May/June 2002
Challenges
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Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES
Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Richard J. Morris, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Susan Reed MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761.
CONTENTS VOLUME 4, NO. 3
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Consumer Protection Law Victory
3
Editor’s Message Index to Advertisers
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COLLEAGUE INTERVIEW
M AY / J U N E 2 0 0 2
Scott Crow, M.D.
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FEATURE
The Mental Health Carveout as an Instrument of Patient Discrimination
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No Room at the Inn: The Shortage of Psychiatric Inpatient Beds in the Twin Cities
To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of HMS or RMS.
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The Shortage of Child and Adolescent Psychiatrists
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Mental Health and Public Health
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Public Academic Liaison: Medical Centers’ Relationship to their Communities
19
The Effectiveness of Addiction Treatment
Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. E-mail: nbauer@mnmed.org.
21
SOAPBOX
MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available.
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Parallel Missions of Medicine and the Courts RAMSEY MEDICAL SOCIETY
24 25 26 27
President’s Message Caring Hearts for Homeless People/Call for Resolutions New Members/In Memoriam
May/June 2002
For advertising rates and space reservations, contact: Betsy Pierre, 2318 Eastwood Circle, Monticello, MN 55362; phone: (763) 295-5420; fax: (763) 295-2550; e-mail: betsy@pierreproductions.com.
Mind-Body Medicine
RMS Alliance HENNEPIN MEDICAL SOCIETY
28 29 31 32
Chair’s Report/Call for Delegates and Resolutions New Members In Memoriam
Challenges
FOR MENTAL HEALTH CARE
HMS Alliance On the cover: A look at the state of mental health in our community. Related articles begin on page 3. Artwork by Madelyn Bauer.
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
May/June 2002
1
Consumer Protection Law Victory
H
HMS AND RMS, in collaboration with a coalition of providers and consumer organizations, declared victory on a bill to protect the consumer’s rights to full benefits when injured in an automobile accident. Senate File 1226 was signed by Governor Ventura on March 25, 2002. The bill represents a great victory for the consumer and physicians. Consumers retain open access to see the physician of their choice, the reasonable and necessary standard of care for benefits was affirmed, and auto insurance companies are prohibited from signing con-
tracts with health plan companies. The legislation also prohibits products that deliver managed care reimbursements and limits access to injured parties under auto insurance. Key players supporting and lobbying for the Consumer Protection Law were: Minnesota Brain Injury Association, Minnesota Medical Group Management Association, Minnesota Chapter of American Physical Therapy Association, Minnesota Chiropractic Association, Minnesota Consumer Alliance, Metropolitan Medical Practice Forum
(Hennepin and Ramsey Medical Societies), Northwestern Health Sciences University, Minnesota Podiatric Medical Association, and the Minnesota Trial Attorneys. This was the first time the coalition has worked together. The success on this major legislation is the foundation for future legislative issues. The legislation won unanimous approval in all committees of the House and Senate. The Senate passed S.F. 1226 on a vote of 61-0. The House then adopted the Senate language and passed the bill on a vote of 130-0. ✦
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MetroDoctors
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Editor’s Message This issue of Metro Doctors looks at the state of mental health in our community. Lee Beecher, M.D., graciously agreed to serve as a “guest physician advisor” to the editorial board, recommending article content and guiding Metro Doctors staff. We are appreciative of his input.
