Chair: Mark Johnson                                                     Staff: Mike Barry/Jessica Cafarella

0. CONTINUING POLICY ISSUES
1. Preventive Medicine Residency Funding

ACPM’s top policy priority continues to be funding for preventive medicine residency training. ACPM’s Preventive Medicine Residency Funding Task Force (PMRFTF) has taken the lead in developing strategies and advocating for policy aimed at increasing the number and level of preventive medicine residency funding opportunities.

In recent months, the PMRFTF has focused on:

• formulating ACPM’s position on all-payer GME legislation;
• advocating for increased Title VII funding for preventive medicine residency programs;
• working with the Department of Veterans Affairs to develop additional training opportunities;
• examining opportunities to leverage funding from the administration’s initiative to expand community health centers;
• promoting preventive medicine training opportunities from the American Cancer Society; and
• expanding eligibility in the National Health Service Corps to preventive medicine physicians.

Please see the complete report of the PMRFTF elsewhere in this briefing book.

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

One key focus area for ENACT is advocating for legislation to grant the Food and Drug Administration (FDA) meaningful authority over tobacco. The most promising bills before Congress are H.R. 1097 and H.R. 1043, introduced by Representatives Ganske, Dingell, and Waxman. These bills would require tobacco companies to test additives for safety purposes, inform consumers about what is in their products, and take action to make their products less harmful or addictive. In addition, they would restrict those forms of marketing that have the greatest appeal to children. The Ganske legislation also addresses concerns by tobacco growers and retailers. Going into the August recess, there were over 100 co-sponsors of the Ganske/Dingell/Waxman bills.

At the same time, the coalition is strongly opposing a tobacco industry-backed bill, H.R. 2180, "The National Youth Smoking Reduction Act," introduced by Rep. Tom Davis (R-VA). Although it ostensibly grants the FDA authority over tobacco, the bill would fail to protect children from tobacco company marketing and contains loopholes that would prevent the FDA from requiring tobacco companies to reduce the harm their products cause even when the technology already exists to do so.

ENACT/ACPM is also monitoring issues regarding coverage for cessation services (Graham "Medicare Wellness Act"), appropriations for Centers for Disease Control and Prevention (CDC) tobacco prevention and control programs, and funding for the Department of Justice lawsuit against the tobacco industry.

Regarding the federal lawsuit against the tobacco industry, ACPM sponsored a resolution at the AMA House of Delegates meeting in June calling on the AMA to aggressively support the DoJ lawsuit (see section 2.3 of this report). In testimony before the Senate Judiciary Committee in early September, Stuart Schiffer, Acting Assistant Attorney General, Civil Division, said that the DoJ lawsuit against the tobacco industry will be fully funded at a level of $44 million and fully staffed. He also expressed confidence in the strength of the government’s case. This action begins to repair the damage done to the case earlier this year when DoJ initially did not request the necessary level of funding and then announced it would seek to settle the lawsuit after Administration officials declared anonymously that they believed they had a weak case.

As of October 1, Congress still had yet to consider the Labor-HHS-Education appropriations bill. The bill was delayed due to disagreements over discretionary spending limits and funding for education programs, and it was expected to be taken up by the Labor-HHS-Education Subcommittees in early October.

Funding for the Health Resources and Services Administration (HRSA) health professions training programs (including preventive medicine residency programs) was slashed by more than $200 million from the previous year in the administration’s Fiscal Year 2002 budget proposal, although Congress has yet to establish its own funding levels for health professions. Overall funding for the CDC, HRSA, and the Agency for Healthcare Research and Quality (AHRQ) also remain uncertain.

The health appropriations process undoubtedly will be impacted by the events of September 11. Congress already has passed $40 billion in supplemental funding for FY 2002, including $20 billion which will proceed through the normal appropriations process in tandem with one of the last regular bills, possibly Labor-HHS-Education.  The supplemental funding will include money for national security programs related to biological and chemical attacks and basic public health infrastructure, including up to $1.6 billion for CDC programs. However, almost all added funding for public health infrastructure considered since September 11 will go into the supplemental bill, which means the programs may not receive sustained funding increases in future years.  There may be a small increase in the CDC bioterrorism line in the FY 2002 mark-up, but this may come at the expense of other programs in the CDC budget.

