Medical Care
Section Newsletter
Winter 2011

Letter from the Chair

Dear Colleague,


How do the Medical Care Section, APHA, and the fortunes of the United States all fit together?  Clearly all are caught in a reactionary political period following the economic crisis and the political progress that moved the country closer to the goal of having everyone under the health care “tent.”  No one should recognize the reaction that has followed better than our president, who described in clear terms the reverse swing of the political pendulum that followed the 1960s civil rights and antiwar movements in his first book, “The Audacity of Hope”.  The outcome of our evolving political landscape will depend on the strength of our institutions including the media, our economy, and the effects of climate change which have thus far been significantly under-rated.  We are under duress.  But we should note that the United States has emerged from earlier periods of perplexing technological change and shifting organizational and geopolitical relationships with strong “Win the Future” attitudes and capabilities.     


How does this affect us in the public health sector?  My own top three priorities are innovating toward a healthier future (public health), protecting health reform, and addressing climate change.  Personally, I try to be involved in all three areas.  I am on a Green Committee that addresses the carbon footprint of my institutions, I teach policy and educate about the benefits of health reform in my community, and I work to re-invent primary care by incorporating elements of the chronic care model (self management, a broader cohesive office team, and better measurement) and the Patient Centered Medical Home. Each person has to set their own priorities; but there is no lack of worthy objects of your energy.  


The Medical Care Section is charting a course with priorities that reflect its members.  Ellen Shaffer covers developments in health reform through her EQUAL Health Network.  Ollie Fein continues to speak in favor of single payer systems.  Wayne Myers is educating us about the farm subsidy program.  (Note the subsidies for commodities in our agricultural system.)  Renee Carter is on a regional board of Planned Parenthood which will step up defense of its contraceptive activities which are threatened because it is also an abortion provider.   Gordy Schiff is working with a network of practices to improve patient safety.  Julie Zito is guest editor of a special edition of the journal Medical Care that will be issued on the 50th anniversary of FDA reviewer Frances Kelsey’s decision to refuse approval of Thalidomide in America.  At our recent mid-year meeting, there was interest in inviting speakers on these topics and others. 


We seek to recruit new members, encourage student APHA members to join us, and identify new leaders to succeed us in leading the Section and APHA.   Committed public health advocates with drive, ambition and eagerness to find and build solutions should join us.



Mona Sarfaty MD, MPH, Chair of the Medical Care Section

Public Health Under Attack: Call for Leadership

Ellen Shaffer, PhD, MPH


Congress is proposing an onslaught of cuts to domestic spending, including cuts to vital public health services. Initiatives by the Center for Policy Analysis aim to carry out the Call for Direction in 2011 by the EQUAL Health Network.  The Call for Direction can be found at the EQUAL Health Network’s website


The EQUAL Health Network’s listserv disseminates news and opinions consistent with these views, and provides a discussion blog for debate on how best to achieve them.


Ellen Shaffer can be reached at

Vermont on a Path to Single-Payer Health Reform

Oliver Fein, MD


On Jan. 19, Harvard health care economist William Hsiao presented testimony to the Vermont legislature stating that Vermont could provide every resident with health insurance and still save money by consolidating its multi-payer private health insurance industry into a single-payer health care system. Hsiao, who had been hired by the state legislature to come up with three possible designs for a new health care system, said his team had calculated a single-payer system would save $2.1 billion in health spending by 2025. 


Details of his three options were to be released on Feb. 17. At this writing, the general characteristics of each option are known:  Option #1 would be a state government-run single payer program; Option #2 would create a health insurance exchange with a public option; Option #3 would create an independent board with representatives from employers, patients, providers and government agencies to oversee a single payer program. Hsiao believes the third option is most feasible because it is likely to be accepted by a broad cross-section of Vermonters.


Dr. Deb Richter, a family physician in Cambridge, Vermont, and past president of Physicians for a National Health Program (PNHP) commented: “Dr. Hsiao has performed an extraordinary service. I encourage everyone to familiarize themselves with his team’s report and to participate in the public discussion of it.”


