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Community Health Planning and Policy Development
Section Newsletter
Spring 2005

Message from the CHPPD Chair: Communicating for a vision

Close-up of Forsythia blooming 
Spring Celebration
Photo credit: Rohinton K. Irani
Welcome to spring . . . a time of new life, new opportunities and new commitments . . . it is also a time for spring cleaning, spring gardening and spring rains. As the Chair of the Community Health Planning and Policy Development Section (CHPPD), I find myself torn between the enthusiasm of the season and the reality of responsibilities. Such is the dilemma for our volunteer efforts as we pursue the vision of what could be while weighed down by the daily pragmatism of what is. How do we balance our time?

For me, “vision” is simply a more sophisticated term for “dreams” . . . and without dreams, we are without purpose, and without purpose, we are without motivation. It is all too easy to be overcome by the workaday world, and allow our time to be consumed by urgencies and details. Many of us have been faced with trying to “do more with less” as budgets have been painfully reduced and workloads increased. For example, my planning and regulatory office has lost over 70 percent of its staffing while we now produce more than 200 percent more revenue than just five years ago. The vision dims as the back bows.

And yet, a clear plan for the future is more important now than ever before in order to guide new policy development at all levels. In health care, we are faced with heightened expectations while struggling with diminishing resources, personally and professionally. The misguided path of competition in health delivery needs to be replaced by a reinvestment in cooperation and caring. As planners, this is our time to step forward with a restored vision.

At the risk of repeating myself, communication has been repeatedly discussed as one of the most important things that we can work on this year. This takes many forms from local and state interaction to annual face-to-face conference contacts. At CHPPD, we want to continue to develop our valuable communication vehicles such as the newsletter, e-mail exchanges, listserv dialogue and Web site service. Member input is an important way to help us respond to needs, so it is vital that we hear what you have to say and how we say it.

Stay in touch, and drop me line if you have ideas or just want to leave a greeting: <macquest@mchsi.com>. Communication continues to be a two-way street and a scenic drive, and our dreams only become visions when we work on them together.

At 55 sessions, CHPPD sets record in New Orleans APHA

This year we received more abstracts than in the last five years. We received approximately 580 completed abstracts. Almost 15 of them were transfered to other sections, mainly International Health. Since the meeting is in New Orleans we were able to add sessions, granted from APHA, largely because the convention hall is so large and has so many meetings spaces. Therefore we have a total of 55 sessions, the largest ever. Forty-five sessions are scientific and include two round table sessions; of these, 18 are invited sessions and 27 are contributed sessions. In addition, we have 10 poster sessions. However, this still means rejecting over 120 abstracts or about 20 percent of the submissions.

One exciting aspect of the submissions is the unusually large number of student abstracts received this year. In past years we usually had between 10-13 student submissions, whereas this year we received 55 student abstracts! Over half of these will be in scientific or poster sessions.

The abstracts continue to focus on methodology, including new GIS and Web-based methods, obesity and diabetes, the environment and its relation to asthma and childhood diseases, as well as prevention strategies for cardiovascular health and cancer screenings. The new areas to be presented are based on innovative uses of the bioterrorism funding to local health departments. Some have been used to develop infrastructure, while others were used for new community approaches to vaccinations, especially during the flu season.

The official APHA acceptance/rejection notices went out May 31, and the program is now available at <www.apha.org/meetings>.

CHPPD Section Creates New Opportunities for APHA Student Members

As the Student Assembly Liaison to the Community Health Planning and Policy Development Section, it is my pleasure to announce several new opportunities for students to become more involved and visible within the Section.

This year CHPPD leadership announced new abstract submission opportunities for students, and as a result saw an increase in student submission. The first are two new student awards for the best submissions by a masters and a doctoral student. Please keep your eye out for the announcement of these awards in the next CHPPD newsletter. Each award recipient was chosen on the basis of their abstract review scores, and were accepted to present in a CHPPD oral session. They will also be given a $200 travel scholarship to the Annual Meeting and an award presented at the CHPPD social hour. As usual, all student abstracts receiving good scores were incorporated into the CHPPD program. This year, however, students receiving scores below the acceptance level will be offered constructive feedback on their abstract from volunteer CHPPD faculty members. The purpose of this new process is to provide new student members and first-time submitters with feedback to help them improve their future APHA abstracts.