ACPM and other health organizations already are planning for FY 2003 appropriations. Funding for FY 2003 will be lean and the public health community is anticipating cuts rather than growth. ACPM is working with the PMRFTF to create an advocacy brochure that emphasizes the importance of funding preventive medicine training, especially in light of September 11.

ACPM’s activities in patient safety over the past several months have mainly been through participation in the Patient Safety Coalition, organized by the AMA. The coalition’s main focus has been on promoting among congressional policy makers the "General Principles on Patient Safety Reporting." Among the variety of legislative initiatives under consideration, the coalition is rallying support for the "Patient Safety Improvement Act," expected to be introduced by Senators Frist, Kennedy, and Jeffords. The bill’s purposes are to: (1) establish a Center for Quality Improvement and Patient Safety within AHRQ to disseminate information about, and to conduct and support research on, the measurement and improvement of the quality of health care and enhancement of patient safety; (2) encourage a culture of safety in the United States health care system by providing for the legal protection of information that is reported for the purposes of quality improvement and patient safety; and (3) ensure accountability by raising standards and expectations for continuous quality improvements in patient safety through the actions of the Secretary of Health and Human Services.

At the April 23-24 National Summit on Patient Safety Data Collection and Use, Secretary of Health and Human Services Tommy Thompson announced the creation of a federal patient safety task force. The task force's goal is to integrate and streamline existing federal patient safety reporting systems. The task force consists of representatives from AHRQ, CDC, Centers for Medicare and Medicaid Services (formerly HCFA), and the FDA.

After much consideration and discussion with several College experts, ACPM decided in the spring not to submit a proposal to the National Patient Safety Foundation in response to its call for proposals in patient safety research. Several factors, including the limited number of grants, average grant amount, and a slant toward individual academic researchers, influenced the decision.

In March 2001, the Bush administration delayed and re-opened for public comment the final rule that the Clinton administration issued in late December to protect the privacy of medical records. ACPM seized the opportunity to submit comments reemphasizing the need for an effective balance between privacy protections and access to patient data needed for prevention research. While the final rule included public health surveillance, investigations, and research among the "public purpose" uses of protected health information for which written consent or authorization may be waived, ACPM expressed concerns about the process by which these waivers must be obtained.

However, shortly after the public comment period closed, the administration abruptly changed course and announced HHS would immediately begin the process of implementing the rule.  The HHS secretary stated his department would issue guidelines on how the rule should be implemented "to clarify some of the confusion regarding the impact this rule might have on health care delivery and access."  He also said the department "will consider any necessary modifications that will ensure the quality of care does not suffer inadvertently from this rule."

As part of the administration’s effort to develop implementation guidelines, the Subcommittee on Privacy and Confidentiality of the National Committee on Vital and Health Statistics (NCVHS) invited the AMA to testify on the issue of consent. Based on a reading of AMA’s statement, ACPM is concerned that AMA’s position on the issue is diverging even further from that of ACPM. While it is clear AMA’s position continues to advocate for the good of individual patients, AMA appears to ignore the broader population-based view ingrained in preventive medicine physicians.  AMA appears to be pushing for a narrowing of the definition of routine health care operations, possibly excluding functions such as public health surveillance and epidemiological research. Requiring individual patient consent for these routine public health activities could create barriers that pose a significant threat to the health of populations.

ACPM seeks guidance from the Policy Committee on the relative priority of this issue and, if appropriate, on ways to work with AMA and HHS to ensure the unfettered continuation of public health surveillance and research. ACPM sponsored a resolution on this topic at the AMA HoD 2000 interim meeting, which was referred to the Board of Trustees (and still pending action).