Since then, Gov. Peter Shumlin has introduced a bill in the Vermont legislature that spells out how the state could move to a single-payer plan in three stages over four years. The first stage would start this year. Vermont would do the planning needed to establish a health insurance exchange as called for under the federal health care reform law.


The second stage would begin in 2014 when the health insurance exchange would begin operations.  The exchange would include employer groups with fewer than 100 employees, and state and municipal employees.


The third and final stage would be implemented when the federal government granted Vermont waivers to include Medicaid, Medicare and worker’s compensation into a single, publicly financed exchange. At that point, all Vermonters would receive coverage by virtue of their residency for a comprehensive package of health care benefits, which would be funded by taxes.  Coverage would not be linked to employment, and most Vermonters would pay into an equitable system for financing this coverage.  The bill doesn’t spell out the exact financing system – payroll, income, corporate taxes, and taxes on unearned income, or a combination of all of these   but calls for continued research. The private health insurance industry would be limited to offering supplemental coverage that does not duplicate the public coverage.


Dr. Richter declared: “We have the potential of setting an example for the entire nation about how to bring justice and equity to health care, one based on the principle of everybody in, nobody out. We can make history.”


Oliver Fein can be reached at


The Farm Bill: Why You Should Care About It

Wayne W. Myers, MD


The inaccurately named “Farm Bill,” usually renewed about every five years, seems likely to be reauthorized in 2012.  Even if you have you have no interest in farming, there are some things you should know about this $300 billion monster.


The first major element to consider is that there will be a lot of money involved.  The largest provisions in the bill are driven by formulas rather than appropriations, so spending on programs authorized by the bill varies from year to year, depending on factors ranging from unemployment to wheat prices.  The annual dollar cost is about three times the cost of the Iraq war. 


If the new bill follows the outline of the current measure, there will be 12-15 “titles.”  Many of these will be of interest only to rural people, but we should all be aware of the big provisions.  The first in the current bill provides over $100 billion a year in “commodity payments” to growers of cotton, corn, wheat, soybeans, rice, and legumes and oil seeds (the payments include owners of land that grows these commodities).  The structuring of the “commodity payments” is very complex, is different for every commodity and is changed in every farm bill.  The reason for the frequent changes?  There is no good way to give away all that money without messing up domestic and international markets and incentives. 


The current bill has had numerous international and domestic implications.  It has driven Haitian rice farmers out of business, kept West African cotton farmers in dire poverty and driven up Mexican corn prices.  U.S. cotton policy has been judged illegal by the World Trade Organization in an action brought by Brazil, but the penalty levied was not sufficient to motivate a U.S. policy change. The scheme for converting petroleum-plus-corn-plus-government-subsidies to ethanol-plus-private-profit is widely debated.  The commodity programs will be hard to phase out, though most of the money goes to three states: Texas, Iowa and Illinois.  The value of the payments has been factored into land values.  Discontinuing the payments would be likely to precipitate a land mortgage crisis.


The second major element to consider is Title IV in the current bill, the Supplemental Nutrition Assistance Program (SNAP), better known as the Food Stamp Program.   In November 2010, 43 million Americans -- about one in seven --  received Food Stamps averaging $133 per individual per month in value.  That equates to an expenditure of about $70 billion per year. 


The Farm Bill, with its commodities and export titles, is being defended as a jobs bill, a whole new twist.  This is ironic, since for decades industrial agriculture has been bragging about how few farmers it takes to produce a ton of food as it drives most farmers off the land.  Now lobbyists are pitching commodity exports as pulling America out of the recession. 


Wayne Myers can be reached at



Renewed Congressional Threats to Women’s Health

Renée Carter, MD, MPH, FACP


The recent mid-term elections have turned the once Democratic House over to Republicans, and its new Speaker, Rep. John Boehner (R- Ohio), has pledged to be “the most pro-life Speaker ever.”  He kicked off his newly earned position meeting with anti-choice extremist Randall Terry. Boehner and fellow conservative House members have wasted no time in developing their anti-choice agenda. 


