IN THIS ISSUE

* A review of closed malpracticeclaims dataPage 154

RES EA RCH U P DAT E from theAAP Division of Health Policy Research_> m ct4 n.,

Data raise concerns about Medicai access* Tips for targeted Web searchesPage 159

* AAP Voters' GuidePages 163-167

by Sue Wallace, R.N.Correspondent

:_ _ ~~~Every time he read about an aban-_s_ ~~doned infant found dead, John, ~~~Richardson, M.D., of Fort Worth,

; - ~~Texas, wished something could be_done to prevent future tragedies.

I got to talking with people in<~:v l; [Austin and contacted state represen-

tative Geanie Morrison. She intro-Dr.ichadson duced a bffl that these children could

be turned over to an emergencymed-ical technician. It was passed in summer 1999 andbecame law that September," said Dr. Richardson, amember of the Board of Trustees of the Baby MosesProject, a nonprofit organization that publicizes thealternative to newborn abandonment.

SeeAbandonment, page 152

patient care increased by 20 percentage points to 67%between 1993 and 2000. This change parallels analmost two-fold increase in Medicaid-paid visits togeneral pediatricians, from 9.6 million in 1993 to 18.7million in 1998, accordingto the NationalArnbulatoryMedical Care Survey conducted by the National Centerfor Health Statistics.

Yet, despite overall higher acceptance of Medicaidpatients in 2000, private office-based primary carepediatricians are significantly less likely to fully partic-ipate in Medicaid than pediatric subspecialists or pri-mary care pediatricians in safety-net settings.Nonetheless, to achieve the goal of providing everyMedicaid-eligible child with a primary care medicalhome, fulfl participation by primary care pediatriciansin private practice settings is key, especially when cli-nicians working in public safety-net settings, such ascommunity health centers and hospital-based clinics,are already practicing over capacity.According to the 2000 AAP survey, participation by

primary care pediatricians in private office-based set-tings is substantially lower than participation by pedi-atric subspecialists or primary care pediatricians insafety-net se'ttings based on two alternative measuresofparticipation. The first measure is the proportion ofprivate office-based primary care pediatricians accept-ing all Medicaid patients who request care ("full par-ticipation"). The second measure is expressed as theratio of providers accepting all Medicaid vs. non-Medicaid patients ("relative participation"), which has

SeeMedicaid, page 149

Medicaid and Title XXI (SCHIP) programs haveincreased the number of children eligible for healthinsurance. But their impact on access to pediatric careand the financial viabflity ofproviders is less obvious.New AAP data show a strong correlation between

payment rates and willingness to participate inMedicaid. Those pediatricians getting the lowest reim-bursement rates have the lowest levels of Medicaidparticipation. Without pediatrician participation, thecapacity of the Medicaid program to provide qualitycare to children is at risk. Thus, monitoring the partic-ipation of pediatricians is key to assessing the capac-ity ofthe system. Because oftheAcademy's long-stand-ing commitmnent to the Medicaid program and for thepurpose of improving this program, we are interestedin b-oth monitoring the levels of pediatrician partici-pation and understanding the barriers to increasedpediatrician participation.To that end, the AAP Division of Health Policy

Research asked more than 13,000 pediatricians abouttheir participation in Medicaid and SCHIP, in one ofthelargest surveys ofmembers ever undertaken. The sur-vey was mailed during the winter of 2000, and morethan 8,300 members responded for a response rate of67%. The Academy conducted a similar study onMedicaid participation in 1993.According to our findings ofpediatrician participa-

tion in public and private health insurance programs,more than one-third of pediatricians' patients wereenrolled in Medicaid or SCHIP in 2000, up from one-fourth enrolled in-Medicaid in 1993. At the same timne,participation in Medicaid by all pediatricians in direct

The change has heated the debate ink: the medical comrnunityoverthevalue

dotoand potential harm ofDTC ads.

rdoctorN Some physicians caution that_ ~~~~DTCads can confuse, mislead or

- _ ~~~result in inappropriate prescribing.Others say ads make patients aware

IE of medical advances. Still others usepatient questions about advertised drugs

*-* ~ as red flags -insight into patient con-

j ~~cerns.

toay. The debate goes onFellows' opinions on the efficacy ofDTC

advertising tend to vary, but many agreeadvertising is transforrning the patient-pediatrician rela-tionship.

