Chair: Bob Harmon                                                      Staff: Mike Barry/Jessica Cafarella

0. CONTINUING POLICY ISSUES
1. Preventive Medicine Residency Funding

At PREVENTION 2000, the Board of Regents endorsed a Policy Committee recommendation to make preventive medicine residency funding a top policy priority for the College. The Board agreed to increase policy initiatives on residency funding, establish an ACPM presence at the Council on Graduate Medical Education (COGME) and other national meetings on graduate medical education, and create an ad hoc committee to address preventive medicine residency funding issues.

1. PMR Funding Task Force

ACPM established the Preventive Medicine Residency (PMR) Funding Task Force, which includes the Chairs and Vice Chairs of the ACPM Policy Committee and Education Committee, and representatives of the Graduate Medical Education Subcommittee, Young Physicians Section, Association of Preventive Medicine Residents, and the Joint Council of Preventive Medicine Residency Directors. Chaired by ACPM Fellow and residency program director Gary Goldbaum, the Task Force held the first of its monthly conference calls in July 2000, during which it agreed upon the following charge:

• Assess the current state of preventive medicine residency funding
• Identify strategies for strengthening existing funding sources and targeting new sources
• Determine an advocacy role for ACPM by identifying future events/actions

The Task Force has prepared its first report for consideration by the ACPM Board (see Tab M for a copy of the report). In the report, the Task Force outlines the need for specialists trained in preventive medicine, identifies challenges to current funding sources, and proposes steps for securing increased residency funding from both private and public sources.

Despite elimination of preventive medicine residency funding in the Administration’s Fiscal Year 2001 budget proposal, final legislation emerging from the Labor-HHS-Education (L-HHS-Ed) Appropriations Conference Committee provided for a 10 percent increase in Health Resources and Services Administration (HRSA) Titles VII and VIII funding for public health workforce programs in FY 2001. Funding for the Public Health/ Preventive Medicine/Dental line item increased from $8.1 million in FY 2000 to more than $8.9 million in FY 2001.

This represents an important triumph for the preventive medicine community and likely will translate into the first increase for preventive medicine training in nearly a decade. While the final bill has yet to be enacted, it appears the HRSA workforce numbers agreed to by the Conference Committee will remain unchanged. Despite the increase, funding for preventive medicine training continues to be on shaky ground and woefully inadequate. As such, it remains a top policy priority for the College.

ACPM was active in the fight to restore residency funding. The College drafted letters to House L-HHS-Ed Appropriations Subcommittee Chairman Porter (R-IL) and Senate L-HHS-Ed Appropriations Subcommittee Chairman Specter (R-PA), and organized a letter writing campaign that generated more than 30 letters from ACPM members (see Attachment A).

In the spring, ACPM members and staff visited congressional offices as part of "Health Professions Leadership Hill Day." The day was organized by the Health Professions and Nursing Education Coalition (HPNEC) and was designed to educate members of Congress and congressional staff on the importance of increasing funding for health professions training programs.

ACPM and the American College of Occupational and Environmental Medicine (ACOEM) also worked together to sponsor a congressional briefing on the shortage of preventive medicine and occupational medicine-trained physicians. ACPM President George Anderson joined ACOEM President Robert McCunney in moderating the session.

ACPM submitted a detailed letter to COGME in response to its draft report, "Financing Graduate Medical Education Programs in a Changing Health Care Environment" (see Attachment B for a copy of the letter). ACPM urged COGME to insert language in the report recognizing that preventive medicine residencies deserve GME funding, and supported COGME’s all-payer approach to GME financing reform (which calls for GME financing to be spread more broadly across all sectors of society). ACPM also supported COGME’s principle that federal funding should be flexible and allow funding allocation decisions to be made at the local level.

ACPM staff attended COGME meetings in April and September to stress the College’s commitment to improving the current system of financing graduate medical education. At the September meeting, staff provided oral comment highlighting the College’s written comments.

ACPM continues to stay active in the effort to implement strong national policies and legislation to curb tobacco use, including active participation in the ENACT (Effective National Action to Control Tobacco) Coalition — an alliance of over 50 national medical and grassroots organizations.

ACPM has joined ENACT in urging Congress to support continued funding for the Department of Justice’s (DOJ) lawsuit against the tobacco industry through Hill visits, phone calls, and letters to congressional offices (see Attachment C). ACPM also has participated in meetings with officials from the White House, the DOJ, and the Campaign for Tobacco Free Kids to discuss Congress' willingness to fund the suit.