The third U.S. Preventive Services Task Force (USPSTF) released its first set of recommendations in mid-April in a special supplement of the American Journal of Preventive Medicine. The recommendations address:

• Screening for chlamydial infection – USPSTF recommends screening all sexually active women ages 25 years and younger and all women regardless of age who have had more than one sexual partner, an STD in the past, and/or do not use condoms consistently or correctly.
• Screening for lipid disorders – USPSTF recommends removing the upper age limit of 65 for screening and extending screening to all men aged 35 and older and all women aged 45 and older. Persons aged 20 years and older with risk factors for coronary heart disease should also be screened.
• Screening for skin cancer – USPSTF found insufficient evidence to recommend performing total body skin examinations to reduce illness and death from skin cancer.
• Screening for bacterial vaginosis in pregnancy – USPSTF concluded the evidence does not merit regular screening to reduce the incidence of pre-term delivery.

Senators Bob Graham and James Jeffords introduced the Medicare Wellness Act of 2001 (S.982) in June, which would begin to shift the emphasis of the Medicare program from illness to wellness. ACPM worked closely with Senator Graham’s office to craft the bill.

The bill would add several benefits recommended by the U.S. Preventive Services Task Force to the Medicare coverage package, including:

• nutrition therapy for seniors with cardiovascular disease;
• screening for hypertension;
• counseling for tobacco cessation;
• screening for vision and hearing loss; and
• screening for cholesterol.

In addition, the bill contains a requirement that Congress use a "fast track" process to vote on recommendations from the Institute of Medicine based on review of the science every three years. This will not only help to fill research gaps concerning preventive services, but will eliminate the onerous, often politically-driven, system that requires Congress to expand coverage of preventive services on a service-by-service basis. Policy Committee Chair, Mark Johnson, was quoted in a June issue of American Medical News noting that preventive services are widely supported but poorly funded.

Effective July 1, Medicare began providing expanded coverage for colorectal and cervical cancer screening. The expanded benefits, mandated by the Beneficiary Improvements and Protections Act of 2000, now cover (1) colonoscopies every ten years for individuals who are not at increased risk for colorectal cancer and (2) pap smears and pelvic exams every two years for women who are not at high risk for cervical cancer. Beginning in 2002, Medicare will cover annual glaucoma screening tests for people at high risk for diabetes.

At the February 2001 meeting of the ACPM Board of Regents, the Board endorsed a statement on handgun injury that ACPM had developed in conjunction with the Doctors Against Handgun Injury (DAHI) Coalition. The Board resolved, however, that ACPM should develop a separate position statement on handgun injury and control that takes a stronger stance than the DAHI statement.

The Prevention Practice Committee has coordinated development of the statement, which is authored by Committee member Christopher Armstrong in conjunction with handgun policy expert Joseph Sudbay. The statement builds on the DAHI statement by:

• favoring expansion of the Brady Act to require background checks on all firearm sales, including sales between individuals;
• supporting the redirecting of revenue generated by federal and state sales taxes on handguns and ammunition to fund handgun injury prevention;
• urging each state to adopt a handgun licensing and registration system;
• supporting legislation making handgun owners responsible for the safe storage of their weapons; and
• supporting legislation to prevent violent criminals from purchasing handguns.

A draft of the statement was reviewed by ACPM leadership in April and the Prevention Practice Committee in June. The draft statement currently is being reviewed by the Policy Committee, and it is expected be sent to the Board for approval later this year.

In 2000, Congress passed the Public Health Threats and Emergencies Act (Frist/Kennedy co-sponsors), which authorized funding for public health capacity-building, reducing antimicrobial resistance, and preparing for bioterrorism. Earlier this year, Congress introduced the Brown/Bilirakis/Ganske bill (HR1771) to authorize additional funding for the federal, multi-agency Public Health Action Plan to Combat Antimicrobial Resistance. In June, the House of Representatives passed an amendment introduced by Rep. Brown to the Agriculture Appropriations bill directing $5 million of existing FDA funds to implement provisions in the Public Health Action Plan. ACPM signed-on to the letter supporting this action. Action on the original Brown/Bilirakis/Ganske bill is currently pending (referred to House Energy and Commerce Subcommittee on Health), as are appropriations for antibiotic resistance programming under the Frist/Kennedy legislation. (In March 2000, ACPM adopted the 1999 statement by the Council of State and Territorial Epidemiologists on use of antibiotics in animal feed.)