against psychiatric patients. It is important to note strong leadership from HMS and RMS on mental health issues at the Minnesota Medical Association House of Delegates. Since 2001, the MMA and AMA have adopted policy positions opposing behavioral carveouts in insurance systems and recommend integrating psychiatric care in general medical care. Yet, there is much work to do in shaping Minnesota and the nation’s care systems to support mental patients and the doctors who treat them. ✦
C
CURRENT PRESIDENT of the Minnesota Psychiatric Society, Scott Crow, M.D., in his Colleague Interview, cites Senator Paul Wellstone’s pioneering federal mental health parity efforts to achieve funding for mental disorders on a par with other medical conditions. Additional progress towards the goal of mental health parity came with the June 2001 settlement agreement of a suit filed by State of Minnesota Attorney General Mike Hatch against Blue Cross and Blue Shield of Minnesota (BCBSM), citing medical necessity denials by BCBSM of appropriate treatments and shifting care costs to taxpayers. As part of the settlement negotiations, which involved Hennepin County Chief Judge Kevin Burke, a panel of three retired Hennepin County judges now promptly and impartially reviews appeals of BCBSM mental health medical necessity insurance denials. HealthPartners and Medica have also signed on to use the appeals panel. A perspective on stigma and segregation of the mentally ill is offered by Dr. George Realmuto in the feature article. Present day behavioral carveouts are an extension of historic mental health Jim Crow. Skepticism about psychiatric diagnosis and treatment has also been based on spurious theories of mental illness and addictions. Psychiatric treatment, including psychotherapy, as with other medical treatments, is evolving as evidence-based medical practice. In a similar MetroDoctors
vain, Doctors Aslam and Willenbring show that the effectiveness of addiction treatment in 2002 is comparable to care effectiveness for other chronic medical conditions, despite widespread negative stereotypes of substance using patients by professionals and insurance payers. Dr. Will Dikel recommends a public health approach to mental health epidemiology and provider resource allocation, especially for children, adolescents, and the chronic mentally ill. Pointing out the current fragmentation of psychiatric care systems, Drs. Nemecek and Gibbs alert us to a crisis shortage of hospital beds which results in transferring adolescents and other patients from metro ERs to out-state facilities away from their families and communities. Our writers agree that there is a shortage of psychiatrists in Minnesota, especially child/ adolescent psychiatrists. Dr. Charles Schultz, chair of the psychiatry department at the University of Minnesota, describes collaborative efforts with community advocates and providers to sharpen psychiatry’s scientific base and bringing the “gown” to the town. We are proud that HMS and RMS stand against stigma and discrimination
The Journal of the Hennepin and Ramsey Medical Societies
Lee Beecher, M. D., is a psychiatrist in private practice in Saint Louis Park. He is also president of the Minnesota Physician-Patient Alliance (MPPA), and is a west metro MMA trustee.
May/June Index to Advertisers Allina Education and Research .................. 10 Billing Services .......................................... 12 Brainerd Medical Center ........................... 14 Financial Network .................................... 18 Hamm Clinic ........................................... 16 HealthEast Care System ............................ 12 HealthPartners ............................................ 5 I-Retrieve .......................... Inside Back Cover Methodist Hospital .................................. 15 Minnesota Medical Foundation ............... 32 MMIC ............................. Inside Front Cover RCMS Inc. ............................................... 27 Riverway Clinics ....................................... 16 U of M CME ................. Outside Back Cover Wally McCarthy Cadillac ............................ 2 Wally McCarthy Hummer .... Inside Front Cover Weber Law Office ....................................... 9
May/June 2002
3
COLLEAGUE INTERVIEW
Scott Crow, M.D.
Editor’s Note: Scott Crow, M.D., is the president of the Minnesota Psychiatric Society. He received his Bachelor’s Degree in microbiology from the University of Minnesota and remained at the University to obtain his Medical Degree, complete a Psychiatry residency, and fellowship in consult-liaison psychiatry. Dr. Crow has been a faculty member in the Department of Psychiatry at the University of Minnesota since 1992, specializing in the area of eating disorders.
Q A
What suggestions do you have regarding the reasons for and solutions to the problem of the shortage of adolescent psychiatry beds in the Twin Cities? Child and adult psychiatry beds are in severely short supply in the Twin Cities. The Minnesota Psychiatric Society is convening a work group to try to address this problem. One major component will be to address the willingness of third party payers to provide adequate coverage for inpatient adolescent services although this alone clearly will not be sufficient, nor is this the sole cause of the problem.