One such bill is HR 3, better known as the “No Tax Payer Funding for Abortion Act.” Introduced last month by Rep. Christopher Smith (R- N.J.), the bill would make permanent, and expand, provisions of the Hyde Amendment, which restricts the use of public funds for abortions except in cases of rape, incest, or threats to mothers' lives. The bill would narrow these restrictions to only allow abortions in cases of so-called “forcible” rape, and limit the incest exemption to only when the victim is a minor.


Rep. Pitts has also introduced HR 358, the “Protect Life Act.” This bill rehashes his previous attempt at limiting abortion coverage through health insurance exchanges depicted in the ACA. In addition, the “Protect Life Act” would hold harmless hospitals that refuse to provide patients life-saving treatment, for example, in cases of medically indicated abortions to save the life of the mother.


The “Title X Abortion Provider Act”, HR 217, introduced by Mike Pence (R- Ind.), prohibits the Department of Health and Human Services from providing federal funding for family planning providers that provide abortion care services even with private monies. This bill will essentially gut Planned Parenthood of critical funding that makes primary health care and cancer screening services available to rural and low income communities, negatively impacting millions of women.


The onslaught began in 2009 when Rep. Bart Stupak (D- Mich.) and Rep. Joe Pitts (R-Pa.) proposed their anti-choice amendment to the Patient Protection and Affordable Health Care Act (ACA). The amendment required women to purchase separate abortion coverage beyond their primary health insurance. It also prohibited the use of federal funds in connection with private health plans that provide abortion coverage. Though the House version of the amendment passed, the Senate version was voted down, keeping the amendment out of the final health care reform bill.  Just when it appeared that things could not get worse regarding reproductive freedom for women, we now have a vociferous group of congressmen and women who want the nation to return to pre-Roe v Wade days.



Renée Carter can be reached at See for the Trust Women/Silver Ribbon Month campaign by public health groups and others to increase the visibility of pro-choice views.  


Medical Loss Ratios: NEJM Letter to the Editor Reprint

On Nov. 11, 2010, the New England Journal of Medicine Blog ran a Perspectives article by Timothy Jost, JD,  entitled, “Writing New Rules for Insurers — Progress on the Medical Loss Ratio”. Ellen Shaffer sent the following Letter to the Editor in response.  



To the Editor:

In his Perspective article, Jost (Nov. 11 issue) (1)  discusses the medical loss ratio — the percentage of an insurer's premium revenue that it spends on clinical services for enrollees. In assessing the medical loss ratio, medical expenses must be defined narrowly to effectively provide incentives for cost control and ensure that premiums intended to pay for medical care are not diverted into marketing, administration, and excessive executive compensation.


Current proposals give the insurance industry two enormous new bites into the apple. The new health care reform law (the Affordable Care Act [ACA]) includes “activities that improve health care quality.” (2) Contrary to Jost's statement that the regulation proposed by the National Association of Insurance Commissioners (NAIC) was consistent with the ACA, the NAIC regulation takes an additional giant step beyond the ACA by giving the industry credit for broad categories of activities that “improve health outcomes,” including wellness and prevention programs. The industry has already begun to game the system, creating and benefiting from marketing efforts and insubstantial programs that masquerade as clinical treatments. (3)


The Medicare program and many large insurance companies achieve a medical loss ratio of 95 to 98% without these cushions. The ACA requires only 80 to 85%. The Department of Health and Human Services should review the NAIC's otherwise laudable work to ensure that the medical loss ratio provides strong incentives to reduce the administrative burdens placed on physicians and patients.


Ellen R. Shaffer, PhD, MPH
EQUAL Health Network, San Francisco 

(1)  Jost TS. Writing new rules for insurers -- progress on the medical loss ratio. N Engl J Med 2010;363:1883-1885


(2)  PPACA Sec. 2718 (a)(2).


(3)  U.S. Senate Committee on Commerce, Science, and Transportation, Office of Oversight and Investigations, Majority Staff. Implementing health insurance reform: new medical loss ratio information for policymakers and consumers — staff report for Chairman Rockefeller. April 15, 2010. (

New AHRQ Funded PROMISES Malpractice and Safety Project in Massachusetts

Gordon Schiff, MD


Two decades ago, researchers from the Harvard Malpractice Study team published groundbreaking findings demonstrating that iatrogenic harm was epidemic (1),(2). These findings ultimately helped catapult two key Institute of Medicine panels and reports into national prominence and launch a national movement for patient safety (3),(4). That study demonstrated that not only was preventable harm in hospitalized patients much more common than previously suspected, but the spotlight on malpractice suits failed to illuminate the seven of every eight cases where preventable harm was occurring.  A newly funded study proposed to extend this work by broadening the focus from the inpatient setting (the focus of the original Harvard Malpractice Study) to outpatient practice where most health care is delivered and where the majority of malpractice claims now originate.