Funding for the DOJ’s lawsuit has been hotly debated in Congress. Regardless, the suit has won some recent victories that have allowed it to move forward. In June 2000, the House voted to support the DOJ's ability to tap monies from other federal agencies for its litigation efforts. In September, a federal court ruled that the DOJ can pursue the claim that the tobacco industry violated anti-racketeering laws by conspiring for 45 years to mislead the American public about the dangers of smoking.

2. Master Settlement Agreement

ACPM reported on the status of each state’s decisions regarding spending tobacco settlement dollars in the spring issue of ACPM News. The College concluded that it was premature to establish a "hall of shame" for those states that did not dedicate any money to tobacco prevention, as the Policy Committee and Board had recommended, since states had only recently received their first installment of tobacco settlement dollars, and many had not yet decided how they would allocate these funds.

ACPM is considering ways to recognize at Preventive Medicine 2001 the five states that are meeting the Centers for Disease Control and Prevention’s recommended levels of funding for tobacco prevention programs (as noted in an October 2000 report by the American Heart Association, American Cancer Society, American Lung Association, and Campaign for Tobacco-Free Kids). These states are Indiana, Maine, Massachusetts, Minnesota, and Mississippi.

2. Coverage of Preventive Services

In September 1999, Senator Bob Graham (D-FL) introduced the Medicare Wellness Act of 1999 (S. 1618) to add several new preventive benefits to the Medicare program —including screening and/or counseling for hypertension, tobacco, glaucoma, hormone replacement, vision and hearing, osteoporosis, and cholesterol. (A complete copy of the Medicare Wellness Act can be found at http://thomas.loc.gov/cgi-bin/query/z?c106:S.1618:). At the time this report was written, legislation expected to be signed by the President incorporated several provisions of the Wellness Act, including glaucoma screening.

3. Appropriations

At the time this report was written, the President had yet to sign a final FY 2001 L-HHS-Ed appropriations bill. Funding for most health programs, however, was expected to remain the same as figures proposed by the congressional Conference Committee.

According to figures reported by the Coalition for Health Funding (the Conference Report was never filed), the L-HHS-Ed Conference Committee earmarked $456 million to health professions programs in its FY 2001 report, including $125 million for pediatric GME and $331 million for the Titles VII and VIII programs. This translates to a $29 million (9.6 percent) increase for Titles VII and VIII and is just shy of the $335 million recommended by ACPM. The Public Health/Preventive Medicine/Dental line item received an increase to $8.9 million (up from $8.1 million in FY 2000).

The Conference Committee also dedicated $20.5 billion in funding for the National Institutes of Health, an increase of $2.7 billion (15.2 percent), and $270 million for the Agency for Healthcare Research and Quality (AHRQ), a $71 million (35.8 percent) increase. ACPM has advocated for an additional $30 million in funding for AHRQ, as most of the AHRQ increase is earmarked for patient safety initiatives (see Attachment D for a copy of the letter to Congress). Under the Conference Committee figures, despite the budget increase, the portion of AHRQ’s budget devoted to investigator-initiated grants will drop from approximately 17 percent in FY 2000 to 7 percent in FY 2001.

ACPM drafted and signed on to letters to Congress pertaining to several prevention-related appropriations, including Title VII funding and funding for the DOJ tobacco lawsuit. The College also went on Hill visits and actively advocated as a member of the Coalition for Health Funding, CDC Coalition, Friends of HRSA, Friends of AHRQ, and HPNEC for appropriations that support preventive medicine activities.

4. Patient Safety

Patient safety issues were near the top of the public policy agenda in 2000 as the health care community continues to interpret and respond to the Institute of Medicine (IOM) report on medical errors, "To Err is Human: Building a Safer Health System." The report estimated that anywhere from 44,000 to 98,000 Americans die each year because of medical errors and recommended a four-tier approach to reducing medical errors.

ACPM has supported a set of general principles for patient safety reporting systems developed by a group of national organizations representing healthcare professionals and organizations. The principles encourage the reporting, evaluation, and sharing of information about medical errors. They also emphasize that, for error reporting systems to be effective, they must be non-punitive, provide appropriate confidentiality and legal protections, and facilitate learning about errors and their solutions.

