AHRQ: Physician Supply Increases in States with Caps on Malpractice Lawsuit Awards

Study says rural areas reap greatest benefit

States that have capped malpractice lawsuit awards have seen a larger growth in the number of practicing physicians than those states without such caps, according to a new study from HHS’ Agency for Healthcare Research and Quality.

Between 1970 and 2000, the number of physicians per 100,000 residents more than doubled in the 13 states that enacted caps on non-economic damages during the 1980s, compared to an 83 percent physician growth rate in the 23 states that didn’t cap malpractice awards before 2000, according to the authors, AHRQ’s William E. Encinosa, Ph.D., and Fred J. Hellinger, Ph.D. The study is published on the Health Affairs Web site at content.healthaffairs.org/cgi/content/abstract/
hlthaff.w5.250.

“Malpractice litigation reforms can ensure better access to quality care for all Americans,” says HHS Secretary Mike Leavitt, according to an AHRQ press release. “Our nation’s health care system should no longer be held hostage to frivolous medical lawsuits, which only drive up health care costs, lead to defensive medicine, and make it harder for America’s doctors to provide safe and accessible care.”

Drs. Encinosa and Hellinger found that the dollar amount of the cap also had an impact on the supply of physicians, especially in rural areas. Between 1975 and 2000, the growth in the median number of rural physicians per 100,000 residents in states with caps of $250,000 was 9 percent higher than in states with caps above $250,000. Currently, 27 states have caps on malpractice awards; of those, five states have caps with a $250,000 limit.

Surgeons and obstetrician/gynecologists — who are most likely to be sued and who often pay the highest malpractice premiums — were the specialists most likely to be affected by caps of $250,000. The median number of surgical specialists per 100,000 increased by 41 percent for states with caps of $250,000, but only by 31 percent for states with caps above $250,000. For obstetrician/gynecologists per 100,000 women ages 15 to 44, the increases are 61 percent in states with caps of $250,000 and 49 percent for states with higher caps.

“This study contributes to the growing foundation of evidence underpinning efforts to reform malpractice laws in this country,” says Carolyn M. Clancy, M.D., director of AHRQ in the release. “This research will help inform states as they work to balance the concerns of physicians and the need to ensure access to services for their citizens.”

Drs. Encinosa and Hellinger used county-specific data from the Area Resources Files maintained by HHS’ Health Resources and Services Administration. They compared physician supply in 49 states, excluding Alaska and the District of Columbia, from 1985 to 2000 to study the impact of the malpractice caps. Caps generally increased physician supply by 2 to 3 percent three years after adoption, after accounting for other factors that impact physician supply. These other factors included fixed differences across counties, such as socioeconomic, political, cultural, and regulatory factors, as well as factors that could impact the demand for physicians, including HMO and Medicare enrollment, whether the county has a medical school, disease rates, and the county’s birth rate. In addition, the authors also accounted for the effects of four other state malpractice reforms, including collateral source rule reform, prejudgment interest reform, joint and several liability reform, and caps on punitive damages.

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AHRQ: Task Force Recommends HIV Screening for all Pregnant Women

The U.S. Preventive Services Task Force issued a new recommendation calling for all pregnant women, not just those identified as at risk for contracting HIV, to be screened for the infection. This recommendation is based on evidence that currently available tests accurately identify pregnant women who are HIV infected and that recommended treatment strategies can dramatically reduce the chances that an infected mother will transmit HIV to her infant.

The Task Force also reaffirmed its earlier recommendation that all adolescents and adults at increased risk for HIV infection be screened and has broadened its definition of high risk. In addition to patients who report high-risk behaviors, all patients receiving care in high-risk settings such as homeless shelters or clinics dedicated to the treatment of sexually transmitted diseases should be tested. The Task Force found at least fair evidence that screening adolescents and adults who are not at increased risk can improve health outcomes, but concluded that the balance of benefits and harms is too close to justify a general recommendation. The new recommendations are published in the July 5 issue of the Annals of Internal Medicine.

In 1996, the Task Force recommended a targeted strategy of routine counseling and screening of high-risk pregnant women and those who live in communities with a higher rate of HIV-positive newborns. However, recent evidence indicates that prenatal counseling and HIV testing has gained wider acceptance among pregnant women and that universal testing increases the number of women diagnosed and treated for HIV prior to delivery. Currently recommended treatment of HIV-infected pregnant women has been shown to significantly reduce the number of women who pass the virus to their newborns.

Treatment includes combination drug therapies taken during pregnancy that have been found safe for both mothers and infants. In addition, elective cesarean section and avoidance of breastfeeding have been shown to further reduce the chances of a woman’s passing HIV infection to her infant. Infected mothers who receive treatment can reduce the chance that their infants will be infected to as low as 1 percent, as opposed to 25 percent of infants born to HIV-positive mothers who aren’t treated during pregnancy.