Last month, CHPPD leadership also voted to pledge a contribution of $500 to the Student Assembly, in order to support their new Student Assembly Conference Scholarship. This donation exceeds that suggested by the Student Assembly, as it is the feeling of the Section that this is a worthwhile cause. Students often struggle to fund their travel and registration at the Annual Meeting, and yet are the future leaders in public health and APHA.

The CHPPD Section is also involving students in local arrangements this year in New Orleans. These students will help coordinate any local activities, receive CHPPD booth materials prior to the meeting, and will help set up and man the booth throughout the meeting. These students include Audrey Lipham, Jonathan Alford, and Salman Baghian from Louisiana State University, and Kim Nguyen from Baton Rouge Community College. In return for their invaluable assistance, the section will cover their student membership and provide each with a $150 stipend for Annual Meeting housing and travel arrangements. If you see these students at the booth, please be sure to introduce yourself.

These new student opportunities allow the Section to draw more students into CHPPD and encourage wider participation in the Section’s activities, contribution to the Section’s Annual Meeting program, and involvement in the Section’s leadership. It is my opinion that increased student participation in the Section will increase membership, enthusiasm, and long-term sustainability in our already vibrant Section! If you are interested in being involved in the CHPPD student committee, please contact me.

Universal Health Care Revisited

The last attempt to formulate a national plan for universal health care ended 11 years ago with the collapse of the Clinton Plan for “health care reform.” Since then, there have been incremental initiatives toward greater health care coverage, notably HIPAA and SCHIP, but as laboratories for developing universal health care, the states have not been able to marshal the necessary political and economic resources. This may now be changing. According to the National Conference of State Legislatures, at least 18 states currently have introduced legislation regarding universal health care: California, Colorado, Connecticut, Florida, Hawaii, Kansas, Illinois, Maine, Maryland, Massachusetts, Minnesota, Missouri, New Hampshire, New York, Ohio, Oklahoma, Rhode Island, and Vermont.

Maine’s Dirigo Health plan has gotten considerable attention since it was signed into law in 2003. It is a voluntary, market-based plan, intended to achieve universal coverage in the state by 2009. It was designed to provide small businesses and employees with an option for coverage. But as a voluntary plan, it will fall far short of universal coverage, for it uses private marketplace health insurance, with premiums subsidized by the state on a sliding scale based on family income. Maine contracts with Anthem Blue Cross and Blue Shield of Maine and competes with existing health plans to offer health coverage to employees who work at least 20 hours per week. Employers must offer coverage to dependents and families. Employers cover at least 60 percent of the cost of the workers' premiums, and employees must then pay the remainder of the cost. The state now provides coverage for families earning up to 200 percent of the federal poverty level.

California has been considering a much more radical approach, one that would use a single-payer to achieve true universal health insurance. State Senator Sheila Kuehl’s legislation, dubbed the California Health Insurance Reliability Act, would provide medical, dental, vision, hospitalization and prescription drug benefits for all Californians. It would replace private insurance plans and also extend coverage to approximately 7 million Californians who have no health insurance. The program would be funded by a system of means-based premiums, and all uninsured residents would have to buy coverage or enroll in a sponsored program. A Lewin Group study found that a single-payer system could cut health care expenses in California by $25 billion per year, and save California $343.6 billion in health care costs over the next 10 years, mainly by cutting administration and using bulk purchases of drugs and medical equipment.

On April 21, the Vermont House passed and sent to the Senate a bill to create a single-payer system under which all Vermonters would gain coverage for all health services determined to be "essential" by the state government. It would create a health care delivery system that is “equitable, universal, well-coordinated, patient-centered, cohesive, unified, comprehensive, continuous, sufficient, fair, sustainable, and accountable,” establish cost containment targets, and enforce them through global budgets for hospitals and caps on physician reimbursement rates. The state would impose “play or pay" taxes on both employer payrolls and employee paychecks at businesses that don't offer health insurance. State health planning would be brought back in the form of an “integrated, community-based system” overseen by regional community health boards composed of citizens. The cost to the state would be about $2 billion per year. Of course, if enacted, the funding available to the state legislators will help them decide what services are “essential.” The legislation does not address how to integrate Medicare, Medicaid and other public health insurance programs into the state’s universal health care.

The fundamental problem in the states is that they contain within them the same competing interests that doomed the Clinton plan, and so a greater countervailing force from outside the states is needed. In a nation where business prosperity is paramount and competition is respected and feared, the decisive push to do something may be found in what it will take for businesses and states to prosper today.