Consistent with the position of College leaders and policy experts, ACPM drafted a letter of support to the sponsoring organizations that urged further refinement and delineation of the

Principles (see Attachment E for a copy of the letter and of the general principles). ACPM emphasized that refinements should stress public health approaches to the surveillance of medical errors and encourage medical error reporting that supports epidemiological analyses and the widespread implementation of prevention interventions.

ACPM staff remain active in the area of patient safety. In addition to making patient safety a key topic area at ACPM’s upcoming annual meeting, the College has supported the Association of State and Territorial Health Officials’ (ASTHO) efforts to develop a statement on patient safety. The College held meetings to discuss patient safety issues with both the Medical Group Management Association (MGMA) and with John Eisenberg, MD, Director of AHRQ. ACPM also nominated ACPM Fellow Jeffrey Davis, MD, to testify before the National Summit on Medical Errors and Patient Safety Research, and worked with Dr. Davis in drafting testimony, although Dr. Davis ultimately was not selected to give testimony.

In addition, ACPM staff attended a leadership forum on Medical Errors sponsored by the American Association for World Health, a presidential campaign forum, "Ensuring Quality Health Care in the Next Millennium," and meetings of the AMA’s Working Group on Patient Safety.

ACPM has been active in the debate surrounding medical privacy, in particular, espousing the position that any privacy legislation should strike a balance between patient privacy protections and access to individually-identifiable data for epidemiological studies and prevention research. ACPM adopted a position statement on this issue in 1998 and has weighed in on the HHS privacy regulations at meetings of national medical specialty societies and at the AMA House of Delegates.

At its meeting in March 2000, the ACPM Board adopted the Policy Committee recommendation to develop an action plan to ensure important data are available for epidemiological research. The plan could include: identifying strategic partners, convening a workshop on medical privacy leading to development of a white paper, and studying the relationship between medical privacy issues and patient safety/medical errors. Since the March meeting, ACPM has been working closely with Partnership for Prevention on this issue. Partnership is developing an action plan on this topic and, for the most part, Partnership’s position is consistent with ACPM’s. ACPM has provided input into Partnership’s action plan and will continue to do so as the plan evolves. Partnership’s membership – consisting of a wide variety of health organizations – puts them in the best position to mobilize consensus.

On the legislative/regulatory front, the Department of Health and Human Services (DHHS) published in August 2000 the final rule governing national standards for electronic transactions as part of the 1996 Health Insurance Portability and Accountability Act (HIPAA). As a result of this rule, DHHS is working on guidelines governing security and privacy, which should be available in the coming months. Health care organizations must comply with the regulations by the end of 2002. To view a copy of the final rule, visit http://aspe.hhs.gov/admnsimp/.

As part of its Environmental Health Education Program and partnership with the Mt. Sinai Center for Children’s Health and the Environment, ACPM has been actively engaged in public policy issues related to children’s environmental health. These activities include:

• Advocating passage of the Children’s Health Act of 2000, which the President signed in October. The bill includes an $18 million authorization to the National Institute of Child Health and Human Development to plan and develop -- in collaboration with the CDC, the Environmental Protection Agency, and other NIH Institutes -- a national longitudinal children’s cohort study. The purpose of the study is to assess environmental influences on children’s health, and to develop essential information that can be obtained in no other way on the environmental, biological and social determinants of potentially preventable childhood disease and disability.
• Working closely with the Pew Environmental Health Commission and Health Track to support federal appropriations for a national monitoring and tracking (surveillance) system for chronic and neurologic diseases and conditions. The Commission has recommended linking this tracking system to new and existing data on exposures to environmental contaminants such as PCBs, heavy metals, pesticides, and air and water-born toxicants to help elucidate possible relationships between environmental exposures and disease.
• Asking Congress to increase support for the CDC’s National Biomonitoring Program to facilitate the direct measurement of individual human exposure to 50 toxic substances known to cause cancer, birth defects, and other diseases.
• Strongly opposing the Regulatory Openness and Fairness Act (the Pombo bill), introduced and cosponsored by 230 House and Senate members, which would have created significant new procedural hurdles for the EPA and effectively undermined many of the protective provisions of the Food Quality Protection Act.

