Intersection of Clinical Care
and Public Health
Ron Davis, MD
President-elect
American Medical Association
AcademyHealth
2007 Annual Research Meeting
June 4, 2007 / Orlando
1847 – Founding of the AMA and
Publication of the Code of Medical Ethics
“Physicians, as conservators of the public
health, are bound to bear emphatic testimony
against quackery in all its forms.…”
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.”
Medicine and Public Health Initiative (MPHI)
– continued
• 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
Medicine and Public Health Initiative (MPHI)
– continued
• 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
Medicine and Public Health Initiative (MPHI)
– continued
LM Beitsch et al, AJPM 2005; 29: 149-53
“The Medicine & Public Health Initiative:
10 Years Later”
• “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.”
Medicine and Public Health Initiative (MPHI)
– continued
To reinvigorate the MPHI, Beitsch et al
recommend:
• 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
Medicine and Public Health Initiative (MPHI)
– continued
RM Davis, AJPM 2005; 29: 154-157
“Marriage Counseling for Medicine & Public Health”
• 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
Medicine and Public Health Initiative (MPHI)
– continued
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
Medicine and Public Health Initiative (MPHI)
– continued
RM Davis, AJPM 2005; 29: 154-157
“Marriage Counseling for Medicine & Public Health”
“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
2006 Prevention Priorities
Short Name
CPB
CE
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
5
8
3
Total
2006 Prevention Priorities
Short Name
CPB
CE
Total
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 Services
Short Name
Tobacco Cessation Counseling
Total Score
National Delivery Rate
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)
Preventive Services in HEDIS
– continued
• 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)
Parallels between Public Health and
Managed Care
Public Health
Managed Care
• Primary
prevention
• Demand
management
• Secondary
prevention
• HEDIS measures
(mammogram, Pap)
• Tertiary
prevention
• 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 Paulk
Grade 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 Andrews
Grade 12
Renaissance High School
Tobacco Control –
Health Partners (Minneapolis)
Tobacco Control –
Health Partners (Minneapolis)
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
Henry Ford – on partnership
“Coming together is
a beginning;
keeping together is
progress;
working together is
success.”