The project -- a collaboration between the Massachusetts Department of Public Health, the Massachusetts Medical Society, Brigham and Women’s Hospital, the Department of Public Health, the Institute for Healthcare Improvement (IHI), the Massachusetts Coalition for the Prevention of Medical Errors (Coalition), and the Massachusetts Medical Society -- has been launched to learn from and reduce outpatient malpractice risk.   Entitled PROMISES (Proactive Reduction in Outpatient Malpractice: Improving Safety Efficiency and Satisfaction), the demonstration project seeks to recruit and reimburse 16 general medical and family practice offices to work with (and receive free consultation from) the world’s leading improvement and efficiency experts to develop ultra-safe practices. 

This project has been funded with $2.9 million for three years by the Agency for Healthcare Research and Quality. PROMISES’ primary goal is to significantly improve and reduce problems in three areas that have potential for malpractice errors and suits: a) medication reconciliation; b) follow-up of test results and c) referral management.  In addition, a second and overarching aim seeks to improve communication — both among staff within office practices and, most importantly, between the office staff and patients -- during clinical encounters and to more effectively address patient concerns.  Growing evidence shows that problems in these three high volume processes (medication reconciliation, results follow-up and referrals) as well as breakdowns in patient communication, lead to frustration and anger, and underlie most malpractice claims.


This research project is designed to improve patient safety and reduce malpractice risk premiums in the Commonwealth.  During the third year of the project, we will evaluate and disseminate the lessons learned and share successful intervention tools and strategies across the Commonwealth with a broader audience of practices, practitioners, payers, and policy makers. Forums will be hosted by the MMS, the Coalition, Healthcare for All, as well as publications prepared by the research team based at Brigham and Women’s Hospital and the Harvard School of Public Health.


The project is currently recruiting the 16 demonstrations (and 16 control) practices, developing the improvement curriculum, and evaluation measurement tools. 


For more information contact Gordy Schiff at


Gordy Schiff, MD, is Clinical and Research Director, PROMISES Clinical and Research Center at Brigham and Women’s Hospital and Past Chair Medical Care Section APHA. 


   (1) Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324(6):370-376.

   (2) Leape LL, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA et al. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med 1991; 324(6):377-384.

   (3) Kohn L.T, Corrigan J.M, Donaldson M.S. To Err is Human. Washington: National Academies Press, 2000.

   (4) Committee on Quality of Health Care in America IoM. Crossing the Quality Chasm. Washington: National Academy Press, 2001.

Call for Papers for Special Edition of Medical Care Journal

Readers of the newsletter will be interested in the details of the February 2011 call for manuscripts on pharmaceuticals and the health of the public. Details are shown below.




The past two years have marked important anniversaries in the history of public health-oriented medical care. First, 2009 was the 35th anniversary of Silverman and Lee’s seminal work Pills, Profits and Politics. Second, 2010 marked the 50th anniversary of Dr. Frances Kelsey’s distinguished service award for her decision to thwart the marketing of thalidomide, which averted an impending disaster for drug-exposed fetuses. Such milestones spurred the Drug Policy and Pharmacy Services Committee of the Medical Care Section to mark these occasions with a special edition of the Journal.  The special edition will feature clinical and health policy research advances related to medication prescribing and use.  Specifically, we are seeking manuscript submissions to support sound medication use, as well as the societal and professional practices and policies to guide this objective. The Medical Care Section of APHA is committed to a mission to assure that the U.S. health care system provides access to an affordable, quality health care system.  Appropriate use of medication is integral to that mission.


Manuscripts are sought within any of the following topic areas:

·         Effectiveness and comparative effectiveness, including observational studies from large databases and secondary analysis of data from clinical trials.