“This recommendation is an important advancement in reducing the rates of HIV in the United States,” said Task Force Vice-Chair Diana Petitti, M.D., who is also Senior Scientific Advisor for Health Policy and Medicine for Kaiser Permanente Southern California. “More accurate HIV testing during pregnancy and new treatments for HIV have been shown to be safe and effective for mothers and infants and may reduce the number of infants born with the disease.”

Since 1995, advancements in treating HIV-positive patients with Highly Active Antiretroviral Therapy (HAART), a treatment regimen that combines three or more medications, have been shown to slow the progression of the disease as well as to reduce HIV-related death rates.

There are an estimated 850,000 to 950,000 Americans infected with HIV who are unaware that they have the virus. If left untreated, almost all infected individuals will develop acquired immunodeficiency syndrome. AIDS is the seventh-leading cause of death in Americans between the ages of 15 and 24 and the fifth-leading cause of death among those 25 to 44 years old.

People who are or have been intravenous drug users, have had sex with an HIV-infected partner and men who have had sex with men after 1975 are among the groups at high risk for contracting HIV.

In addition, data from AHRQ’s Healthcare Cost and Utilization Project indicate that, of approximately 4.7 million women who were hospitalized for pregnancy or childbirth in 2002, nearly 6,300 were infected with HIV.

The Task Force, which is supported by AHRQ, is the leading independent panel of private-sector experts in prevention and primary care. Its recommendations are considered the gold standard for clinical preventive services. It conducts rigorous, impartial assessments of the scientific evidence for a broad range of preventive services.

The Task Force grades the strength of its evidence from “A” (strongly recommends), “B” (recommends), “C” (no recommendation for or against), “D” (recommends against), or “I” (insufficient evidence to recommend for or against). The Task Force strongly recommends that clinicians screen all pregnant women for HIV (an “A” recommendation). The Task Force strongly recommends that clinicians screen all adolescents and adults at increased risk for HIV infection (an “A” recommendation). The Task Force makes no recommendation for or against routinely screening for HIV among adolescents and adults who are not at increased risk for HIV infection (a “C” recommendation).

The recommendations and materials for clinicians are available on the AHRQ Web site at www.ahrq.gov/clinic/uspstf/uspshivi.htm. Previous Task Force recommendations and summaries of the evidence and related materials are available from the AHRQ Publications Clearinghouse by calling (800) 358-9295 or sending an e-mail to ahrqpubs@ahrq.gov.

Source: AHRQ press release from June 28, 2005, embargoed until July 4, 2005.

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Mygdal Inducted as President of the Society of Teachers of Family Medicine

William Mygdal, Ed.D., director of the Family Practice Faculty Development Center of Texas in Waco, was installed May 4 as the 33rd president of the Society of Teachers of Family Medicine at its Annual Spring Conference in New Orleans. STFM is a multidisciplinary medical organization that offers numerous faculty development opportunities for individuals involved, whether full- or part-time, in family medicine education. In this position, Mygdal will serve as chair of the STFM Executive Committee and the STFM Board of Directors. He will oversee all activities of the society.

Mygdal also serves as STFM liaison to the National Institute of Program Director Development and is a member of the Academic Council for the Program Director Fellowship. During his previous service on the STFM Board, he completed the federal Public Health Policy Fellowship in 2000. He served as STFM liaison to the AAFP’s Commission on Education and to the National Institute for Program Director Development. He was the recipient of the 2003 STFM Excellence in Education Award. He has also chaired the STFM Education Committee and the STFM Group on Faculty Development.

Mygdal obtained his bachelor’s degree from Stanford University, his master’s degree from Middlebury College, and his doctorate in Educational Psychology from Baylor University. Prior to his involvement in academic family medicine in 1982 he served as a Peace Corps volunteer, a high school teacher and principal, and the director of a college counseling center.

The FDC is a unique regional educational resource designed to strengthen the academic infrastructure of family medicine departments and residencies. Under Mygdal’s direction, the FDC’s year-long fellowship program has produced 156 graduates. The FDC offers other innovative programs, including the annual Texas Family Medicine Leadership Conference, the Chief Resident Conference, and a preceptor workshop series. In 1997, the Pew Health Professions Commission awarded the FDC the Primary Care Achievement Award for Education.

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Is an Electronic Health Record in your Future?

A consultant can make all the difference

By Stephanie Svoboda

The world of electronic health records, or EHRs, can be mysterious and overwhelming. There’s the client-based server versus Web-based server. Speech recognition software versus templates. What’s the secret to seeing through the fog? Working with a vendor-neutral consultant will help you to identify your workflow changes, technology needs and EHR goals.

Texas Medical Foundation offers professional consulting services at no cost for small- and medium-sized primary care practices through an initiative called Doctor’s Office Quality — Information Technology. DOQ-IT is a national initiative led by the Centers for Medicare and Medicaid Services in response to President Bush’s call in 2004 for an EHR for every patient within the next 10 years.

