Chair: Bob Harmon                                                                     Staff:  Michael Barry

ACPM continues to monitor the implementation of the Balanced Budget Act with respect to Medicare graduate medical education (GME) funding for preventive medicine residencies and appropriations funding issues related to preventive medicine.

1. Graduate Medical Education

ACPM continues to monitor the Congressional recommendation to fund non-hospital based residencies, which was included in the Balanced Budget Act of 1997. On March 16, 1999, the Bipartisan Commission on the Future of Medicare held its final meeting at which it considered whether to adopt its final report to Congress and the Administration, entitled "Building a Better Medicare for Today and Tomorrow." The report made recommendations regarding the future and solvency of Medicare. In this report, following opposition from 62 medical and health professions organizations including ACPM, the Commission appeared to soften its original stance to move direct GME payments from Medicare to the appropriations process. Rather, it recommended that Congress provide a separate mechanism for continued funding of these functions through either a mandatory entitlement or multi-year discretionary appropriation program. (See Attachment A for relevant section from the commission’s report.)

The report was never submitted to Congress, however, as the Commission deadlocked on several key issues—such as prescription drug benefits—and could not reach agreement on final recommendations. Both the House and Senate have shelved any further action on Medicare reform in this legislative session. ACPM staff will continue to monitor reform proposals and oppose any proposals that would subject GME payments to the competitive appropriations process.

In August 1999, the Medicare Payment Advisory Commission (MedPAC) released its "Report to Congress: Rethinking Medicare’s Payment Policies for Graduate Medical Education and Teaching Hospitals." (See Attachment B for a copy of the report executive summary.) In this report, the Commission recommended that Medicare’s two payments to teaching hospitals that are currently labeled as medical education be combined into one payment that better accounts for the higher costs of the enhanced patient care those hospitals provide to Medicare beneficiaries. This recommendation reflects the Commission’s belief that payments to teaching hospitals should be viewed as payments for patient care, not as payments for training. The commission recommends a phase-in approach for implementing the adjusted payment methods. MedPAC is expected to analyze the potential effects and policy issues of this recommendation for its March 2000 report to Congress. ACPM will continue to track and report on MedPAC recommendations that may have implications for preventive medicine residency training.

2. HRSA Title VII/VIII Programs

As of the time of this report, Congress had yet to pass the Labor-HHS Appropriations bill, as the Federal Government continued to operate under a continuing resolution. While it was not clear what the final appropriations would be, ACPM and other medical and health professions organizations appeared to have achieved their goal of overturning President Clinton’s original FY 2000 budget proposal to zero out funding for the public health and preventive medicine residency programs, as well as primary care residency programs within the Titles VII and VIII Health Professions Training Programs administered by the Health Resources and Services Administration (HRSA). As of this writing, it appears that funding will be restored to FY 1999 levels. ACPM played a visible role educating Hill staff about the shortages in certain health professions fields, including preventive medicine and public health, and providing information about the uneven distribution of primary care providers in certain parts of the country. ACPM advocated for a total of $50 million for the preventive medicine/public health training line, which is the figure some at HRSA estimate is needed by these programs (last year’s outlay was $8.294 million). In April, ACPM developed and sent to the Board of Regents an action alert and draft form letter to use to let members of Congress and/or the Chairman of the Labor/HHS Appropriations Subcommittee know about the importance of appropriating adequate dollars to preventive medicine residency training programs. (See Attachment C for copies of the action alert, form letter, and joint ACPM/ATPM statement for the FY 2000 appropriations process.)

3. Other GME Advocacy Efforts

In April 1999, ACPM staff met with Earl Fox, Administrator of the Health Resources and Services Administration (HRSA), Vince Rogers, the new Director of the Bureau of Health Professions, and other HRSA staff, to discuss the possibility of a HCFA/HRSA demonstration project to fund preventive medicine residents through Medicare or Medicaid Graduate Medical Education dollars, and other ACPM related projects. During the meeting, Dr. Fox indicated a strong interest in HRSA helping to support a comprehensive study of the preventive medicine workforce, provided ACPM could find a joint funding partner. An initial request to the Robert Wood Johnson Foundation to be a co-funder was unsuccessful. HRSA did, however, establish a cooperative agreement mechanism with ACPM, which can be used to fund future activities.