In late August, the Coalition to Keep Antibiotics Working developed a list of principles it considered essential to the battle against antibiotic resistance and approached ACPM for support. Based on responses from the Policy Committee, ACPM decided not to sign on to the principles. The prevailing thought was that the statement was too broad and far reaching and needed more focus.  There seemed to be resistance to the idea of an ongoing national surveillance system around antibiotic resistance.  While all agree better data are needed, targeted studies may be the more appropriate route.  Several members also felt uneasy about signing on to the document without knowing much about the coalition (i.e., who's represented on it, what it stands for, its methods for advocacy/implementation of action, etc.) nor the process by which the document was developed

6.   Public Health Workforce Credentialing

The American Public Health Association (APHA) and Association of Schools of Public Health (ASPH) have been leading an effort to develop a certification process for the public health workforce. The goal of the initiative is to increase recognition of public health's members and raise the visibility of the public health workforce, while ensuring high standards that better serve the health of the public. The conceivers of this initiative feel that it will clarify public health as a defined and organized profession, which will lead to increased visibility, respect, and compensation of the public health workforce. The Executive Committees of the two organizations have developed a joint task force to oversee the initiative. The task force has proposed the creation of an American Board of Public Health as the credentialing body and is planning to target initial credentialing efforts toward current leaders in public health practice.

While supportive of the overall concept to strengthen standards for public health workers consistent with core public health competencies, ACPM and other preventive medicine organizations are concerned about the notion of creating a competing certifying Board for public health physicians. Such an entity could have the effect of creating an alternative pathway to preventive medicine training for physicians interested in public health. This could have major implications for the specialty in the long-term. ACPM and the other organizations on the Preventive Medicine Leadership Forum have sent a joint letter to the leaders of ASPH and APHA voicing concerns about the proposal. ACPM and ABPM leaders have held several discussions with the ASPH leadership and will continue a dialog to identify an approach that builds on common ground among the organizations.

ACPM, under the leadership of Joel Nitzkin, is working with the American Association of Public Health Physicians (AAPHP) on an initiative aimed at strengthening the job market for preventive medicine physicians. The Job Market Initiative stemmed from a set of AAPHP-sponsored resolutions approved by the ACPM Board of Regents in November 2000. The initiative is being coordinated by a subcommittee of the ACPM Policy Committee.

The goal of this initiative is to increase the number and quality of job offerings that express a requirement or preference for physicians with preventive medicine residency training. Initial efforts have been focused on the creation of postgraduate fellowships for physicians completing their preventive medicine residency training. These fellowships are intended to enhance the quality and range of employment opportunities for preventive medicine residents and to demonstrate to host organizations the value of preventive medicine training in addressing a wide range of institutional needs. In the spring, ACPM President Dorothy Lane and AAPHP President David Cundiff sent a letter to the ACPM membership encouraging members to help create preventive medicine fellowships in their own institutions. Two such fellowships were created (in California and West Virginia) as a result of the action.

The subcommittee also is conducting outreach to national organizations representing potential employers—where ACPM or AAPHP members currently play leadership roles—to encourage the creation of fellowship opportunities. Targets will include federal agencies, other medical societies, and organizations representing state and local health departments, health plans, academic institutions, and pharmaceutical companies.

Another important activity being undertaken by AAPHP is the development of a Web-based database to track advertisements for preventive medicine-related jobs, including the numbers and types of such jobs and the qualifications for each of them. Such a database will enable ACPM to evaluate the impact of the initiative over time.

At its February in-person meeting, the Policy Committee established a Policy Process Subcommittee to document ACPM's policy setting process and to make it more understandable and accessible to ACPM members. The desire to clarify ACPM's policy process stemmed from the newly-established Open Policy Forum and resolution process. The Policy Process Subcommittee had three distinct objectives:

1. Review and document the ACPM policy setting process;
2. Refine the ACPM Open Policy Forum and resolution process; and
3. Develop a structure for the ACPM policy compendium.

