The American Medical Society (AMA) is alarmed because nonphysicians increasingly seek to perform healthcare tasks usually done by doctors. Permission to do such work must be granted by state legislatures. The AMA has encouraged its state affiliates to oppose this legislation, according to Jay Greene in American Medical News.
What the AMA calls "scope-of-practices" battles often revolve around the prescription of controlled substances. In Tennessee, the AMA affiliate has fought a bill that would enable psychologists to prescribe drugs for their patients. So far, psychologists have prescriptive rights in none of the 50 states, although they won limited rights last year in Guam.
In Pennsylvania, prescriptive rights are being sought by "advanced-practice" registered nurses. A bill in that state's legislature would grant the rights to nurses who receive additional training as nurse practitioners, certified nurse midwives, certified registered nurse anesthetists, or clinical nurse specialists. Such nurses could perform some invasive procedures, as well as prescribe drugs.
To expand their scope of practice in this way, the bill would require Pennsylvania nurses to complete at least six years of training. Physicians, who must receive a minimum of 11 years' training, claim six years is insufficient. Ulana Klufas-Ryall, DO, a former nurse, says, "An excellent nursing educational background did not prepare me to function as an independent practitioner."
At present, nurse practitioners practice independently in 21 states and have limited prescriptive rights in all but one. According to Scott-Levin Associates, a pharmaceutical consulting firm in Newtown, PA, nurse practitioners wrote 15,000,000 prescriptions in 1998, a 66 percent increase over the year before.
Although the AMA supports collaborative arrangements—such as those between physicians, on one hand, and nurse practitioners and physician assistants, on the other—it traditionally opposes the movement of nonphysicians into what it sees as "the realm of medicine." In 1998, for example, the AMA declared that only physicians should be allowed to practice anesthesiology.
Priests Challenged to Stay Well
In 1997 the Corporate Catholic Archdiocese of Seattle (CCAS) took a proactive step to improve the health of priests in the archdiocese by offering them a rewards-based wellness program, developed by Providence Everett Medical Center, Everett, WA, at CCAS's request. Priests who enroll in the Wellness Challenge, as it is called, are asked to carry out a specific number of health-related activities. These activities are assigned point values, and at the end of the program year priests who have earned 13 or more points (out of a possible 17) receive a $200 American Express gift certificate.
Participants earn five points for completing a health risk assessment questionnaire, three points for having a comprehensive physical examination, two points for pledging to wear a seatbelt at all times when in a motor vehicle, and two points for having their blood pressure checked four times in the year. Other activities, such as exercise, are also worth varying point values. Participants receive a monthly newsletter on health issues, a medical guide, and an exercise record book.
Approximately 53 percent of the archdiocese's priests have participated in the program, now in its third year; 46 percent have met the wellness "challenge." The program has led to an increase in overall wellness scores, increases in physical activity levels, and improved well-being.
According to Geralyn Mirante-Marley, the benefits administrator, "The main benefit of a program like this is that it keeps the importance of the health of the priest in the forefront. It has also been a great help in identifying risk factors that may lead to serious medical conditions, such as heart attack or stroke, and supporting participants to take steps to lower those risks."
Care Goes Unmanaged in Rural United States
Managed care, spreading rapidly in urban America, is having trouble taking root in rural areas, writes Daniel B. Moskowitz in Business & Health. Outside the cities, the new payment system meets two big obstacles:
- A shortage of provider networks with which employers might negotiate healthcare plans
- A shortage of employers large enough to negotiate such plans
As a result, only 15 percent of small-town workers belong to HMOs, compared to 31 percent of those in cities, according to the 1998 Mercer/Foster Higgins National Survey of Employer-sponsored Health Plans; 71 percent of rural employees are enrolled in traditional indemnity plans and preferred provider organizations (PPOs), as opposed to only 50 percent of urban workers.
Some large rural employers are organizing their own healthcare networks. Perdue Farms, based in Salisbury, MD, has negotiated discounts with local hospitals and contracted with local physicians to staff clinics at the company's plants.
John Morrell & Co., a meat-packing firm based in Sioux Falls, SD, has essentially created a PPO. The company agreed to funnel its workers to local hospitals in exchange for reduced rates. As for local physicians, Morrell agreed to reimburse them, not at a higher rate, but more quickly than was the usual practice. Warren Ure, Morrell's corporate benefits director, says that the doctors find the improved cash flow "probably worth a 5 percent discount."
Morrell can do this because it has 45,000 workers in the two rural cities where its health network operates. This mass of potential patients gives the company clout in negotiations with providers. Eve Clark, Perdue's corporate director of human resources technology, estimates that a plant must have at least 1,000 workers to negotiate effectively with a physician. Unfortunately, most rural work forces are not that large.
And even if there were more large rural employers, there remain too few providers. The average young physician, leaving medical school $80,000 in debt, knows money is earned in the city, not the country. The federal government has tried to attract doctors to rural areas by boosting Medicare reimbursement rates there, but so far those efforts have failed.
Serving the Consumer of the Future
Cultural competency will be the key to serving increasing numbers of immigrants as their populations in the United States soar in the coming years, writes Roberto Suro in American Demographics. The healthcare industry faces special communications challenges in this era of mass immigration, given that health and medicine are intimate subjects and closely tied to traditional ways and foreign languages.
It is estimated that immigration has added nearly a million people a year to the U.S. population in the past 20 years. As these immigrant populations have children and enter the mainstream workforce, with increased access to health insurance, they will become significant markets for healthcare. Providers will have to know how to attract them.
For example, Kaiser Permanente, in an effort to attract a large share of the Asian population in San Francisco, put up multilingual signs at one of its major San Francisco medical centers. Then a Chinese module, with support staff fluent in several Chinese dialects, was created to help take clients from registration to treatment to release. Chinese physicians and technicians were hired. Over the course of five years, as Kaiser Permanente was implementing these changes, its share of the Chinese market in San Francisco almost doubled.
"The healthcare industry has a huge opportunity for organic growth over the next 20 years as immigrants, minorities, and others move up the economic ladder and gain access to healthcare coverage," says Alfred L. Schreiber, president of Diversity Business Imperative, a strategic planning and recruitment firm. "But achieving that growth will require efforts to bridge gaps created by language, culture, and history, because healthcare is still very much geared to the traditional white consumer."
Copyright © 2000 by the Catholic Health Association of the United States
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