General Motors and the other automakers are a case in point for the inability of business to continue to bear the burden of health insurance benefits and compete in a multi-national marketplace. Wal-Mart, and other low-wage employers that fail to provide full health insurance to many of their employees, have raised issues of unfair competition by, in effect, shifting their costs to the states through the states’ safety net programs. At the same time, the states are so short of revenue to continue funding Medicaid and other programs in their budgets that they are looking to tax their businesses for increased revenue. In addition, the states are facing rapidly rising costs for the health benefits they continue to provide to their own former employees in retirement.

Can there be any solution to this short of a federal takeover of the financing of health care? With its own rapidly growing costs for an expanded Medicare program and over half the costs of Medicaid, how else but by realizing the administrative efficiencies of a single-payer health care system can the federal government accomplish it? By consolidating federal, state, and private health insurance programs under one administration, the savings could be more than sufficient to fund a true universal health care program.(1)

Some of us see this as incremental too, for it addresses the financing of health care, but does nothing to rationalize its delivery. To do that, further steps are needed to remove the remaining profit motive from the delivery system and restructure its priorities toward prevention and public health. Only then might we as citizens and taxpayers receive full value for what we spend on health, a measure in which we ranked 72nd among all nations in the World Health Report 2000.(2)


References

  1. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med 2003;349:768-775
  2. .
  3. For a useful summary of the World Health Report 2000 and its insights for the US health care non-system, see “With Liberty and Justice for All?”

Experiences of a New Mexico City on Including Public Health & Safety in the Master Plan

Map of New Mexico State with Portales 
If you throw a dart at the middle of the straight line part of the border between Texas and NM and hit about 1/8" slightly SW of that line you will be in Roosevelt County. Its largest town is Portale
Each county in New Mexico is mandated to have a volunteer Health Planning Council. One of the major responsibilities of each Council is to identify the health status of its citizens. This can include, but is not limited to, such issues as: gaps in consumer knowledge about available services; safety issues such as unsafe roads, lack of safe cross-walks, sidewalks, and ADA access compliance; issues involving vacant and unsafe buildings, abandoned vehicles and other heavy equipment; health disparities such as access to health care providers, specialists, uninsurance, and undocumented worker access to health care. Once issues are identified and prioritized, then the Health Council must identify solutions and find resources to help overcome identified problems. This requires coordination and cooperation with other agencies, community based organizations and city and county governmental agencies.

In Spring 2004 the New Mexico city of Portales, Roosevelt County, contracted with an outside firm to evaluate the needs of the city and surrounding county. A “comprehensive work group” was formed to provide input and general assistance with development of a 20-year Comprehensive Plan. Unfortunately, no one in the public health community was included in this work group, nor were they aware that such a work group had been initiated. By November 2004 a draft Comprehensive Plan had been developed. This plan included a tentative timeline for implementation of recommendations. In late November 2004 the Roosevelt County Health Planning Council (RCHPC) became aware of the proposed plan and asked for a copy for review and comment. Fortunately, the period for public comment had not expired, and the RCHPC was able to make useful contributions to the plan.

RCHPC identified the need for a health planning council member to to be part of the comprehensive work group. Among the important public health issues identified by RCHPC are:

  1. Students of all ages living within one mile of their respective schools must walk to school. Most students, all ages, have to walk on, and cross over busy streets. There are very few cross walks, no pedestrian bridges except one at the University, and very few sidewalks in Portales.

  2. The elderly have few safe sidewalks to walk on.

  3. There is no safe way for pedestrians to cross the railroad tracks from one part of town to the main downtown area, the university and the high school.

  4. There are no safe walking and bike riding paths for city residents to utilize. The inclusion of such would greatly enhance citizen ability to get more exercise thus decreasing their susceptibility to such conditions as obesity and diabetes.

  5. Big-rig trucks drive through town and park on city streets and in the residential neighborhoods. These big rigs in residential neighborhoods create multiple health and safety issues, as well as causing extensive damage to downtown and residential roadways.

  6. There are many abandoned and vacant buildings and houses in the Portales and in the county; many of which have abandoned equipment on them. These locations are breeding grounds for disease and pose great risk to public safety, especially for children and animals.



These issues are not unique to the city of Portales or Roosevelt County. The solution is for members of the public health community and other interested citizens to become active members of their County Health Planning Council, attend City and County Planning and Council meetings and become active members of special task forces or work groups. Local newspapers, radio and television stations need to be monitored daily for issues important to the overall health, safety and well being of the community. The public health community needs to have an active voice in identifying and educating local policy makers about the importance of these and related issues and the impact these issues have on the well being of the overall community.