What can be done to alleviate the severe shortage of psychiatrists and child psychiatrists in the Twin Cities?
Is psychotherapy an essential component in a comprehensive treatment plan? If so, is it covered by the plans?
Two steps can be taken to eliminate the severe shortage of psychiatric services that are available right now. The first is to enhance recruitment into psychiatric residencies (which nationally, but particularly locally has improved slightly in recent years). The second is to further bolster the abilities of primary care physicians to provide effective psychiatric treatment. At present, psychiatric illnesses are widely under-treated and yet even in face of that, we have a severe shortage of psychiatrists. As stigma diminishes and knowledge and acceptance improve, our need for effective psychiatric treatment will only grow and much of this increased need can best be addressed by primary care physicians (whom the patient may also be comfortable or willing to see).
Psychotherapy is an essential part of treatment for many, though probably not all people with psychiatric disorders. At present, psychotherapy is covered by most plans but usually restricts either frequency or amount of sessions (or both) falling short of what has been shown to work in controlled trials, and also falls short of what care would be recommended by experts.
What is the appropriate role for primary care physicians in managing behavioral and mental disorders? Primary care physicians clearly represent the first line in managing psychiatric illnesses. The optimal approach probably involves having primary care physicians initiate treatment for illnesses with which they feel comfortable; in most cases this represents mood and anxiety disorders. Psychiatric referral would then be used for complex or more severe conditions (for example, bipolar illness, schizophrenia, or obsessive compulsive disorder) and for treatment refractory mood and anxiety disorders.
How has parity benefited psychiatric care? How has its disappearance affected care? Is there a need for federal parity if we have state parity? Initial efforts toward parity of payments for mental and general medical disorders have been helpful but there remain many loopholes, namely equating adequate or optimal mental health sessions with the restricted care provided by behavioral carveouts. Achieving federal parity would be a useful backup to the partial state parity that exists.
Have any recent legislative issues supported best practices for psychiatry? If so, which and how have they helped? Are there any issues on the horizon that need support from the medical community as a whole? One issue potentially on the horizon that will need support from the entire medical community is the issue of psychologists prescribing of psy-
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May/June 2002
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The Journal of the Hennepin and Ramsey Medical Societies
chotropic medications. This has been contemplated in a number of areas including military settings but always has been rejected. Last month the New Mexico legislature passed a bill that was signed into law establishing prescribing privileges for “appropriately trained” psychologists. This is clearly an extraordinarily bad idea. It springs to some extent from a shortage of psychiatric providers in New Mexico. Similar shortages exist other places including, to a lesser degree, in our state. It seems clear, however, that this problem is not best solved by setting up a situation that would involve psychotropic prescribing by individuals without any formal medical training. It is unclear whether this will surface in Minnesota or not but if it does, it will be extremely helpful to have support from the entire medical community.
Has AG Hatch’s efforts to “clean house” by challenging BCBSM and other payers resulted in any concrete changes to help psychiatrists provide care? If so, how?
How has stigma impacted access to care for psychiatric disorders?
What advances do you foresee in the future for psychiatric treatments?
Historically, issues of stigma about mental illness have had profound impact on access to care for psychiatric disorders in two ways. First, because of stigma, individuals with psychiatric disorders are less likely to seek help and people broadly are often not comfortable with the idea of “going to see a psychiatrist.” Second, it seems clear to me that differences in coverage for psychiatric illness versus other medical illnesses both stem from and contribute to stigmatization of psychiatric patients.
The 1990s were termed “the decade of the brain.” I think this was misleading in some sense. Knowledge about the brain and about illness of all sorts affecting the brain did explode in the 1990s but this appears certain to be dwarfed by the changes to come in the next 10 to 20 years. The great majority of patients receiving psychopharmacologic treatment today are receiving treatments not available 15 years ago and that seems likely to be as true or even more so 15 years from now. We also foresee the integration of psychiatric services within general medical care. ✦
We are very hopeful that the Attorney General’s efforts will provide great benefit to psychiatric patients and access to the people who provide care for them. The June 2001 settlement set up a panel of three retired judges to review medical necessity denials, requires access to a mental health professional within 10 days, and stops the BCBSM Behavioral Carveout base from being funded by captitation. Frankly, it is perhaps a little too early to provide a full answer as to how these changes will impact care but the potential for improvements appears to be great.