·         Drug safety in community populations

·         Regulatory sciences, for example: the impact of boxed warnings on utilization, cost and safety of pharmaceuticals; the impact of the Prescription Drug User Fee Act (PDUFA); the legacy of the Joint Commission on Prescription Drug Use; recent FDA panel decisions and impact on drug utilization.

·         Drug safety studies with AERs data, the FDA Sentinel Initiative or other models.

·         Impact of direct-to-consumer prescription drug advertising on utilization, cost and safety of pharmaceuticals.

·         Medication error, and systems to reduce its incidence and improve outcomes.

·         Strengths and weaknesses of the U.S. drug development system.

·         The role of government in assuring the health of the public with a focus on pharmaceutical efficacy, effectiveness, safety and access.

·         Off-label prescribing practices and policies, both in the United States and in other health systems.

·         Global health: ethics and regulation from a global pharmaceutical perspective.

·         Disparities (regional, racial, ethnic, and vulnerable populations) in medication utilization patterns.

·         Medication persistence or adherence;  consumer/ patient medication education.

·         Impact of Best Pharmaceuticals for Children Act and similar legislated mandates for effectiveness and safety of pediatric medicines.

·         Cost of illness, cost-effectiveness, and insurance coverage of pharmaceuticals.

·         Comparative international approaches: NICE guidelines in the U.K. vs. U.S. medical specialty guidelines.

·         Technology assessment and drug insurance coverage.


All manuscripts should be submitted through Editorial Manager by July 31, 2011.  A Letter of Intent should be submitted by March 31, 2011.


When uploading manuscripts for this issue, select “Special Issue on Pharmaceuticals” as the manuscript type. The accompanying cover letter should request consideration for the special theme issue. Manuscripts should follow the standard formatting requirements described in the instructions to authors, with full reports limited to a maximum of 4,000 words. Our usual standards of rigorous peer review will apply. Inquiries are welcomed and may be directed to Managing Editor Sue Houchin at

New Book Note

Marc A. Rodwin, “Conflicts of Interest and the Future of Medicine: The United States, France and Japan”.  New York.  Oxford University Press, 2011.  $29.95


Most physicians would agree that the ideal doctor–patient relationship is one in which physicians provide appropriate and timely treatment — not too much, and not too little — to patients.  Yet this delicate balance is extremely difficult to maintain because of the potential for conflicts of interest.  Such conflicts result from insurers’ demands for high profits and from doctors’ desire to defend their primacy over insurers, hospitals, and the state.  The consequences of such conflicts of interest can be devastating for the patients — and the society — stuck in the middle.


As most Americans know, conflicts of interest riddle the U.S. health care system. Yet widespread conflicts of interest are not unique to the United States. In fact, they exist in different form in virtually all advanced nations. In “Conflicts of Interest and the Future of Medicine,” Marc A. Rodwin examines the development of these conflicts in the United States, France and Japan.  As he shows, the variations in the type and prevalence of such conflicts are a product of the national differences in the organization of medicine, insurance and public policy. Rodwin then analyzes the unique strategies that each nation employs to cope with them.


Unfortunately, many proposals to address physicians’ conflicts of interest do not offer solutions that stick. But as Rodwin demonstrates, it is possible to mitigate these problems with carefully planned reform and regulation. Drawing on the experiences of these three nations, Rodwin looks at the effectiveness of measures taken in the private and public centers to preserve medical professionalism — and concludes that there just might be more than one prescription to this seemingly incurable malady.

Nominations for APHA-wide Boards and Committees

Dear Medical Care Colleagues:


The Medical Care Section wants to help interested Section members get appointed to the APHA-wide boards or committees of their choice.  Listed below are the boards and committees to which a member of the Medical Care Section can be nominated in 2011:

        Action Board  -  11 vacancies

        AJPH Editorial Board- 5 vacancies

        Annual Meeting Program Planning at Large - 3 vacancies 

        Awards Committee - 4 vacancies

        Committee on Bylaws - 2 vacancies

        Committee on Membership- 1 vacancy

        Committee on Women's Rights (COWR) - 2 vacancies

        Education Board- 5 vacancies

        Equal Health Opportunity Committee (EHOC) - 3 vacancies

        International Human Rights Committee (IHRC)- 5 vacancies

        Intersectional Council Steering Committee  -  no vacancies

        Martha May Eliot Award Committee - 2 vacancies

        Publications Board - 5 vacancies

        The Nation's Health Advisory Committee - 3 vacancies


For the full list of openings and more detail on each committee, go to list of 2011 Open Positions.htm


Materials are due to APHA by March 31. 