"Given all the things that I should be doing in mypractice -talkng about counseling, about cigarettes,about wearing seat belts and substance abuse, drinkingand television watching- it is a total and utterwaste of

SeeAdvertising, page 150

by Taunya EnglishCorrespondent

A mother hears about a new drug from a friend.A rel-ative's child gets a prescription. The local station airs astory on the evening news. The parent sees an adver-

r _ ~~tisement onTV, which directs herto thel _ ~~Internet for more information.r _ ~~~Richard P. Walls, M.D., Ph.D., FAAP,i _ ~~~calls it a "tipping effect."

_ ~~~~"They are probably getting the mes-sage from a variety of sources. Finally,

- ~~~~they say, 'That's it, I have to go talk to the_ ~~~~doctor," saidDr.Walls, ofLaJolla, Calif.,

Dr. Walls and a member of the AAP Committeeon Drugs.

Direct-to-consumer (DTC) prescription drug adver-tising has exploded in the United States.Commercials beseeching parents to "Ask your pedia-

triciarn" are so familiar today that many forget that untilthe early '80s pharmaceutical companies traditionallydirected their messages to physicians and limited theiradvertising to medical journals.

,X,,il,~~~~~~~~~~~~~~~~~~~~= Wil I 1ii a -lit 1

! p u~~~~or doctor about NAsk your Child sdoctor For more infornwio~n salli

Now the XI prescribed pill for,is available in a once-a-day dose.-unq4 s

- - ^' ~~~~Why live this way another mnonh? Tlalk to your doKtor tI

Lastyear, a study ofdrugads in consumer maga-zines found that the number ofyearlynew ad introduc-tions rose to 76 in 1998 from just 3 in 1989 (Bell RA, et al.J Fam Pract. 2000;49:329-335). And after 1997, manymore advertisers turned to television when the U.S.Food and DrugAdministration relaxed its guidelines forbroadcast ads. Overall ad spending is predicted toquadruple, reaching $7.5 billion, by 2005, according tothe study.

Phsicians disagree on value of direct-to-consumer a ve ts niI r

Adveitising Continuedfrom page 143-------time to spend time counter-educating with patients,"said Michael S. Wilkes, M.D., a LosAngeles internist andco-author of a DTC advertising study (Wilkes MS, et al.HealthAff 2000;19:110-128).When a patient requests aspecific drug that is different from what he has pre-scribed, Dr. Wilkes takes time to explain his recom-mendation."Commonly, it takes several minutes of explanation;

less commonly but not rarely, it takes a bit of an argu-ment," Dr. Wilkes said.Depending on the patient's education level and per-

sistence, these conversations may include clarificationof the workings of the managed care system and reas-surances that he would neverjeopardize patient care tosave money, he said.

Dr. Walson, a clinical pharmacologist at Children'sHospital Medical Center ofCincinnati, said parents alsogeneralize DTC claims and assume the medication willbe beneficial for their children."Fewofthe [advertised] medications are appropriate

for kids," Dr. Walson said. He, too, spends time not justeducating, but counter-educating, patients.Parents most often ask about prescription drug

brands in the anti-flu, antibiotics, immunization andallergy categories, according to several pediatricians.

S. Michael Marcy, M.D., FAAP, who practices at KaiserFoundation Hospital in Panorarna City, Calif., is a mem-ber of the AAP Committee on Quality Improvement

Subcommittee on Management oftAcute Sinusitis.

It isuncommon for a parent to ques-_ ~~tion his treatment plan, but he occa-_ ~~~sionally faces parental resistance.

_ [ ~~After diagnosing common otitismedia, Dr. Marcy often prescribes

_ ~~~amoxicillin. But aparent mayaskaboutDr.arcy azithromycin.Dr.Marcy Dr. Marcy recounts a typical parent

inquiry: "I've heard azithromycin is only given once aday. I work -it's extremely difficult for me to give thisdrug three times a day. And, the nursery school hates togive drugs."

After explaining that amoxicillin is the first-line drugofchoice for otitis media, Dr. Marcy mentions that DTCads often promote the most expensive drugs in a classof medications and notes that amoxicillin can be giventwice a day. Once he addresses concerns about con-venience, efficacy and cost, the parents are usually sat-isfied. Parent requests for a specific drug are rarelyovertly aggressive, Dr. Marcy added.Jon Abramson, M.D., FAAP, chair of the AAP Com-