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MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
May/June 2002
5
FEATURE STORY
The Mental Health
Carveout as an Instrument of Patient Discrimination
T Separating mental and physical diagnoses and treatments via managed care behavioral carveouts is a modern myth derived from the archives of the treatment of mental illness.
THE ORIGINS OF MENTAL HEALTH CARE IN THIS COUNTRY did not derive from the accumulated knowledge of neuroscience. The motives for the systems of care and control of the mentally ill stem from religious beliefs, public health, public safety, and criminal justice practices and concerns, management of the poor and destitute and, then as now, rampant stigma and discrimination against those afflicted with mental illnesses. For example, the practice of phrenology, i.e., measuring the shape of the skull, was a theory to explain human behavior. But this theory did nothing to inform patient treatment. The “treatment” for the most ill inevitably meant banishment—often in a large facility far from the scrutiny of citizens. As recently as the late 19th century one finds notations of self-abuse (masturbation) as presumably related to mental disorders, and as recently as 1973 the American Psychiatric Association viewed homosexuality as a mental disease. So it is no wonder that systems of care that developed with no body of validated scientific knowledge has perpetuated many myths, and to the extent that that system of care persists today it brings with it many artifacts and peculiarities. Separating mental and physical diagnoses and treatments via managed care behavioral carveouts is a modern myth derived from the archives of the treatment of mental illness. At the start of the 20th century the newest and boldest treatment approach was psychoanalysis, a theory and practice that imparted a developmental and environmental theory to the causes of mental illness. The brain in psychoanalysis is a black box, as is the case with B. F. Skinner’s behaviorism based on experimental techniques. Psychoanalysis, seen as a theory of conflict between the intrapsychic mental forces of conscience and primitive impulses of drives, found favor among American intellectuals, theologians, and teachers in the early 20th century. Ironically, during this same timeframe the psychotics were sent off to remote hospitals for the insane in large, state supported hospitals, often with their own farms and craft communities. Subsequently, programmatic behavior modification, social learning, and language-based conceptualizations and coping techniques became established as talking techniques in individual and group psychotherapy. Around the middle of the 20th century the accidental discovery that depressed patients with tuberculosis showed improvement in their mood when treated for TB antimicrobials and the observation that chlorpromazine, originally intended for the treatment of nausea, caused significant reductions in mental symptoms suggested that medications could be produced in the laboratory to benefit the mentally ill. These discoveries had a very important implication: For the first time there was a legitimate claim that
BY GEORGE REALMUTO, M.D.
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The Journal of the Hennepin and Ramsey Medical Societies
mental illnesses are disorders of brain physiology which could be treated like other biological medical conditions. Psychiatry’s emergence and place within modern medical pharmaceutical care may have begun here, but this tender union endures salvo after salvo to destroy it. We seem to resist accepting that our brains, and minds as the product of human brains, are proper organs for medical attention. Mental health and regular medical health care systems have very different traditions, and continue today as separately conceptualized, organized, and funded systems of care delivery. Sources of funding are key in the understanding of the separation of psychiatry from medicine. During WW I and WW II the Department of Defense knew that healthy soldiers broke down during intense combat and were unable to return to battle for psychological reasons. The need to keep a viable fighting force, and successes and lessons learned in war with counseling and respite for the shell shocked, was a motive for appropriations to create training programs and faculty for departments of psychiatry to increase the psychiatric workforce. Another major factor in isolating psychiatry from other branches of medicine was its research-funding base. One would think that nothing would be more uniting among medical specialties than using scientific method to move all medical fields forward; however, funding for psychiatric research came from a separate funding source not affiliated with the National Institutes of Health. The Alcohol Drug Abuse and Mental Health Administration (ADAMHA), was on its own to solicit Congress for research funds for the basic scientific understanding and treatment of mental illness. Only in the past 15 years have the National Institute of Mental Health (NIMH), the National Institute for Drug Abuse (NIDA), and the National Institute for Alcohol and Alcohol Abuse (NIAAA) been absorbed into the fold of the NIH. And there are many signposts of economic discrimination and separation in insurance systems. Different rules and procedures for the care of the mentally ill can be seen in differences in lower rates of reimbursement, higher copays, and limited benefits offered in government programs, specifically the federal Medicare program. Federal funding for community mental health centers, the child guidance movement, and a variety of family supports to free-standing mental institutions inevitably reinforced the separate development of psychiatric services from those of mainstream medicine.