2. OTHER ACPM POLICY ACTIVITY

ACPM was an active participant in the Annual Meeting of the AMA House of Delegates (HOD) in June 2000. In addition to advocating for policies related to preventive medicine, ACPM sponsored three resolutions at the meeting. Two were adopted into policy. The first calls for the AMA to support a universal code of ethics for Internet health sites; and the second directs the AMA to study and report on how to ensure the proper disposal of syringes and needles that are used outside the health care setting. The House declared the third resolution—related to patient privacy and access to data—to be consistent with existing AMA policy. The resolution asked AMA to support legislative approaches to patient privacy that will not restrict access to medical data with personal identifiers for epidemiological research purposes. ACPM believes the House’s decision was in error and is planning to resubmit the resolution for the House’s consideration at its next meeting.

Also at the annual meeting in June, ACPM officially announced the candidacy of Ron Davis, MD, MPH, FACPM, for election to the AMA Board of Trustees in June 2001. Dr. Davis, nationally recognized as a leader on tobacco prevention issues, has been a member of the AMA House of Delegates for nearly 20 years, serving the College in that role since 1987. This is Dr. Davis' second run for the AMA Board, after a narrow defeat (2 votes) in 1999.

ACPM continued its role in staffing the Section Council on Preventive Medicine, which provides a caucus for the preventive medicine specialty organizations to have a voice in AMA policy making. At the end of the June meetings, the chairmanship of the section council was turned over to ACPM’s Delegate, Ron Davis. ACPM is currently preparing for the Interim 2000 AMA HOD meeting, December 3-6, in Orlando, Florida. Between the Annual and Interim meetings, ACPM convened a subcommittee of the Section Council to propose changes to the Council's bylaws, particularly with regard to the structure and voting rights of the council. ACPM anticipates a vote on the proposed changes at the full Section Council meetings in Orlando.

ACPM also is preparing to submit several resolutions for consideration at the 2000 Interim Meeting of the AMA HOD.

ACPM frequently is called upon to comment on legislation, statements, or draft reports on policy topics within the scope of preventive medicine. The College typically does so by compiling comments from members (often members of the Policy Committee) or by composing an official letter from the organization. The following represents a synopsis of items for which ACPM has issued comments during the past seven months:

• American Medical Association (AMA) Council on Scientific Affairs draft report "Screening and Early Detection of Prostate Cancer." (3/00)
• U.S. Preventive Service Task Force chapters on screening for depression, breast cancer chemoprophylaxis, developmental screening in children, vitamin supplementation to prevent coronary heart disease and cancer, unintended pregnancy. (03/00)
• AMA Council on Scientific Affairs draft reports "Use of Antimicrobials in Consumer Products" and "Combating Antibiotic Resistance Via Physician Action and Education." (04/00)
• "Diagnosis, Management, Treatment, and Reporting of Diarehheal Foodborne Illness: A Primer for Physicians," produced collaboratively by the AMA, the Centers for Disease Control and Prevention, the Food and Drug Administration, the Center for Food Safety and Nutrition, the United States Department of Agriculture, and the Food Safety and Inspection Service. (04/00)
• AMA General Principles for Patient Safety Reporting Systems. (07/00)
• Council on Graduate Medical Education draft report "Financing Graduate Medical Education Programs in a Changing Health Care Environment." (07/00)
• AMA Editorial Revision of Preventive Medicine Notes and Preventive Medicine codes. (08/00)
• Partnership for Prevention Privacy Statement. (08/00)
• Agency for Toxic Substances and Disease Registry Draft Environmental Public Health Research Agenda 2002-2010. (09/00) (see Attachment F).
• Commission on Unity Federation Survey. (09/00)
• New Jersey Health Wellness Promotion Law. (10/00) (see Attachment G).
• AMA Council on Scientific Affairs draft report "Medical Preparedness for Terrorism and Other Disasters." (10/00)
• AMA Council on Scientific Affairs draft report "Women’s Health: Sex and Gender-Based Differences in Health and Disease." (10/00)

ACPM periodically nominates members to serve on expert panels, committees, advisory groups, or to serve as liaisons to other organizations working on preventive medicine issues. The following is a list of positions and committees for which ACPM has nominated members during the last seven months:

• CDC Special Emphasis Panels (SEPs) within the Prevention Research Centers Program. (04/00)
• Department of Health and Human Services’ Advisory Commission on Childhood Vaccines. (06/00)
• Board of Directors of the National Patient Safety Foundation. (08/00)
• National Summit on Medical Errors and Patient Safety. (09/00)

The College often is asked to attend conventions or participate in one-day meetings or hearings on specific preventive medicine topics. The following is a list of conferences and meetings (outside of local coalition and other regular meetings of medical associations) at which ACPM staff or members have represented the College over the past seven months:

• The Council on Graduate Medical Education business meetings. (04/00, 09/00)
• Health Professions Hill Leadership Day, sponsored by the Health Professions and Nursing and Education Coalition. (04/00)
• Leadership forum on medical errors sponsored by the American Association for World Health. (03/00)
• Health Resources and Services Administration’s Maternal and Child Health Bureau invitational meeting on women’s health. (05/00)
• Summit on Promoting Healthy Eating and Active Living: Developing a Framework for Progress. (05/00)
• Ensuring Quality Health Care in the Next Millennium: A Presidential Campaign Forum. (06/00)
• AMA Commission for the Prevention of Youth Violence Town Hall Meeting. (05/00)
• Annual Meeting of the National Council on Folic Acid. (06/00)
• AMA briefing on infectious diseases’ emerging and re-emerging threats. (06/00)
• Open forum before the National Academy of Sciences’ Panel on Musculoskeletal Disorders and the Workplace. (06/00)
• CDC expert meeting on revision of the STD Treatment Guidelines. (09/00)
• Executive Forum ("Can We Achieve Population Health?") sponsored by ACPM and the US Medicine Institute for Health Studies. (09/00)
• Council on Linkages Between Academia and Public Health Practice. (10/00)

ACPM is asked regularly to sign-on to letters and statements or co-sponsor events initiated by other organization and medical associations that address preventive medicine topics. The following represent some of the many ACPM has endorsed over the past seven months:

• Coalition to Fight Sexually Transmitted Diseases funding request for the CDC’s STD Prevention and Control Program. (03/00)
• AMA Letter on the Physician Supervision Requirement for Certified Registered Nurse Anesthetists. (03/00)
• AMA Letter on the Medicare Payment Advisory Commission’s (MedPAC) Graduate Medical Education Proposal. (04/00)
• Food and Nutrition Labeling Group comments on the FDA’s "Strategy for Implementation of the Pearson Court Decision." (04/00)
• Department of Health and Human Services updated Smoking Cessation Clinical Practice Guideline. (03/00)
• Physicians for Social Responsibility’s opposition to legislation affecting the Food Quality Protection Act. (05/00)
• Health Professions and Nursing Education Coalition letters requesting increased Title VII funding for training of health professionals. (05/00, 07/00, 08/00, 09/00)
• Coalition for the Prevention of Alcohol Problems letter on the dangers of health-enhancing liquor drinks. (06/00)
• AMA letter on the Medical Financial Privacy Protection Act. (06/00)
• National Association of Children’s Hospitals Fiscal Year 2001 Appropriations Request for Emergency Medical Services for Children. (07/00)
• Friends of AHRQ letter requesting increased funding for the Agency. (07/00)
• National Alliance for Nutrition and Activity letters requesting increased funding for nutrition and physical activity promotion. (07/00, 08/00)
• General Principles for Patient Safety Reporting Systems. (07/00)
• American Federation for Medical Research letter urging support of the Clinical Research Enhancement Act. (08/00)
• American College of Occupational and Environmental Medicine comments on the World Health Organization’s Framework Convention on Tobacco Control. (08/00)
• AMA letter addressing the Public Health Threats and Emergencies Act. (09/00)
• Briefing on the U.S. 2000 Health Report Card. (09/00)
• First Monday 2000: Unite to End Gun Violence. (10/00)

By participating in several coalitions, ACPM is able to more closely monitor policy activities of federal agencies and national organizations in areas of interest to preventive medicine and more easily form strategic alliances with these organizations. The Coalitions in which ACPM participates or supports include: Effective National Action to Control Tobacco (ENACT), Partnership for Prevention, Friends of HRSA, CDC Coalition, Health Professions and Nursing Education Coalition, the Coalition for Health Funding, AAMC Ad Hoc Group for Medical Research Funding, National Environmental Health Coalition, Friends of NIOSH, Friends of AHRQ, the Children’s Environmental Health Network, the National Council on Folic Acid, and the National Alliance for Nutrition and Activity.

Through Coalition meetings, sign on letters and coordinated Capitol Hill visits, ACPM remains a visible member of the public health community as it helps to fight for public health and prevention dollars. In addition, ACPM staff participate in a variety of listservs and electronic discussion groups to stay abreast and contribute to the national debate around a variety of policy issues.