mittee on Infectious Diseases, said he hears simiflar sce-narios from colleagues and other Fellows. He said par-ents learn about ceftriaxone from anad or a friend, and ask, "Why not just

igive my child one shot?"_Physicians also report more parent _

inquiries about palivizumab, the mon-oclonal antibody used against respira-_tory syncytial virus (RSV), said Dr.

-Abramson, Pediatrics Department _chair atWake Forest University SchoolE .. ~~~~~~~~~Dr.Abasn

!.of Medicine.Talking to parents about the judicious use of antibi-

otics and outlining the AAP Red Book committee's lay-ered recommendation on palivizumab can be a lengthyand complicated conversation. Parents are sometimesstrained and defensive, several pediatricians said.

'r: "Physicians are upset, they feel that the [pharmaceu-ticall companies are interfering in the relationshipbetween family and physicians," Dr. Abramson said. "Ido see other physicians just caving in," he added.Adarn L. Hartman, M.D., FAAP, a member of the AAP

Section on Clinical Pharmacology and Therapeutics,?' ~~~said an adversarial relationship can? _ ~~~develop between famfly and provider

_ _ ~~whenDTC ads are positioned as strongj_ ~~recommendations, rather than

options._ ~~~~Dr. Hartmanwouldratherseebigad

0 _ ~~budgets invested in research anddevelopment. Nevertheless, he sup-

Dr. Hartman ports responsible DTC advertising.Balanced promotions can be patient

education, he said."I think patients become more aware oftheir options.

As a result, they become more active partners in theirhealth care," Dr. Hartman said.

"In turn, these discussions offer me the chance tomention other options they might not even know about,'including certain preventive measures," he added.

"I think that physicians who are more comfortable

with a paternalistic model of care are more likely to beuneasy with DTC than those who use a collaborativemodel."The use of pamphlets and fact sheets to reinforce

pediatricians' dialogue with families is an option. TheAAP pamphlet Your Child andAntibiotics is one usefultool to counter the ads parents see as they flip throughwaiting-room magazines (visit the AAP Bookstore atwww,aap.org).

Dr. Hartman said the DTC phenomenon can nudgepediatricians to stay current with pharmacotherapy andinformed about the nature of advertising in order tomaintain their role as patient advocate.

Ifdrug advertising proliferates as predicted and morepatients come with ads in hand and prescriptions inmind, more physicians may make that shift.

Appointment time sfips awayDr. Wilkes estimates that 80% of patients leave satis-

fied that he is doing what is in their best interest."But, maybe 20% of the time they leave unsatisfied,= ~~and of that, half are actually angry at

me; the other half are just a little con-fused," he said.

Philip D.Walson, M.D., FAAP, amem-ber of the AAP Committee on Drugs,sees similar confusion. Many DTC adsdownplay toxicity and play up efficacy,

_ leavingpatientswithunrealisticexpec-Dr. Walson tations, he said.

Wi,

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History of DTC advertisementregulation

1938* The Federal Food, Drug and Cosmetic Actrequires new drugs to be shown safe beforemarketing.

* U.S. Food and Drug Administration (FDA)charged with oversight of advertising of pre-scription drugs.

1951*Durham-Humphrey Amendment definesdrugs that require a prescription from alicensed practitioner.

1ff62*Kefauver-Harris Drug Amendments requiremanufacturers to prove drug effectivenessbefore marketing.

11970*FDA requires patient package inserts to informpatients about risks and benefits.

Matly 1980sA few pharmaceutical companies begin mar-'keting to consumers.

*VoluntaryFDAmoratoriumn on direct-to-con-sumer advertising.

*1985* FDA moratorium lifted.

1997*FDA relaxes regulations requiring indications,side-effect and contraindication summariesin advertising, allowing more marketing ontelevision.

Source: FDABackgrundenMilestnes in U.S. FoodandDruzgLawHistory (Wm.qsfda.gov1miIestomlhtmlI).