Objective 1 (Review and document the ACPM policy setting process): The Subcommittee and ACPM staff conducted a thorough review of existing ACPM policy and policy setting process. Over the course of several conference calls, the Subcommittee created a comprehensive Policy Setting and Implementation Process document, which details sources of ACPM policy, the policy approval process, criteria for setting and implementing ACPM policy, types of ACPM policy, and maintenance of policy. The document creates a clear picture of the ACPM policy process and is designed to serve as a resource both for ACPM members and staff. The document is accompanied by a calendar of policy events, a schedule of activities/logistical guidelines accompanying the Open Policy Forum, and a schedule of activity for the American Medical Association (AMA) House of Delegates meeting. The document (see Attachment A) is under review by the Policy Committee and will be presented at the in-person Committee meeting in Atlanta for approval/recommendation to the Board.

Objective 2 (Refine ACPM Open Policy Forum and resolution process): The Subcommittee assessed the strengths and weaknesses of the Open Policy Forum, which made its debut in February 2001, and made several recommendations to improve it. The Subcommittee specified that the ACPM Policy Committee should set the agenda for the Open Policy Forum (perhaps spiked with hot button issues), and that the agenda should be distributed to all Preventive Medicine attendees in advance of the Forum. The agenda should include: 1) a review of ACPM policy priorities and recent activities; 2) a structured discussion of select policy issues; 3) an established time period for Forum attendees to extract and discuss specific resolutions from the list of all resolutions submitted; and 4) an "open mic" period during which any attendee can come to the microphone and present an issue, propose ACPM action, and stimulate debate. The Subcommittee also recommends that the Policy Committee designate members to serve on a working group (reference committee) to review the testimony heard on each resolution and prepare recommendations for the full committee. As noted above, the Subcommittee also created a schedule of activities/logistical guidelines accompanying the Open Policy Forum which clearly outlines what needs to be done in preparation for the Forum each year (see Attachment A, Appendix A).

Objective 3 (Develop a structure for the ACPM policy compendium): To create an ACPM Policy Compendium, Subcommittee members worked with staff to examine the policy mechanisms of other medical societies and to review existing ACPM policy in order to establish a compendium structure most appropriate for the organization. The Subcommittee emerged with an organizational framework for the compendium that reflects topic, date, and policy type.

With the help of a summer intern, ACPM staff were able to identify and codify all ACPM policy beginning in January 2000 and to organize the policy into several three-ring binders. (ACPM staff will bring the Policy Compendium binders to the in-person Policy Committee and Board of Regents meetings in Atlanta). All future policy will be coded, added to the inventory, and placed in the appropriate binder. Each policy contained in the inventory will be cross-referenced to a topic index for easy retrieval and contain information about the active status of the policy. ACPM plans to make its policy compendium available via the Policy section of its Web site. (See Attachment B for the 2001 Policy Compendium table of contents.)

ACPM’s success at the June AMA House of Delegates annual meeting in Chicago was highlighted by the election of Ron Davis to the AMA Board of Trustees. Dr. Davis, who has represented ACPM in the HoD since 1987, will serve a four-year term on the 18-member principal governing body of the AMA. The election represents the culmination of a hard-fought campaign waged by Dr. Davis with support from ACPM, the Michigan State Medical Society, the Wayne County Medical Society, and many others. Dr. Davis’ election to the Board will not only enhance the visibility of the College within the medical profession, but will add a strong public health and prevention presence to the AMA leadership.

ACPM also was successful in its policy activities at the HoD meeting. The House passed three resolutions sponsored or co-sponsored by ACPM, which called on the AMA to: (1) advocate for adequate funding of the U.S. Department of Justice’s ongoing lawsuit against the tobacco industry; (2) prepare a report on the increased incidence of childhood asthma and develop recommendations for policy, public education, and legislation to reduce the incidence of childhood asthma; and (3) address bullying behavior among youth through a variety of measures, including evaluating intervention programs, advocating for research, and preparing educational materials. A fourth ACPM-sponsored resolution, calling on AMA to recommend low sodium diets and engage in efforts to reduce the amount of salt added to foods, was deemed to reaffirm existing AMA policy.