Also in April, ACPM members Dorry Lane and Hugh Tilson, along with Kristine Gebbie from the Columbia University School of Nursing, testified about the importance and future of the preventive medicine workforce. Together, they made a compelling case for national policies to increase the supply of preventive medicine physicians. In fact, based on the recommendations, COGME is considering issuing a separate report on preventive medicine.

ACPM continues to stay active in the effort to enact 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.

1. Tobacco Settlement

One of the key issues for ENACT in the Spring was the push for the federal government to require that states earmark 25% of their tobacco settlement dollars to tobacco control programs in exchange for the federal government waiving its claim on these funds. Unfortunately, these advocacy efforts were unsuccessful, as an amendment to this year’s emergency supplemental appropriations legislation waived the federal government’s right to these funds without any requirement that a single dollar of these funds be spent on tobacco prevention or cessation programs. However, ENACT continues to urge the Administration and Congress to require states to spend a substantial portion of their tobacco settlement funds on programs to reduce tobacco use.

On a more positive note, the Department of Justice filed a civil lawsuit against the largest cigarette companies to recover the billions of dollars the federal government spends each year through Medicare and other federal health programs on smoking-related health costs, a step for which ENACT strongly advocated. ACPM and the other ENACT organizations were successful in getting legislation passed that defeated the tobacco industry’s attempts to prohibit the federal government from pursuing litigation with the major U.S. tobacco companies. In addition to signing on to ENACT letters, ACPM sent a separate letter urging the Senate to support a floor amendment to a bill that clarified DOJ’s right to move ahead with the lawsuit (see Attachment D).

Another tobacco-related development has been HHS’ recent decision to begin enforcing the Synar Amendment—a requirement passed by Congress seven years ago for states to reduce minors’ access to tobacco or risk losing federal monies needed to address substance abuse issues. For the first time since its enactment, the federal government has issued letters to seven states informing them they are not in compliance with the law and risk losing a total of $37 million for the coming fiscal year. All seven states are appealing the ruling, and their plight has caught the attention of Congressional leaders, where a bill has been introduced to end the penalties. However, it appears the Senate is ready to compromise on a proposal to scale back the penalties but increase the ultimate goal to a higher percentage of kids unable to buy cigarettes. Under the proposed change, states would have a longer time to reduce the percentage of teens with access to cigarettes to 10 percent, half of the 20 percent target under current law. The issue was exacerbated by the just-released findings from a Robert Wood Johnson Foundation-funded research study that showed as many as 19 states and territories violating the statutory requirements of the law—most of which, the researcher contends, make no attempt to enforce the law prohibiting vendors’ sales of tobacco to youth. HHS is disputing the findings, saying that the Synar Amendment has been extremely successful in curbing youth access to tobacco.

In July, ACPM sent a letter to the head of the Occupational Safety and Health Administration (OSHA) expressing concern about the lengthy delay in issuing the final regulations on Indoor Air Quality, including environmental tobacco smoke in the workplace. The proposed regulations were issued five years ago. ACPM cited the overwhelming response to the regulations, the decidedly lopsided support for banning smoking in the workplace or allowing it only in designated ventilated areas, and the preponderance of scientific evidence to support the regulations as reasons for OSHA to make this a top agency priority. In the OSHA response, OSHA cited complicated scientific and procedural issues associated with rulemaking and assured ACPM that it is making every attempt to expedite the rulemaking process. The ACPM leadership remains concerned that the tobacco lobby has successfully stalled the rulemaking process. (See Attachment E for copies of the ACPM letter and OSHA reply.)

ACPM also signed on to ENACT letters to Congress and to the President in support of Centers for Disease Control and Prevention (CDC) tobacco control initiatives, particularly for a $27 million increase (36%) in the Office of Smoking and Health budget for the new National Tobacco Control Program; a federal tobacco tax; the DOJ lawsuit; and earmarking tobacco settlement dollars for prevention. In addition, ACPM signed on to letters from the Campaign for Tobacco-Free Kids to state departments of education speaking out against forming partnerships and accepting funds from tobacco companies—a disturbing new tactic being deployed by the tobacco industry to gain credibility.