City and County Planning and Council meetings are open to the public. The more who attend, the more seriously policy-makers will consider issues of public health and safety. Interested individuals can get started by requesting a copy of the City or County Comprehensive “Master” plan. Then review it, discuss what it contains and what it does not contain with other public health professionals and make recommendations to benefit the public’s health.

The Master Plan for the city of Portales was expected to be available in late April. At the time the CHPPD newsletter was submitted, RCHPC was trying to get a copy of the plan to see if their input had been reflected in the final recommendations.

Role of the Payer in Establishing Community Health Policy: The Case of Emerging Medical Technologies and "Medical Policy"

Introduction

Community health planners, researchers and local health care advocates are all well aware of the traditional mechanisms by which health policy is determined. These range from open political processes and public forums to the potential impact of internal governmental staff, to the lobbying activities of physicians and health care organizations. Philanthropists and major foundations also have a significant role within local health care policy, with their scope of influence frequently integrated with local political engines. These activities comprise the mortar that occupies the varying spaces left between the masonry of state and federal mandates.

The role of the health insurer is rarely cited for its impact upon community health policy, yet it can rival the region’s health care providers as a significant policy influence. The payer is in the unique position of having well-defined, and often conflicting, contractual obligations with service providers, group insurance purchasers (including state/federal government), individual subscribers & patients, state & federal insurance regulators and stockholders. Within this context and under the influence of these customers, the payer has the responsibility to determine whether they will pay for thousands of medications and treatment technologies.

Under most conditions, this dilemma is appropriately resolved by allowing the treating physician to make the determination of efficacy. However, in the case of expensive, emerging medical technologies, payment decisions include many factors other than the treating physician’s recommendation. The review mechanisms and the guidelines for this process vary by payer, and are established as the “Medical Policy” for the plan. Payers with a dominant local market share become quasi public health agencies, able to dramatically influence patterns of care based upon these patterns of payment.


The Need for “Medical Policy”

Recent advances in chemotherapy and radiotherapy for oncology patients, genetically engineered drugs, artificial body parts and telemedical surgery have created an even greater burden on the payer to stay appraised of new health care technology. Increasingly, the lines between “investigational” and “state-of-the-art” are blurred, and are strongly influenced by market forces, investors, committed researchers and a public hungry for more effective health care. Appropriate monitoring of the efficacy of emerging technologies should include:


  1. Definition of the stage of clinical refinement for the technology.

  2. Does the technology provide an appreciable improvement over other interventions?

  3. Does the technology address an unmet need?

  4. How do similar technologies compare from a benefit/cost standpoint?

  5. Does the technology reasonably provide a therapeutic benefit to the specific patient in question?



A regional health insurer is typically uninterested in operationally addressing these complexities and unwilling to support the cost of necessary infrastructure. Even with a comprehensive, clinically sound technology assessment program, each health insurer is still faced with physician and consumer perception that the process is self-serving and with minimal objective value. There also is rarely a cogent rationale to have significant differences between payers concerning medical policy, unless that difference is due to an insurer’s marketing schema concerning more liberal/conservative coverage strategies (e.g., alternative medicine) or for the identification of medical technology assessment as an added-value “core competence” within their marketing portfolio.

The responsibility of the payer to develop medical policy related to emerging technologies must be addressed in a comprehensive manner, which both protects the patient and also recognizes the payer’s obligations to provide a cost-efficient health insurance product. And with rapid insurance market consolidation, there is a decreasing likelihood that the local market will be able to engage in a constructive dialog with the payer concerning the payer’s rationale for coverage of various advanced technologies.

Currently, each payer faces a “build versus buy” decision, which respect to medical policy (the Blue Cross Blue Shield Association is the most common vendor in this regard). Outside of state legislated mandates and Medicare + Choice requirements, each payer is provided significant latitude in the development of their Medical Policies (traditional Medicare allows its fiscal intermediaries to determine Medical Policy on their behalf, creating inconsistencies in payment policy on a national level). And unlike the statement of benefits, plan inclusions and exclusions which are required disclosures to each subscriber, medical policies are never disclosed to subscribers at time of enrollment. Subscribers only learn about the plan’s medical policy from their physician, if their prescribed treatment is not a currently covered service.


