Intersection of Clinical Care and Public Health

Intersection of Clinical Care and Public Health

AcademyHealth 2007 Annual Research Meeting

June 4, 2007 / Orlando

Ron Davis, MDPresident-elect

American Medical Association

“Physicians, as conservators of the public health, are bound to bear emphatic testimony against quackery in all its forms.…”

1847 – Founding of the AMA and Publication of the Code of Medical Ethics

AMA mission

• To promote the science and art of medicine and the betterment of public health

• Unchanged since 1920

AMA’s health care advocacy agenda for 2007

• Expand medical coverage for the uninsured

• Reform the Medicare physician payment system

• Reform the medical liability system• Improve the quality and safety of

health care• Improve public health through …

• Healthy lifestyles • Reducing health disparities• Disaster preparedness

Topics

• Medicine and Public Health Initiative

• Clinical preventive services

• Health promotion & disease prevention in managed care

• Examples• Prevention activities in the medical sector

• Collaboration between medicine and public health

• Tobacco, alcohol, and obesity

Medicine and Public Health Initiative (MPHI)

Hippocrates urged physicians to recognize the environmental, social, and behavioral determinants of disease:

• the airs “peculiar to each particular region”

• the “properties of the waters” inhabitants consume

• their “mode of life … whether they are heavy drinkers, taking lunch, and inactive; or athletic, industrious, eating much and drinking little”

Medicine and Public Health Initiative (MPHI) – continued

Rudolf Virchow (1821–1902), founder of cellular pathology:

“Should medicine ever fulfill its great ends, it must enter into the larger political and social life of our time; it must indicate the barriers which obstruct the normal completion of the life-cycle and remove them. Should this ever come to pass, Medicine, whatever it may then be, will become the common good of all.”


• Formed in 1994 by the AMA and APHA to bridge the gulf between medicine and public health

• National Congress in March 1996 (> 400 delegates from both disciplines)

• RWJF and AHCPR formed the “Cooperative Actions for Health” Program, which funded 19 state MPHI projects

• NPO: UT-Houston Health Science Center


• NY Academy of Medicine examined the history of collaboration between medicine and public health

• Identified 414 discrete examples• Medicine & Public Health: The Power of

Collaboration monograph sent to all medical schools in the U.S.

• Pocket Guide to Cases of Medicine & Public Health Collaboration

www.cacsh.org/mphguide.html


• “Although (the) MPHI was embraced in some states and localities, it was unable to bridge the cultural and institutional divide in others.”

• There has been “difficulty in sustaining the momentum of (the) MPHI.”

LM Beitsch et al, AJPM 2005; 29: 149-53“The Medicine & Public Health Initiative: 10 Years Later”


• Visible renewal of the shared commitment to partnership among AMA, APHA, ACPM, APTR, CDC, and others

• Professional education to integrate elements of public health and medicine into each other’s curriculum

• Research into effective strategies to overcome barriers across the medicine-public health chasm

• Leadership by local medical and public health communities to translate the MPHI into action

To reinvigorate the MPHI, Beitsch et al recommend:


• State and local medical societies should establish public health committees

• Organized medicine should be represented on public health advisory committees and boards of health

• Medical societies should form foundations to expand their work in public health

RM Davis, AJPM 2005; 29: 154-157“Marriage Counseling for Medicine & Public Health”


• Leaders in medicine and public health should offer speaking opportunities to their counterparts at meetings and conferences

• Public health and preventive medicine physicians need to join their county and state medical associations and the AMA



“An Issue to Rally Around” – work together to bolster the funding of each sector

• Tobacco taxes

• Tobacco settlement funds

• Alcohol taxes

• Taxes on non-diet soft drinks


Clinical Preventive Services

• Guidelines for clinical preventive services issued by the U.S. Preventive Services Task Force

• Administered by the Agency for Healthcare Research & Quality (AHRQ)

• Based on a rigorous review of evidence

• Services are divided into categories of screening, counseling, immunization, and chemoprophylaxis

Clinical Preventive Services– continued

• Recommendations have been issued for ~ 75 services

• Guidelines are updated and new guidelines are released on an ongoing basis

• www.ahrq.gov/clinic/uspstfix.htm

• AHRQ website includes “Put Prevention Into Practice” program – tools and information aimed at improving implementation of clinical preventive services guidelines

• www.ahrq.gov/clinic/ppipix.htm

Clinical Preventive Services– continued

• Yarnall et al estimated that primary care physicians, in order to fully satisfy the USPSTF recommendations, would need to spend 7.4 hours per working day (Am J Public Health 2003; 93: 635-641)

• National Commission on Prevention Priorities prioritized clinical preventive services based on the clinically preventable burden and cost-effectiveness (Am J Prev Med 2006; 31: 52-61)

2006 Prevention Priorities

Short Name CPB CE Total

Aspirin Chemoprophylaxis – “high risk” 5 5 10

Childhood Vaccination Series 5 5 10

Tobacco-Use Screening & Intervention 5 5

10


Colorectal Cancer Screening 4 4 8

Hypertension Screening 5 3 8

Influenza Immunization – adults 4 4 8

Pneumococcal Immunization – adults 3 5 8

Problem Drinking Screening & Brief Counseling 4 4 8

Vision Screening – adults 3 5 8




Cervical Cancer Screening 4 3 7

Cholesterol Screening 5 2 7

Breast Cancer Screening 4 2 6

Chlamydia Screening 2 4 6

Calcium Chemoprophylaxis 3 3 6

Vision Screening – children 2 4 6

High-Priority, Low-Use ServicesShort Name Total Score National Delivery

RateTobacco Cessation Counseling 10 35%

Colorectal Cancer Screening 8 25%

Pneumococcal Immunization – adults 8 56%

Chlamydia Screening 6 40%

Aspirin Chemoprophylaxis 10 ?