A key provision of the Health Insurance Portability and Accountability Act of 1996 dealt with protecting the privacy of health information. Pursuant to that law, the Secretary of Health and Human Services delivered recommendations to Congress in September 1997 on the confidentiality of individually-identifiable health information. Congress, however, failed to enact legislation governing standards regarding the privacy of health information by the August 21, 1999, deadline. Therefore, HIPAA requires the Secretary to promulgate such standards by regulation. Proposed regulations, based generally on the above recommendations to Congress, are expected to be published this fall for comment. The Policy Committee may recall that ACPM endorsed and adopted the position statement developed by the American College of Epidemiology (ACE) on data privacy. In October, ACPM sent a letter to the Secretary in support of privacy standards that do not limit access to data for epidemiology and public health research (see Attachment F). The letter attached the policy statement, drawing attention to the principle advocating for regulations that assure the continued availability of health data for the purposes of monitoring patterns of disease, understanding the risk factors for and causes of disease and injury, health care delivery practices, health care outcomes, health care organization, financing, regulation, and accreditation. ACPM will continue to stay abreast of the draft regulations and advocate for this position.

In June 1999, ACPM submitted a letter to the FDA Commissioner urging the agency to update its regulation requiring fortification of food products with folic acid to reduce neural tube defects in children. Citing the ACPM policy statement included in the April issue of AJPM, which provides evidence of the health- and cost-effectiveness of higher fortification levels, ACPM made a strong case for raising the standard from the current 140 micrograms of folic acid per 100 grams of product to 350 micrograms. The FDA sent a reply in September indicating the FDA’s belief that it is premature to suggest changes in the current folic acid fortification program based on available data. (See Attachment G for copies of the ACPM letter and FDA reply.)

At the March 1999 Policy Committee meeting, one member raised the point that ACPM should take the lead, working with all relevant organizations, in establishing an accreditation program for local health departments. Currently, a coalition of public health organizations being led by the CDC is developing and testing national performance standards for public health systems, and the National Association of County and City Health Officials is exploring the feasibility of a system of voluntary accreditation for local health departments based on these standards. As per the suggestion of the Policy Committee, ACPM is drafting a letter to the American Medical Association reminding it of the ACPM-sponsored resolution in support of local health department accreditation (which was submitted and passed at the December 1998 meeting) articulating the specialty’s interest in evidence-based prevention, and offering assistance as needed.

The issue of reducing the prevalence of antibiotic resistance in humans through banning the subtherapeutic uses of antibiotics in livestock was raised at the last Policy Committee meeting, but referred for further research. Because of the gap in staffing for ACPM policy work, this issue has not been further addressed. Time has been allotted at the upcoming Policy Committee meeting to revisit this issue.

In the past six months, ACPM has become involved in or initiated dialogue around several emerging issues of importance to the preventive medicine community. Below are brief descriptions of these issues, ACPM involvement to date, and questions for consideration by the Policy Committee.

In May 1998, the Federation of State Medical Boards (FSMB) adopted a policy to strengthen requirements for initial licensure to practice medicine. The policy recommended that all applicants for full and unrestricted licensure have completed three (3) years’ of progressive postgraduate training in an ACGME- or AOA-approved postgraduate training program, including completion of the third year of postgraduate training (PGY3). (See Attachment H for position statement.) The intent of this policy is to eliminate the practice of resident physicians obtaining unrestricted licensure following only one year of residency training—often for the purpose of engaging in employment outside the residency program ("moonlighting")—when these physicians may lack sufficient training and expertise in the aspects of primary health care necessary to provide unsupervised patient care, especially in an emergency setting. Based on a 1996 study of the status of resident licensure in the U.S., FSMB found that only one state required three (3) years of training for graduates of U.S. or Canadian medical schools to obtain initial licensure.