Mental health and regular medical health care systems have very different traditions, and continue today as separately conceptualized, organized, and funded systems of care delivery.
(Continued on page 8)
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May/June 2002
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Carveout (Continued from page 7)
All of medicine, however, was to undergo a revolution with President Richard Nixon’s promotion of legislation in 1973 establishing federal support for Health Maintenance Organizations (HMOs). Some of us thought that psychiatry would finally be taking consults for medically ill patients in hospitals, discussing cases in psychosomatic multidisciplinary rounds, and contributing and collaborating with physicians in a common venue. How brief this fantasy of egalitarianism was! While intended to promote preventive health care services and bring discipline to cost containment by giving providers financial incentives to reduce the provision of excessive or unnecessary services to patients, managed care organizations and HMOs decided to separate out these mental health services. We have, in the past 15 years, witnessed a severe contraction of the independent practitioner as a major force in psychiatric patient care funded by insurance. As physicians joined or were swept up as employees of large multi-specialty care groups and networks supported by health plans and insurance companies, a growing concern arose about the cost of mental health care and what increased access would mean to payers’ resources. For example, it was said that if the conduct disorder of children and adolescents were included in the employee’s benefit package it would bankrupt the industry. Of course the juvenile justice system was not really ever a full partner in the care of these children, and social services that were and continue to be legitimate responsibilities of child welfare were intermittent participants—but not substitutes for proper coverage for children’s psychiatric services. Enter the carveout. Management of care in psychiatry required all of the restrictive and physi8
May/June 2002
cian disempowering rules and procedures experienced by other medical specialties. In addition, however, psychiatry was split off administratively and economically. To fiscally protect itself the payer hired separate organizations specifically to manage mental health care. Rules promulgated by the larger organization have been reinterpreted by the carveout company in ways that would not be tolerated by physicians or patients in the larger medical enterprise. The administrating corporation contracts mental health services to another entity whose bid for this capitated population guarantees the administrating organization a profit by reducing treatment outlays. How do such deals work in practice? Each successive subcontractor provides lower quality care by hiring less qualified therapists and limiting access to psychiatrists and other medical professionals. Without advocates, mentally ill individuals have no chance to obtain optimal or even adequate services. The quality of care of the carveout treatment organizations does not need to be equivalent to the standards of the large contract negotiated with the employer. The details of care are up to the carveout organizations, which have financial incentives often to provide only minimal care. When patients complain, they are directed to a customer service representative of the carveout company who has little power to help them. The utilization of mental health care controlled by carveout companies is one of the unregulated businesses in corporate America. Thirty-seven states have mandated parity, but often even the calculation of parity is based on the existence of for-profit managed care behavioral health organizations to set the standard. So, the federal government’s analysis of cost of including full parity for mental health care showed that the increased cost of care would be minimal, but where is the starting point and what is the target? Still, we are making progress to reduce the discrimination MetroDoctors
with Minnesota Senator Paul Wellstone and New Mexico’s Pete Dominici’s federal mental health parity legislation, the Individuals with Disabilities Act (IDEA), Minnesota’s mental health ombudsman provisions, and the recent settlement between Blue Cross and Blue Shield of Minnesota and Minnesota Attorney Mike Hatch. All of these developments have resulted in meaningful changes and improvements. Fair payment for psychiatric services and integration with primary care foster a rapprochement of medical and mental health services delivery and funding. With striking scientific advances in our understanding of brain functioning, neuroscience does support both biological and psychosocial treatments offered by the specialty of psychiatry and other mental health professionals and primary care physicians. We now have treatments for mental and addictive disorders that are as effective as treatments for hypertension and arthritis, and our scientific understanding of the molecular and cellular basis of mental illnesses and treatments is growing exponentially. By confronting and eliminating discriminatory financial barriers to care, studying biological substrates of mental illness and providing medical treatments on a par with other medical specialties, the discriminatory practice of behavioral carveouts must be eliminated. ✦ George Realmuto, M.D., is an associate professor of psychiatry at the University of Minnesota as well as the director of Pediatric Mental Health Consultation. He is codirector of the Autism Clinic and Research Center.
