APHP "Master Strategy"
Proposed November 27, and adopted at the December 20, 1996 Conference Call Board Meeting.

Introductory Comment: Theis "Master Strategy" is in three parts. The first deals with AAPHP membership recruitment. The second deals with development of a job market rich in quality offerings in Public Health and Preventive Medicine. The third is a collection of sample anecdotes.

I. AAPHP Membership Recruitment to build needed "Critical Mass"

  1. Recommend dues to AMA members, whether AMA comes through with the dues supplement or not, and use this to rapidly build our membership.
  2. With the critical mass secured from the above dues, recruit non-AMA members at the differential rate of $?? per year.
  3. As a second-stage recruitment effort, then market AMA to our $?? members.
  4. Note: Requiring AMA membership as a condition of AAPHP membership may effectively prohibit recruitment among Public Health and Preventive Medicine physicians, especially those in federal government and managed care settings and need careful thought before implementation..

II. Development of Public Health and Preventive Medicine Job Market

1. A PHP is a physician who, by training or experience, has the capability to effectively utilize his or her understanding of:

...to help guide a community, agency or institution in the cost effective pursuit of group or community health goals.

2. The public health physician role, while administrative in nature, is one that utilizes medical knowledge and is guided by principles of epidemiology. In many cases it is also guided by principles of leadership and management and skill in policy development. The goal is to provide a quality and type of leadership that could not be duplicated by either a non-physician administrator or a physician without training or experience in public health.

3. While not "clinical" in the sense of diagnosis or therapy of individual patients presenting themselves in a clinical setting, the public health physician role is one that fully constitutes a "practice of medicine". By it's very nature, this role makes decisions that effect the health of the group being served and, in most cases, the circumstances under which clinical services are rendered.

4. While many public health physicians also see patients on a one-on-one basis in a clinical setting, this direct provision of medical care is not a defining characteristic of the PHP role. The defining characteristic is the use of medical knowledge to meet the needs of constituent population groups.

Policy and technical direction of a local or state health department.

Policy and technical direction of public health and preventive programming within a public or private agency.

Investigation into the causes of:

Quality assurance of medical and preventive services.

Policy guidance and oversight of disease management and demand management programming. While this terminology is new, it is solidly grounded in medical knowledge and principles of epidemiology, as applied to management of health care delivery.

Liaison between the non-physician leadership of health insurance, managed care and hospital entities and their respective medical staffs. The issue here is one of professional acculturation -- with the public health physician being in a position to understand both the "clinical" perspective of the medical staff and the "administrative" perspective of the non-physician leadership. In this role the public health physician is also in a position to best provide medical input into administrative decisions.

  1. Effectively communicate this role and vision to our membership to enable them to articulate this role and vision within each of their individual professional settings.
  2. Articulate this role and vision on behalf of public health physicians to groups and organizations which represent those who define professional roles and job descriptions and qualifications:
  1. Within the medical profession (both practice and academia)

    1. AMA
    2. AAMC
    3. ACPM
    4. ATPM
    5. ABPM

    b. Within governmental public health agencies

    1. NACCHO
    2. ASTHO
    3. NACo
    4. Conference of Mayors
    5. NGA
    6. Major Federal Agencies

HCFA
HRSA
USPHS
CDC
The military services
Other

c. The voluntary sector

1. Heart, lung, cancer and other disease-specific agencies
2. IOM
3. Major Philanthropies
4. National organizations representing hospital, managed care, health insurance and public administrations interests.

d. Private Sector

1. Managed Care
2. Hospital
3. Health Insurance
4. Consultant Firms

  • Proposed AAPHP Modus Operandi with regard to this mission and vision

Development of a library of anecdotal reports of effective use of PHP expertise in each of the settings noted above.

  • An "anecdote" for these purposes is defined as a vignette, 50 to 200 words in length, describing a case in which utilization of PHP skills resulted in a decision or action more functional than one that would have reached without such expertise. The defining characteristics of such decisions are useful of medical knowledge, epidemiologically applied to a group for an administrative action or policy guideline. These are to be true stories, anonymously presented, but in a manner which would allow tracing to the author for verification.
  • Once a member of such anecdotes have been developed, they would be shared with participating AAPHP members to facilitate their generation of their own battery of anecdotes, which they would then use in these advocacy efforts.
  • Sample anecdotes from JLN personal experience:

1. Public Health Impact Anecdote:

Given infant immunization follow-up records indicating lack of immunization at 18 months of age, in the context of a program designed to individually remind and follow-up on on-compliant infants; the data is plotted by neighborhood, and neighborhood-specific immunization programming is pursued in indigent and minority neighborhoods where family mobility from apartment to apartment and poor literacy makes the anticipated follow-up by mail an unworkable option. The result is a highly effective outreach to significant numbers of otherwise unimmunized infants, on an ongoing basis, with resultant elimination of indigenous transmission of diseases preventable by routine infant immunizations within the jurisdiction (cluster immunization program, Miami, Florida, early 1970's) (106 words)

2. Disease Investigation Anecdote:

A skin rash broke out among motorcycle policemen during a period when the police union was engaged in prolonged and bitter salary negotiations with local government administration. Accusations were made to the effect that this alleged rash represented either malingering or a hysterical reaction among some of the policemen. The local health director was asked to meet with the policemen to explore the genesis of this strange epidemic. Upon seeing the distribution and nature of the rash and the strange looking dust and deteriorating ceiling panels in the police locker room, the health director immediately suspected fiberglass exposure, which was quickly confirmed and corrected, with prompt resolution of the epidemic. (109 words)

3. Health Care Delivery Anecdote:

AAPHP, while serving on a part time basis as Medical Director for a public hospital based home health agency, met with discharge planning staff to explore the feasibility and potential impact of increasing indigent client referrals to home care. In the process of these discussions, which consumed only a few hours over a two week period, the PHP gained a clear impression that lack of access to outpatient medications was a significant cause of rehospitalization, at least on some medical services, and that greater flexibility on the part of the home health agency in providing non-reimbursed home care to selected no-pay patients might also reduce hospitalization rates. These suspicions led to mini-studies within the hospital over a single month, with a cost in staff time, but no additional dollars, and lead to significant expansion of pharmacy services and development of a new home health service consisting primarily of health guidance in the home for selected types of patients. Outcome studies are pending. (163 words)

4. Community Impact and Agency Morale Impact:

The Louisiana Office of Public Health had been castigated for ineffective delivery of Maternal and Child Health services because Louisiana infant mortality remained one of the worst in the nation. This situation had persisted for years, and now was being proposed as justification for stripping the health department of these services, and moving them into the "private" sector. A PHP, newly recruited as State Health Director began to explore this issue and quickly discovered that, in Louisiana, African American Infant mortality was about double white infant mortality. In Louisiana, both African American and White infant mortality rates were better that the national averages, despite much higher rates of indigency in both racially defined groups. Since Louisiana was 30.5% African American, as opposed to the national average of 12.5%, the high state infant mortality rate was clearly attributable to demographic factors, and not due to ineptitude in health care delivery within the public sector. This revelation was new to almost everyone involved, helped save the public health agency and Maternal and Child Health programming. This new insight was also used to help secure new grant revenues to help further reduce the better than average, but still-too-high, infant mortality rates. (199 words)

  • AAPHP members, both on their own behalf, and on behalf of AAPHP could use the sample anecdotes as a stimulus to developing their own sets of locally relevant anecdotes. The anecdotes would then be communicated to local elected and appointed officials, hospital CEOs, etc, for the purpose of having PHP qualifications for appropriate public health and preventive administrative and leadership positions. This same process could be repeated at state and national levels.