While the spirit of this policy may be sound, the apparent interpretation of it in some states may begin to pose a serious threat to the long-term sustainability, much less growth, of the specialty of preventive medicine. ACPM has learned anecdotally that, in a few states, some physicians who have completed their preventive medicine residency programs are encountering difficulty receiving unrestricted licensure to practice. Apparently, because of the unique, less-clinically focused nature of the preventive medicine specialty—which includes one year of purely academic training (PGY2) and a practicum year (PGY3) that may or may not be based in clinical settings—some state medical boards do not view preventive medicine residency programs as sufficient training to engage in full and unrestricted medical practice. This problem is further compounded by preventive medicine residents who earned their MPH prior to entering the residency program and are allowed to waive their PGY2 training. (The ABPM does not require the academic year to be part of the residency program.)

On a recent conference call, the ACPM Education Committee discussed this issue and recommended that ACPM initiate dialogue with FSMB to better understand the Federation’s views on this issue and whether ACPM should initiate more formal contact with the Federation. ACPM’s aim would be to clarify this issue at the national level without having to fight this battle in every state. The committee members also suggested that, if necessary, ACPM engage in an informational campaign with all state medical boards so that they can better understand the field of preventive medicine, the unique nature of preventive medicine residency training (i.e., balance between clinical practice and population-based medicine), and how new three-year postgraduate training requirements for licensure could affect preventive medicine residents. The hope is to proactively educate Boards before they propose new regulations for licensure. Currently, the ACPM staff is conducting further research with preventive medicine residency program directors and state medical boards to gauge their interpretations of the FSMB policy, learn what, if any, changes state medical boards have made in their licensure requirements as a result of the policy, and assess to what extent preventive medicine residents are being affected.

The ACPM Policy Committee should also consider this issue and assess to what extent this policy and subsequent action of state medical boards poses a threat to preventive medicine. ACPM might also explore whether the American Board of Medical Specialties, which recognizes preventive medicine as one of 25 distinct medical specialties, as well as the ACGME, could be of assistance in advocating this stance with FSMB and state boards. Other, more long-term measures might include adding another year of clinical training to the preventive medicine postgraduate training requirements or moving toward joint residency programs with other clinical specialties (e.g., internal medicine, family practice, pediatrics).

The AMA and six of the nation’s largest specialty groups have developed a joint policy statement as part of a national campaign promoting universal health coverage, entitled "All Americans Must Have Health Insurance: A Joint Statement." These groups are trying to get other organizations to sign on to the statement. The statement does not propose how to achieve this goal, but lays out three fundamental principles of the campaign: all Americans must have health insurance, all coverage policies should contain good quality benefits packages, and medical necessity determinations should reflect generally accepted standards of medical practice. The statement seems generally consistent with past ACPM policies. The Policy Committee should consider whether ACPM should sign on to this statement and make a recommendation to the Board of Regents accordingly. The current signatories include the American Academy of Family Physicians; American Academy of Pediatrics; American College of Emergency Physicians; American College of Obstetricians and Gynecologists; American College of Physicians-American Society of Internal Medicine; American College of Surgeons; and American Medical Association. (See Attachment I for a copy of the joint policy statement.)

Although Medicare reform legislation is a dead issue for the current Congressional session, Medicare coverage for preventive services continues to be an important issue for the College. Since the last Policy Committee, several bills have been introduced in Congress to strengthen Medicare beneficiaries’ access to preventive services, including the Medicare Medical Nutrition Therapy Act of 1999. Most recently, a bill was introduced by Senator Bob Graham to change the fundamental focus of the Medicare program from a sickness program to a wellness program. In addition to funding a series of studies about the utilization of prevention services among the elderly and establishing a health risk appraisal and education program, the Medicare Wellness Act of 1999 adds 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 (see Attachment J for fact sheets). All of the benefits included in the bill are ranked either "A" or "B" by the U.S. Preventive Services Task Force and those with a "C" ranking are included if, in the Task Force’s opinion, the evidence supports targeting certain high risk groups.