The APHA and the Medical Care Section are committed to having a diverse membership and a diverse leadership.  We seek candidate diversity with respect to race/ethnicity, gender, age, geography and profession.  We invite you to get more involved in the Medical Care Section and in APHA. 


The nomination form can be found at the following link:


Get involved now! 

Many thanks.



Gail R. Bellamy, PhD

Immediate Past Chair



Mona Sarfaty, MD


Registration Now Open for APHA Midyear Meeting — "Implementing Health Reform: A Public Health Approach"

Registration is now open for APHA’s Midyear Meeting: Implementing Health Reform — A Public Health Approach. Join public health colleagues and partners in Chicago, June 23-25, to better understand the health reform law and its implications from a public health perspective. Gain the tools needed for implementing the provisions of the Affordable Care Act and for improving health outcomes in communities across the country. The early-bird registration deadline is April 15. To register or for more information, visit: .



Report on Submissions for This Year's Annual Meeting

As of the time of this writing, we have received a total of 210 abstracts for the Annual Meeting.  Of these, 202 are complete, and only five are student submissions.  They are fairly evenly divided between the categories of Health Services Research (with the most submissions), Quality Improvement, and Primary Care.


For more information on abstracts for the 2011 Annual Meeting, please contact Jim Wohlleb at

Job Opening Notice

Assistant/Associate Professor – Health Promotion Research Center (HPRC) Department of Health Services, School of Public Health

University of Washington, Seattle


The Health Promotion Research Center (HPRC) at the University of Washington seeks to fill one or two full-time (100% FTE) faculty positions as Assistant or Associate Professor, without tenure by reason of funding (WOT) or as Research Assistant or Research Associate Professor. A doctoral degree in a core social science discipline related to public health is required. The ideal applicants will have strong training in intervention research methods, a research interest in promoting healthy aging among older adults and a history of obtaining research funding. Experience in teaching and demonstrated ability to initiate and successfully conduct research and practice in the community is required. HPRC ( is a well-established, innovative multi-disciplinary program whose mission is to improve health by conducting prevention research that is incorporated into community practice.


We encourage applications from candidates committed to preventive intervention research among older adults. The responsibilities of the position include teaching within the social and behavioral sciences area, mentoring students, and supervising theses and dissertations. Candidates would also participate in and lead research projects on approaches to primary and secondary prevention of chronic diseases among older adults, and develop new research in this area.


We are a diverse department (44 faculty, 11 research faculty, 225 Adjunct, Affiliate and Clinical faculty) with national expertise in organization and financing of medical care, health disparities and community-based participatory research, and quality of life and outcomes research ( In addition, there are unparalleled collaborative opportunities at the UW (HPRC collaborates with the Schools of Dentistry, Medicine, Nursing, and Social Work), and in the Seattle area (HPRC collaborates with community-based senior-serving organizations, the Area Agency on Aging, state and local health departments, a national Health Services Research and Development Center of Excellence at the VA, the Fred Hutchinson Cancer Research Center, and the Group Health Research Institute).


The University of Washington is an affirmative-action, equal-opportunity employer. The University is building a culturally diverse faculty and staff and strongly encourages applications from women, minorities, individuals with disabilities, and covered veterans. This position is contingent upon available funding. The successful candidate(s) will be expected to participate in the teaching, research and service missions of the Department of Health Services.


Submit electronic letter of interest describing research and teaching history and plans, curriculum vitae, and four original letters of reference. The position is open until filled, review of applications will commence on March 1, 2011. Send application to:

Holly Bergstrom (

Department of Health Services

Box 357660

1959 NE Pacific Street

Seattle, WA 98195