The Journal of the Hennepin and Ramsey Medical Societies
No Room at the Inn The Shortage of Psychiatric Inpatient Beds in the Twin Cities
I
IT’S MIDNIGHT, AND THE emergency room physician examines his patient. She has made superficial cuts on her arm in a suicide attempt. Psychiatric assessment in the emergency room reveals a recurrence of depression and on-going suicidal thoughts. The physical wounds are treated, and a decision is made to admit the patient to a psychiatric unit for safety and further psychiatric evaluation. The emergency room’s work should be just about finished, but all too frequently now, their work has only begun. Finding an available inpatient psychiatric bed in the Twin Cities can take hours, and occasionally, a patient requires transfer out of the metro area or even out of state to find an inpatient psychiatric bed. There are several factors that may contribute to the apparent shortage of psychiatric inpatient beds in the Twin Cities. First, there are only three acute care hospitals in the Twin Cities that still have inpatient psychiatric units for children and adolescents. While the shortage of psychiatric beds is most evident with children and adolescents, they are not the only patients affected. Adult patients are also being diverted around the city, being held in emergency rooms, and being admitted to medical units until an appropriate psychiatric bed can be located. Inpatient utilization in the Twin Cities has been increasing steadily for the last several years. Psychiatry discharges from Twin Cities’ hospitals increased almost 9 percent from 1998 to 2000, and increased again by about 3 percent through the first half of 2001. This appears to be due to an increase in the number of people presenting for psychiatric care. Outpatient utilization of psychiatric service is also increasing. Other shortages seem to contribute to the
increased inpatient utilization and shortage of inpatient beds. There is a shortage of psychiatrists in the Twin Cities, which creates difficulty for patients to get an appointment with a psychiatrist on an outpatient basis. It is not uncommon for patients to wait 6-10 weeks or more to get an appointment. One study stated that the national average of psychiatrists in a metropolitan area was approximately 14-15/1,000 population. In the Twin Cities, we have between 10-12 per 1,000 population. During this time, some of these patients may decompensate, requiring more intensive care, and ultimately, hospitalization. Also, due to the shortage of psychiatrists in the community, many patients utilize an emergency room as their first point of access for mental health care, and only after their symptoms have reached a crisis. Without alternative resources in the community such as day treatment programs, partial hospitals, intensive outpatient treatment programs, and county support services, these patients require hospitalization to be evaluated and started on a treatment plan that will help them maintain their safety. The shortage of community resources as described above also impacts the hospital psychiatric units as they try to discharge patients back to the community. While much progress has been made in shortening the lengths of stay for patients on psychiatric inpatient units, there are still a number of patients whose symptoms have stabilized, but who cannot be discharged due to the limited community resources available, or the lack of an available community placement. Patients may also wait for weeks in an acute care hospital unit awaiting transfer to a State Regional Treatment Center after being court-committed. These delays in discharge then
prevent the hospitals from admitting another patient who requires inpatient care. Unfortunately, there is no evidence that the crisis is abating. Inpatient utilization continues to increase, and population estimates for the Twin Cities metropolitan area suggest an increase of another 10 percent by 2006. Also, the State of Minnesota continues to look for ways to decrease spending, and the Regional Treatment Centers are prime targets. As the state treatment centers cut back, more responsibility will fall to the community hospitals to care for (Continued on page 10)
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Inpatient Psychiatric Bed Shortage (Continued from page 9)