“DOQ-IT is for physicians who want to implement an EHR and don’t know where to begin or those who have implemented one but are not using it to its full potential. We can analyze what’s best for your practice and help you make decisions about the equipment and software needed,” says Abe Delgado, M.D., medical director for Texas Medical Foundation.

DOQ-IT participants receive assistance in identifying:

• the EHR system that best meets their needs (Texas Medical Foundation is not a vendor of EHR products, nor does it endorse any software provider);
• office design and technology modifications that should be put into place to successfully implement an EHR system; and
• recommended workflow changes to ensure EHR efficiency and ease in adoption.

“The secret to a successful EHR implementation isn’t the product itself, it’s how you use the product,” says Clifford Fullerton, M.D., of Garland, a clinical advocate for Texas Medical Foundation. “The Olympic runner isn’t good because he has the best shoes. He’s a good runner because he knows how to make the most of those shoes.”

Doctors who understand their office process will have a clear picture of what does or does not need to be changed. DOQ-IT consultants use several tools to assess what’s happening currently, such as telephone demand logs, staff and patient satisfaction surveys and workflow mapping. “By examining what’s happening day-by-day, minute-by-minute in your office, practices have the full picture to help select an EHR that complements their practice,” Fullerton says.

While a vendor may begin this type of assessment before the system is purchased, vendor support usually drops off two or three months after implementation. “You spend a lot of time at the beginning just learning how to interface with the EHR and enter a patient encounter. Once you’ve got that part down, the vendor is out of the equation. You still have not fully implemented the process changes needed to improve the quality of care that the EHR facilitates,” Fullerton says.

DOQ-IT assistance offers practices support both before and after implementation. “Our consultants are here to help you build on the product you purchased for years to come. We want you to get the most out of your EHR and feel like your practice is moving forward,” Delgado says.

Practices who seek out this level of assessment through DOQ-IT are also well positioned for what is on the horizon — pay-for-performance. “It is widely expected that physicians who provide better care will be paid more in the future either through CMS or other insurers,” Fullerton says. “By learning how to use the full functionality of the EHR through assistance with DOQ-IT, practices will be prepared for pay-for-performance.”

Interested primary care physicians must apply to be considered for the DOQ-IT initiative, which formally begins in August 2005. More information is available on the Web site at www.doqit-tx.org. You may also call Tara Frease, project manager, physician office quality improvement, for more information at (800) 725-9216.

Stephanie Svoboda is a communications specialist with Texas Medical Foundation. She can be reached at SSVOBODA@txqio.sdps.org.

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New Governance sets Academy Focus on Future of Family Medicine Tenets

By Leslie Champlin

AAFP has integrated the tenets of Future of Family Medicine into all aspects of its new governance structure by matching commissions’ scope of work with those of FFM goals, according to Academy leadership.

The leaders — AAFP President Mary Frank, M.D., of Mill Valley, Calif.; Board Chair Michael Fleming, M.D., of Shreveport, La.; President-elect Larry Fields, M.D., of Ashland, Ky.; and EVP Douglas Henley, M.D., of Leawood, Kan. — described the new Academy structure and answered questions during a May 6 town hall discussion at the National Conference of Special Constituencies and the Annual Leadership Forum in Kansas City, Mo.

The new governance structure comprises nine commissions. Each commission’s scope of work contains tasks that will move the Academy toward meeting FFM goals. Four commissions have mandated subcommittees that preserve student, resident, international graduate and special constituency interests. These commissions continue the Academy’s focus on social justice issues such as health disparities, patients in underserved rural and urban areas, and challenges family physicians face in providing care in underserved areas. Also, each commission can appoint issue-specific subcommittees that will serve for the time required to meet their assignments.

Franks says the commissions have broad scopes of work and the new structure encourages multiple avenues for addressing member concerns because an issue can go to more than one commission, when necessary. As a result, more than one commission can provide its perspective to final Academy action.

“As a board, we love it when we see issues come through several commissions because then we know all the points are looked at and we’ve got a rich program,” she told town hall participants.

Fleming agreed. “In the past, the commissions worked in silos,” he said. “We want to get out of the silos.”

According to AAFP President-elect Larry Fields, M.D., the new governance structure also will ensure greater efficiency in use of members’ dues. “This provides a direct line between our strategic plan, the commission structure and the budget,” he said. “We needed to make the structure more nimble to implement the strategic plan.”

Equally important, Frank says, is that the new structure maintains current commission and committee members’ expertise and service. Those now serving on commissions and committees will receive offers to serve in new positions that most closely match their service and interests.

The nominations process will continue to rely on chapter input. Frank and Fields said the new structure enables chapters to think beyond geographic limits and to submit names for service based on their credentials rather than whether they meet a geographic quota.

“If you’ve got good people with good credentials, submit their names,” said Frank. “We’re looking at credentials first, not geography.”

For more information on the governance structure, visit “New AAFP Structure Puts Focus on Meeting Strategic Goals,” at www.aafp.org/x34175.xml.

Source: AAFP News Now, May 18, 2005. © American Academy of Family Physicians.