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Getting our message across: ACP's advocacy strategy

From the July/August 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Howard B. Shapiro, PhD

How do you do advocacy? This frequently asked question has a complicated answer. In his column in this issue, ACP President William A. Reynolds, FACP, discusses the need for individual and organizational contacts with members of Congress. I will try to expand on his well-made point about ACP's larger, ongoing efforts to shape decisions to reflect our policy positions.

Roughly half of our efforts are targeted at Congress. Testimony before committees and subcommittees is the most visible and most formal effort, but it is only the tip of the iceberg. Testimony raises the College's visibility, both to members of Congress and to the many interested parties who attend those hearings. It also may generate some press attention and help further spread our message.

Perhaps more important, however, are ongoing meetings with members of Congress and their staffs. This past winter, for example, both Dr. Reynolds and ACP's Immediate Past President, Christine K. Cassel, MACP, met with senior leaders such as Rep. Bill Archer (R-Texas), chairman of the House Ways and Means Committee. The ACP Washington Office staff is continuously in contact with key staff on Capitol Hill; in recent months, for example, we have met repeatedly with staff members on various committees to discuss Medicare payment policy. The goal is to make sure that these staff members understand the College's perspective on these issues.

We work with staff in the drafting stages of legislation to develop specific provisions that reflect our views from the very beginning. For example, we have worked with the staffs of Sen. John Breaux (D-La.) and Sen. John Chafee (R-R.I.) this year to incorporate ACP's key recommendations on Medicare reform into the budget legislation.

Chapter involvement

Constituent support is a key element, and that's where our chapters play a significant role. Leadership Day on Capitol Hill each spring gives Governors and other chapter leaders a wonderful opportunity to make contacts with Congressional members and staff, raise the visibility of the College and present our recommendations. As Dr. Reynolds points out in his column, the event has lasting impact only if individual ACP members follow up by contacting members and staff, especially in their home districts and states. One of our challenges is to broaden those communications beyond a few chapter leaders, so that there is a network of activist members in each state willing to write letters and make phone calls to their legislators. Developing a secure ACP forum on the Internet will also give us the tools we need to quickly and inexpensively communicate with ACP members and ask for their support for advocacy efforts.

Perhaps less well known than advocacy in Congress are ACP's efforts to affect the regulatory process. Even with legislation that is fairly prescriptive, which is becoming the norm, federal administrative agencies still play a critical role in shaping and implementing programs. These agencies normally follow a formal process that starts by publishing a proposed regulation in the Federal Register and is followed by having a period for public comments, revising the proposed regulation and then publishing a final rule. The College develops detailed responses to these proposals, and we have seen our comments cited by agencies when they describe their rationale for revisions in the final rule.

We are also in continual contact with regulatory agencies. These might range from meetings with Bruce C. Vladeck, PhD, HCFA's administrator, to discussions with agency staff on details of program implementation. For example, one of our Regents recently raised an issue about Medicare in a letter that we forwarded to HCFA. On the basis of that letter, HCFA identified a gap in its instructions to carriers and corrected it. The point is that there are opportunities to change things, and multiple ways of getting messages across to regulators.

There are also mechanisms and organizations that feed into the regulatory process. We actively participate on the AMA/Specialty Society RBRVS Update Committee (RUC), which recommends work values for physician services to HCFA. HCFA incorporates many of the RUC's recommendations into its yearly update of the Medicare fee schedule. The College is also active in the area of CPT coding. HCFA regularly convenes panels of physicians to review payment recommendations, and the College has identified individuals to serve on those panels.

Additional avenues

Legislation and regulations are the two major avenues for shaping policy, but there are other options. Public commissions, for example, also play a role. The College tries to place ACP members on those commissions and work with them.

We were very pleased that two of our leaders, Dr. Cassel and Risa J. Lavizzo-Mourey, FACP, were named to the President's Commission on Quality and Consumer Protection in Health Care. There has always been an internist on the Physician Payment Review Commission (PPRC)—currently Earl P. Steinberg, FACP—which has played an important role in advising Congress and the administration on payment policies. We have worked closely with PPRC staff and commissioners over many years.

Another group is HCFA's Practicing Physicians Advisory Council, set up several years ago to give voice to practicing physicians as HCFA and the Department of Health and Human Services consider regulatory and other policies. Last year, ACP successfully nominated our former Governor for New Jersey, Mary T. Herald, FACP, now a Regent, to that group. This year we were pleased when ACP's Governor for West Virginia, Derrick L. Latos, FACP, was appointed to the council.

Another avenue for shaping decisions is to work with internists in government positions, many of whom are well known to us before they take those positions. Recently, for example, a member of the Board of Regents, John M. Eisenberg, MACP, was named director of the Agency for Health Care Policy and Research and senior medical advisor to Secretary Shalala. There are several other internists occupying important positions in health agencies.

Coalitions are another mechanism for lobbying, and have the advantage of pooling our resources with others to create strength in numbers. Some of these are ad hoc coalitions focused on a single issue, while others are formal and ongoing. ACP has supported anti-tobacco initiatives, for example, through the Coalition on Smoking or Health and the Campaign for Tobacco Free Kids. And we work with the National Coalition on Health Care to promote health care reform and progress towards universal coverage.

Finally, we use the press as an extension of public policy advocacy. Well-timed press statements, participation in press conferences, ongoing interviews and responses to specific questions—all are ways of raising ACP's visibility and shaping the views of policy-makers. Statements in which we recognize the value of actions taken by individuals or organizations build positive relationships and help the College move forward on issues of importance to us.

The College is a player in many arenas, using a broad array of tools to shape public policy. Our strength is our membership and persuasive arguments backed by sound information. The College has used these strengths to build a reputation as an advocate for patients and the public good.

Howard B. Shapiro is Vice President for Public Policy and heads ACP's Washington, D.C., office.

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