asked constituent chapters in March what help they need to address the proposed laws.
For example ...
Here are examples of chapter responses to the AAFP survey on midlevel providers' scope-of-practice legislation.
Kansas. Information comparing the training of midlevel providers to the training of family physicians could be helpful.
New York. A summary of scope of practice statutes for nurses, NPs and PAs, nurse midwives, et al. would be helpful.
Colorado. Are there examples where working collaboratively with nurse practitioners (on legislation) has worked?
Nebraska. The nurse practitioners in our state very aggressively sought independent practice. One lobbyist said it was a lost battle. We were able to stop their bill with testimony of female family physicians, and we stressed collaborative arrangements.
Pennsylvania. Trying to completely hold back this tide will be impossible. The Academy should work on strategies to educate the membership how to stay successful and viable as small businesses in the face of growing privileges for nonphysicians.
Texas. Any state that says they don't have a scope of practice problem is incredibly lucky or incredibly politically naive.
"The chapters want more information, and we're already starting to supply that," said Mary Jo Welker, M.D., of Columbus, Ohio, chair of the AAFP Commis-sion on Legislation and Governmental Affairs.
The number of scope-of-practice bills for midlevel providers has increased dramatically in the last five years, said Welker.
"Family physicians have always said you should receive privileges based on training and experience," said Welker. "Lots of providers are saying, 'We can diagnose. We can treat. We can prescribe.' We need to look at their training and experience. For example, pharmacists want to prescribe, but they haven't done the patient's history or physical and have no clinical relationship with the patient. Nurse practitioners want to prescribe independently, but what's their background in pharmacology? Will the services of midlevel providers be cost-effective? Will we pay a price in patient outcomes?"
In the survey, 25 chapters said they actively opposed most state legislative proposals to expand midlevel providers' scope of practice. Only four chapters said they didn't oppose most of those bills.
The AAFP plans to seek data on allied health professionals' training, experience, and projected growth and distribution and will share that information with chapters.
Call to action
Ask lawmakers to co-sponsor GME bills
The Academy is asking you for a favor: Encourage your lawmakers to co-sponsor bills that would repair funding problems for family practice residencies.
Congress created the problems inadvertently in 1997 when it set caps on residency slots to reduce the number of physicians.
The Graduate Medical Education Technical Amendments of 1999, S. 541 and H.R. 1222, would correct the problems. For example, the amendments would expand caps on numbers of residents from those trained in hospitals in 1996 to include all of those trained in community settings, most of whom were family practice residents.
The Academy and the Organizations of Academic Family Medicine (including the Society of Teachers of Family Medicine) helped frame language for the bills.
The bills were introduced by Sens. Susan Collins, R-Maine, and Frank Murkowski, R-Alaska, and Rep. John Baldacci, D-Maine. At press time, co-sponsors included Sens. Pat Roberts, R-Kan., Charles Grassley, R-Iowa, and Thad Cochran, R-Miss., and Reps. Gerald Kleczka, D-Wis., Bernard Sanders, Independent-Vt., and Martin Frost, D-Texas.
For sample letters to members of Congress, access http://www.aafp.org/family/ and http://www.stfm.org online. Please personalize your letters and send copies to Susan Hildebrandt at AAFP, 2021 Massachusetts Ave. N.W., Washington, D.C. 20036.
Other News
Protect yourself as Y2K nears
If your desktop computer fails to work after Jan. 1, 2000, it's a hassle you should have dealt with earlier, but it's one you can overcome.
But if a patient, hooked up to failing computer-driven monitoring equipment, suffers needlessly after Jan. 1, 2000, that's a bigger problem. And it's one you should pinpoint in your Y2K preparation efforts now.
Todd Dicus, J.D., AAFP general counsel, said physicians should start creating a "paper trail" for Y2K compliance of equipment in their offices -- and should push hospitals to do the same.
"You're trying to show you're not somehow negligent," Dicus said. "Contact your vendors, and try to establish the value of the information you get back."
If you don't hear back, Dicus said, or if you get a letter that says something like "good question, we don't know," watch out. Information posted on the Y2K monograph portion of the Academy's Web site suggests some companies may not even have Y2K compliance plans in place, or may have decided to quietly go out of business.
Look for sample Y2K compliance letters to vendors on AAFP Express and on the AAFP Web site (other information from the Academy's Y2K monograph is available online as well). On the other hand, you might receive a "canned" response that does not offer specifics. If you receive a letter like this from a vendor, keep pressing for clarity, and keep an eye on the vendor's Web site for up-to-the-minute information, if available.
Try to cover yourself, Dicus said, because in the event of tragedy following a Y2K "glitch," it's likely everyone involved will be named in subsequent lawsuits.
Physicians fight hospitalist mandate
The AAFP, Florida AFP, Texas AFP and other medical groups are fighting the mandatory use of hospitalists.
It's doctors vs. Prudential and CIGNA regional offices, and the health plans just blinked.
"After I complained, Prudential said I could opt out of using hospitalists if I met the utilization standards, and I did," said Richard Hays, M.D., of Lake Worth, Fla., president of the Florida AFP.
Hays had fewer than 1,200 bed days per thousand elderly patients per year, so he -- and others who submit their requests and meet Prudential's criteria -- can still admit patients.
HMOs and PPOs "shall not require the mandatory use of a hospitalist."