Vision Screening – adults 8 ?

Problem Drinking Screening 8 ?

Health promotion & disease prevention in managed care

Several forces are pushing prevention in managed care

• National Committee for Quality Assurance (NCQA) accreditation

• Health Plan Employer Data and Information Set (HEDIS) “report card”

• Pressure from purchasers — public (eg, Medicaid) and private

Preventive Services in HEDIS

• Pap tests (21-64 years old)

• Mammograms (52-69 y/o)

• Colorectal cancer screening (50-80 y/o)

• Childhood immunization• DTP (4), polio (3), MMR (1)

• Hib (2), hep B (3), varicella (1)

• Adolescent immunization (13 y/o)• MMR (2), hep B (3), varicella (1)

• Influenza immunization (> 50 y/o)

• Smoking cessation advice/assistance

• Initiation/engagement of alcohol & other drug treatment (> 18 y/o)

• Chlamydia screening (women 16-26 y/o)

• LDL cholesterol after acute CV event

• Diabetes care (HbA1c, LDL cholesterol, screening for eye and kidney disease)

• Prenatal and postpartum care

• Glaucoma screening (> 65 y/o)

Preventive Services in HEDIS – continued

Parallels between Public Health and Managed Care

Public Health Managed Care

• Primary prevention

• Secondary prevention

• Tertiary prevention

• Demand management

• HEDIS measures (mammogram, Pap)

• Disease management

The language of managed care

• Risk management

• Utilization management

• Quality management

• Disease management

• Demand management

• Physician management?

Tobacco Control – AMA

• AMA SmokeLess States program (funded by RWJF) gave grants to state coalitions for advocacy for tobacco control policies

• > $90M provided to > 40 state coalitions during 1994-2004

• AMA worked with “Partnership for Prevention” and CTFK to successfully petition CMS to provide Medicare coverage for tobacco cessation counseling

• AMA has joined amicus briefs in support of tobacco control litigation in many states

Tobacco Counteradvertising Contest for Schoolchildren in Michigan

• Sponsored by Wayne County Medical Society Foundation and Henry Ford Health System

• Funded by the Community Foundation of Southeastern Michigan and other sources

• Conducted contests in 2002 and 2005

• A third contest is now underway

• www.counteradvertising.com

Omar PaulkGrade 8:

“In the neighborhood, the phrase ‘to smoke’ means to kill someone. ‘He got smoked’ means he got killed. When smokers finish a cigarette, they say they are killing the cigarette. My drawing asks the question, Who’s Smoking Who? It means the cigarette is killing the smoker.”

James Robinson

Grade 11

Cass Technical High School

Damardre Williams

Grade 11

Detroit High School for the Arts

Edwin AndrewsGrade 12Renaissance High School

Tobacco Control –Health Partners (Minneapolis)



Alcohol Control – AMA

• Two AMA programs funded by RWJF• Reducing Underage Drinking through

Coalitions: Youth and Adults United for a Change

• A Matter of Degree: The National Effort to Reduce High-Risk Drinking Among College Students

• www.ama-assn.org/go/alcohol

Alcohol Taxation

• AMA Resolution 438 (A-05)

• RESOLVED, That our American Medical Association support increases in federal taxes on beer, wine, and liquor, with a substantial portion of the new revenues to be earmarked to the prevention of alcohol abuse and drunk driving, treatment of persons with alcohol dependence or at-risk drinking patterns, and public health and medical programs that serve vulnerable populations; and be it further

RESOLVED, That our AMA encourage state and local medical societies to support increases in state and local taxes on beer, wine, and liquor, with a substantial portion of the new revenues to be earmarked to the purposes noted above …

• Chronicle of Higher Education

• College newspapers

DePaul Univ

Univ of WI (Madison)

Univ of Iowa

Georgia Tech

Indiana University

Ole Miss

AMA Primer on Assessment and Management of Adult Obesity

• Available in 3-ring binder, on CD-ROM, and the web

• 10 booklets• Assessment

• Dietary management

• Physical activity mgmt

• Pharmacologic mgmt

• Surgical mgmt

• Office environment

• Communication/counseling

American Academy of Orthopaedic Surgeons

American Academy of Orthopaedic Surgeons

“Coming together is a beginning;keeping together is progress; working together is success.”

Henry Ford – on partnership

Documents

Intersection of Clinical Care and Public Health