In other AMA HoD news, the Council on Scientific Affairs issued its report on safe disposal of used syringes, needles, and other sharps in the community, which was generated in response to an ACPM resolution introduced last year. The report identifies and discusses the public health implications of improper sharps disposal in the community and summarizes current efforts to promote the safe community disposal of used sharps.

Two resolutions calling for the AMA to support Medicare coverage of various preventive services were referred to the Board of Trustees for study and a report back to the Board. In addition, the HoD voted to support a resolution calling for an increase in Medicare payment for screening mammography, which was supported by ACPM. Finally, ACPM was recognized at the Nathan Davis awards gala for its successful nomination of Sir Richard Doll as Outstanding International Physician.

Following the meeting, ACPM named its Alternate Delegate, Mike Parkinson, to be its new Delegate, replacing Dr. Davis. ACPM also named Erica Frank to be its new Alternate Delegate. Drs. Parkinson and Frank both have served the College in various capacities and are true veterans of the AMA House of Delegates.

ACPM, under the leadership of Planning Committee Vice Chair Neal Kohatsu, has put together an outstanding line-up of sessions and speakers for the policy track at ACPM’s upcoming annual meeting, Preventive Medicine 2002. Topics for the sessions include: the obesity epidemic; the economics of prevention; tobacco and HIV from a global perspective; prevention policy dilemmas; nutrition and the American diet; invited abstracts; and the Open Policy Forum. The actual agenda and content of the Open Policy Forum will be determined by the Policy Committee once all resolutions have been submitted and vetted among the committee.

The ACPM Prevention Practice Committee coordinates development of ACPM policy statements, position statements, and patient education statements. After each draft statement is reviewed by the Prevention Practice Committee, the statement is sent to the Policy Committee for further comment before being sent to the Board for approval.

The Prevention Practice Committee currently is overseeing the development of 12 new policy/position statements and the revision of two existing statements. This entails frequent review of draft manuscripts by the Committee leadership and Committee members, as well regular correspondence with authors, expert reviewers, and the National Guideline Clearinghouse. The Committee also is working on developing a list of recommended topics for future statements.

The Prevention Practice Committee has worked in recent months to update the list of statements currently under development, which previously contained inactive statement topics. The 12 statements under development include:

Topic                                                                                  Author

Practice Policies
Vitamin A Supplementation                                                      Nawaz, Katz
Counseling Children/Adolescents on Osteoporosis Prevention          Fleming, Almeida, Patrick
Screening for Chlamydia Trachomatis                                         Hollblad-Fadiman, Goldman
Hepatitis A Vaccination                                                           Kinsinger, Richard

Public Policies
Newborn Hearing Screening                                                      Clark, Kravitz
Violence Prevention                                                                Nawaz, Katz
PPD Screening of School Children                                              Chang
Domestic Violence                                                                  Seid
ECP as an OTC Medication                                                       Howe, Hill, Doshi, Neely
Adolescent Sexuality Education in schools                                   Masui

Position Statements
Handgun Injury                                                                      Armstrong, Sudbay

Patient  Education Statements
Preventing Heart Disease:  The Importance of Physical Activity

Revisions
Adult Immunizations                                                                Fingar, Francis
Childhood Immunizations                                                          Adetunji, Macklin, Kinsinger

2.6 ACPM Coalition Activity

By participating in several coalitions, ACPM is able to more closely monitor the policy activities of federal agencies and national organizations in areas of interest to preventive medicine and more easily form strategic alliances with these organizations. 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, Friends of School Health, the Children’s Environmental Health Network, the National Council on Folic Acid, the National Alliance for Nutrition and Activity, the Doctors Against Handgun Injury (DAHI) Coalition.

ACPM also recently joined the Research to Prevention (R2P) Coalition, a national coalition committed to improving our nation’s health through prevention. The mission of the R2P Coalition is to make prevention and control of chronic diseases and disability a national policy and funding priority through education and advocacy. The R2P Coalition was formed by the American Cancer Society, American Diabetes Association, American Heart Association, Arthritis Foundation, Association of State and Territorial Chronic Disease Program Directors, Epilepsy Foundation, and the National Health Council. More information on the Coalition can be found at www.researchtoprevention.org.

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.