Balancing Access, Safety and Economics

An effective balance must be struck within each market for each payer concerning the responsibilities and obligations listed above. It is my position that the core focus of this balance should be to serve the best medical interest of the identified patient, being respectful of his/her individual desires. The health insurer should also recognize that the vast majority of all clinical cases will not create a situation of such dispute, as may arise in the case of use of emerging medical technology. When the patient’s best interest is paramount, the health plan should be able to effectively balance the following:

Obligation to Patients

  • Protect patient from harm

  • Provided medically related services as contracted

  • “Enable” professionals and service vendors to provide require interventions

  • Provide clinically credible, objective mechanism to review appropriateness of care



Obligations to Health Care Providers

  • Facilitate physician-patient relationship

  • Support physician or caregiver with scientifically based information and education



Technology Considerations

  • Provided mechanism to proactively review medical technology innovations

  • Allow patient to access new technology based upon clinical need and scientific efficacy

  • Develop flexible, appropriate payment methodologies for new technologies

  • Monitor provider use of new technology and provide medically appropriate guidelines for use. Insure that technology is not simply a revenue enhancement strategy, with negligible patient benefit



These obligations are reasonably similar for all payers, including Medicare and Medicaid, and also apply to ERISA-exempt, self-insured companies. They act to address the potential conflict between a patient’s need to access new treatments or tests and the obligation of the health plan to protect the patient’s interest within medically appropriate use of technology. What this does not address, however, is a mechanism to obtain the objectivity in technology assessment, patient-specific case review and availability of such a credible service for all payers within a market.

I would be very interested in your thoughts concerning this issue and any potential remedies to some of the problems which I have described. I will be developing a more detailed research proposal on this topic, using the case for coverage of intensity-modulated radiotherapy (IMRT) to highlight salient issues. Potential collaborators &/or students who would like some experience in policy research would be welcomed.

500-Day Plan, Ethics Among Issues Discussed at APHA Executive Board Meeting

APHA’s Executive Board gathered at APHA headquarters May 18-20 for its second face-to-face meeting of the year. In addition to hearing from outside speakers on issues pertaining to risk management, managing dissent among Board members, and the legal responsibilities of not-for-profit boards of directors, the Board also completed the Executive Director’s annual performance evaluation and voted to extend another three-year contract offer to him.

After a briefing by Government Relations staff, Board members spent an afternoon making Hill visits to their Congressional members to discuss three issues: public health infrastructure funding, specifically $8.65 billion in funding for CDC and $7.5 billion for HRSA; asking members to sign on as co-sponsors, if they hadn’t already, of the Kids Come First Act of 2005 (S. 114/H.R. 1668); and urging support for the Public Health Preparedness Workforce Development Act of 2005 (S. 506). Some Board members also took the opportunity to discuss their concerns about the negative health effects of CAFTA (Central American Free Trade Agreement) with their Congress members.

During his report to the Board, Executive Director Georges Benjamin related details of a visit he had paid to HHS Secretary Michael Leavitt in early May. Discussion centered around concerns about public health’s ability to respond to a possible flu pandemic or other infectious diseases, as well as attacks involving biological agents. Enhancing data system compatibility for improved information sharing as part of the necessary infrastructure to support rapid response was also discussed. Benjamin offered APHA’s assistance with the Secretary’s new initiative, the “500-day plan that will benefit Americans over a 5,000-day horizon,” helping to develop messages for any of the 500-day points related to public health. The 500-day plan is a management tool that details the Secretary’s priorities and provides direction to HHS leadership and management in their role of protecting and improving Americans’ health. See <www.os.dhhs.gov/500DayPlan>.

Responding to a resolution passed by the Governing Council at last November’s Annual Meeting, the Board received and accepted the recommendations contained in the Pfizer Workgroup Report. Governing Councilors had expressed concern about the relationship between Pfizer and APHA, especially that the Pfizer logo was prominently displayed on tote bags meeting attendees received during the registration process. The resolution pointed to Pfizer’s role as an obstructionist in the development and dissemination of cheaper generic drugs in places where they are so badly needed, principally Africa and Asia. As a result of accepting the recommendations of the Workgroup, the Executive Board will task the Executive Director with implementing existing policy on commercial donations and support, and will itself be responsible for reviewing and determining that corporate contributions are consistent with APHA policies. The Board plans to appoint a permanent Development Committee that will be tasked with, among other things, reviewing and recommending revisions, if necessary, to APHA’s policy on acceptance of corporate contributions.

May 31 was the deadline for nominating people for APHA awards like the new Helen Rodriguez-Trias Award for Social Justice, David R. Rall Award for Advocacy in Public Health, Jay S. Drotman Memorial Award, etc. See <www.apha.org/sections/awards>.