-- H.B. 3111 in Texas legislature
However, Hays fears doctors aren't looking at the long-term consequences of forsaking hospital privileges. And he expects other health plans soon to insist on using hospitalists.
"This is going to be like a wildfire," said Hays. "Once it starts, it'll spread out of control."
Prudential HealthCare of South Florida had written its physicians Feb. 12 that hospitalists would begin admitting all adult medical, surgical and non-OB patients this spring.
The AAFP immediately objected, as did the American College of Physicians-American Society of Internal Medicine.
"We must vehemently protest the decision ... to artifically limit the scope of our specialty by denying family physicians in south Florida the opportunity to deliver hospital care," wrote AAFP President Lanny Copeland, M.D., of Albany, Ga., in a Feb. 19 letter to Prudential.
He sent a similar message March 10 to CIGNA HealthCare of Texas, which said it would require physicians to use hospitalists beginning April 1.
"The program CIGNA proposes creates a serious threat to family practice residency training programs," wrote Copeland. Future FPs must have generalist role models for inpatient training, or the residencies cannot meet accreditation requirements.
Jim White, Texas AFP executive director, said research by the national CIGNA office favors voluntary use of hospitalists. "This mandate may be a 'toe in the water' deal," said White.
By late March, CIGNA HealthCare of Texas said it would narrow its mandate, applying it only to emergency room admissions and physician outliers with excessive inpatient utilization.
A legislator working with the Texas AFP and Texas Medical Association recently proposed legislation saying HMOs and PPOs should not require the use of hospitalists. The bill, the first of its kind for any state, is in line with the notion that hospitalist systems should be voluntary for physicians and patients -- the policy of the AAFP, ACP-ASIM, American Medical Association and National Association of Inpatient Physi-cians.
Tom Banning, legislative affairs director for the Texas AFP, said a Humana health plan tried to impose mandatory use of hospitalists in Austin last year and softened its stance after physician groups complained.
"The mandate is a disease," said Banning. "We're trying to short-circuit it through the legislature and come up with a cure."
Assembly to feature fun-filled evening events
After a long day of CME at this year's Scientific Assembly in Orlando, Fla., you'll be able to relax and cut loose at two special evening events.
Kids will enjoy Seuss Landing at the Assembly's All-Member Event at Universal Studios.
- For the All-Member Event, the Academy has reserved Universal Studios' newest theme park -- Islands of Adventure -- for you and your guests from 7 p.m. to midnight on Thursday, Sept. 16. Your imagination can run wild at the five islands within the park: Seuss Landing, Jurassic Park, Toon Lagoon, Marvel Super Hero Island and the Lost Continent. Meet the characters, enjoy the rides and marvel at the special effects -- surprises await you around every corner (without waiting in line!).
- The Presidents' Reception, a complimentary after-dinner event, honors AAFP's current and incoming presidents -- Lanny Copeland, M.D., of Albany, Ga., and Bruce Bagley, M.D., of Albany, N.Y. -- and will get your toes tapping to an eclectic mix of music. Head to the Omni Rosen Hotel from 8:30 p.m. to midnight Friday, Sept. 17, and be sure to visit all three venues: a Palm Beach Garden Party setting, where Academy officers will greet visitors and the Eric Doney Trio will play classical jazz; Club Flamingo, where you'll dance to the rockin' tunes of Johnny Cool and the Mobster Swing Band and the party classics of the Pink Flamingos; and poolside, where Coco Loco will entertain with a Caribbean beat.
As an AAFP member and Assembly registrant, you'll receive two complimentary tickets to the All-Member Event. Your Assembly name badge serves as the ticket for admission to the Presidents' Reception.
The Scientific Assembly will take place Sept. 15-19. More information is included in Assembly registration materials, which will be mailed to AAFP active members this month.
Official call is issued for Congress of Delegates
Pursuant to Chapter IX of the AAFP Bylaws, notice is hereby given of the 52nd annual meeting of the Congress of Delegates.
The Congress, to be held at the Omni Rosen Hotel in Orlando, Fla., will open at 7:30 a.m. Sept. 14 and conclude about noon Sept. 16. AAFP members are encouraged to participate in the Sept. 14-15 reference committee hearings, where issues are debated before being considered by the full Congress.
Proposed amendments to the AAFP Bylaws must be submitted by June 6 to be considered by the 1999 Congress of Delegates. Proposed amendments should be signed by five or more AAFP active members.
Proposed resolutions for the Congress to consider should be submitted by Aug. 15 by constituent chapters.
Both resolutions and proposed amendments should be sent to Executive Vice President Robert Graham, M.D., at the American Academy of Family Physicians, 8880 Ward Parkway, Kansas City, MO 64114-2797 or faxed to him at (816) 333-2237.
The 51st Annual Scientific Assembly will be held Sept. 15-19 at the Orange County Convention Center in Orlando.
Robert Graham, M.D., AAFP Executive Vice President
and Secretary to the Congresss of Delegates
Hantavirus satellite conference
The Centers for Disease Control and Prevention is holding a satellite conference from 1 to 3 p.m. EDT May 27 on clinical and public health information on the hantavirus pulmonary syndrome.
To register, call (888) 232-3299 and enter document #130022, call (404) 639-1510 or access the online address http://www.cdc.gov/ncidod/diseases/hanta/hps/index.htm.
FP Report is published by the AAFP News Department. Copyright © 1999 by American Academy of Family Physicians.
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