The Policy Committee should consider the strengths and weaknesses of the bill and decide whether to recommend to the Board of Regents that ACPM support the legislation. An issue related to the bill is whether to push for coverage of drug benefits that are part of the therapeutic treatment of the conditions for which Medicare beneficiaries are being screened and counseled.

Recognizing the important role employers play in the nation’s health system, Partnership for Prevention commissioned a survey to determine the coverage rates of clinical preventive services in employer-sponsored health plans. The survey focused not only on the magnitude of the business community’s investment in prevention, but also the value businesses might expect from their benefit choices. The study found that employer coverage for some clinical preventive services is high, while coverage for others is low. Overall, however, employers are not always buying preventive health services of proven effectiveness or targeting proven services to those who are at greatest risk. Of most significance, the study found that of all the preventive services included in the survey, counseling to address serious health risks—tobacco use, physical inactivity, alcohol abuse, and poor nutrition—is least likely to be covered by employer-sponsored health plans.

Following the survey, Partnership convened a group of respected business and health industry leaders to examine survey findings and to discuss strategies to increase appropriate use of preventive health services. While this group put forth recommendations for employers, health plans, researchers, professional associations, and the public health community, it also made the following recommendations for federal and state policymakers, which may be of most interest to the ACPM Policy Committee:

1. Policymakers should provide tax incentives to expand Americans’ access to appropriate preventive health care and to help the country achieve national health objectives.
2. The federal government can serve as a prevention leader by requiring health plans that participate in the Federal Employee Health Benefits Plan to cover those clinical preventive services endorsed by the USPSTF. State governments can require their employee health plans to do the same.
3. Federal entitlement programs, such as Medicare, should cover those preventive services recommended by the USPSTF with no co-pays or deductibles. (The aforementioned Graham bill begins to address this recommendation.)

The Policy Committee should consider how the ACPM leadership, members, and staff could play a role in bringing these recommendations to fruition. (See Attachment K for a copy of the study results.)

As health information proliferates on the Internet, there is a growing need for objective, reproducible, widely accepted criteria that can be used to evaluate the quality of the information. To address this issue, the Health Information Technology Institute of Mitretek Systems convened a Health Summit Working Group over a period of 18 months to create and refine a set of criteria for assessing the quality of health information on the Internet. The results of that process are captured in the policy paper, "Criteria for Assessing the Quality of Health Information on the Internet." ACPM member Helga Rippen chaired the group, and several other ACPM members were participants.

In light of the vision expressed by ACPM President George Anderson to "help preventive medicine professionals plan strategically for the 21^st Century and harness the power of information technology to enhance health," ACPM staff view this as an important issue for the Policy Committee and the Home Page Task Force to consider. The paper calls for organizations to become involved in this important effort at some level, whether it be supporting and/or endorsing the policy paper, adopting the use of the criteria, joining the Health Summit Working Group, educating others on this topic, or participating in the tool development and testing process.

1. AMA House of Delegates

Once again, ACPM was an active participant in the Annual Meeting of the AMA House of Delegates in June, 1999. ACPM continued its role in the coordination and staffing of the Preventive Medicine Section Council. ACPM also submitted one resolution before the House of Delegates on the issue of immunization registries, which passed (see Attachment L). ACPM also co-sponsored resolutions related to safe medical devices, medical genetics, and obesity. ACPM delegate Ron Davis, alternate delegate Doug Scutchfield, and several other ACPM members, along with ACPM staff, assisted with the drafting and/or advocating for ACPM resolutions.

2. AMA Policy Statements

Two ACPM members, Haq Nawaz and Spencer Turner, submitted comments to the AMA on ACPM’s behalf on a draft AMA policy statement on preparticipation cardiovascular screening for student athletes. Two other members, Dan Pallin and Bruce Leistikow, submitted comments on ACPM’s behalf on a draft AMA/American Bar Association white paper on national substance abuse policy.

By participating in several coalitions, ACPM is able to more closely monitor other agencies and programs represented in the Labor-HHS-Education funding bill including CDC, NIOSH, AHCPR, and NIH. 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 AHCPR, Partners for Annual Pap Smears, and the STD Coalition. 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