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these psychiatric patients, often those with more chronic mental illnesses that require longer hospitalizations. Also being faced with the need for budget cuts, the metro county agencies will have difficulty maintaining all of the programs they currently have, yet alone increasing the funding and programming available to treat more patients in the community. Last year the Minnesota State Legislature passed a measure changing the state’s legal definition of “mental illness” as it relates to civil commitment proceedings. This is an attempt to lower the threshold for involuntary commitment to allow for earlier hospitalization and intervention for mental illness. While this is an admirable goal, the question remains, where will these patients find a room for their care? If the hospitals are already full, how can even more patients be admitted to the hospital? Hospitals have not been quick to increase psychiatric bed capacity. Managed care has controlled reimbursement for many years, making it difficult for hospitals to even cover their costs. And even if there were more beds available in the city, there might not be any psychiatrists available to care for the patients in those beds. The shortage of psychiatric hospital beds in the Twin Cities is complicated. And it is not unique to the Twin Cities. Many other parts of the United States are struggling with the same problems. The solutions will require creative, collaborative efforts from mental health providers, managed care payers, employers, county and state agencies, and our state legislature. No one can solve this on their own. We need more hospital beds, more psychiatrists, more group homes, more social workers, more treatment programs, and on and on. We need more money to pay for all of these services. Goal Number five of Healthy Minnesotans: Public Health Improvement Goals 2004 is to “promote, protect, and improve mental health.” It specifically targets “children’s mental health.” If we are truly going to meet these goals, we need to find a way to give our mental health patients, and especially our children, the treatment and services they require, including hospitalization, without sending them out of the city and out of the state. ✦ Doug Nemecek, M.D., M.B.A. is executive medical director for Allina Behavioral Health Services.
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The Journal of the Hennepin and Ramsey Medical Societies
The Shortage of Child and Adolescent Psychiatrists
T
THE SHORTAGE OF CHILD and adolescent psychiatrists is real and evident in the metro area. The shortage has resulted in long waits to obtain psychiatric services (and in some areas the inability to obtain psychiatric services at all), a reduction in the number of hospital beds available for child and adolescent psychiatric services, and in emergency cases, sometimes the transfer of patients long distances, such as to Fargo or Duluth, to receive inpatient care. A number of factors have contributed to this shortage, including some having to do with managed care, some with the change in the public’s demand for psychiatric services, and some within our own specialty. Both short-term and long-term solutions are currently being promoted. In order to provide the best mental health treatment for our children, collaboration with pediatricians and family physicians in addition to the careful utilization of child and adolescent psychiatric services should be undertaken. Just ask any parent who has recently tried to find a psychiatric evaluation for their child. They will tell you of physicians not currently accepting new patients, wait times of up to three months to get an appointment, inability to reach the child and adolescent psychiatrist by phone, and, often, difficulties understanding whether the consultation is covered by insurance or not. In my own outpatient practice, wait times for a new appointment generally run two to three months and new patients almost always say they reached me after talking to two or three offices that were not accepting patients. On the inpatient side, hospital beds for child and adolescent psychiatry have decreased recently. Although this is partly due to pressures from insurance companies for shorter B Y T I M O T H Y P. G I B B S , M . D .
MetroDoctors
lengths of stay, a major factor has been the lack of child and adolescent psychiatrists willing or able to do inpatient hospital work. Currently, inpatient care reimbursement for the physician is generally less than the reimbursement to physicians for outpatient care. In the past, when psychiatrists were mostly in solo private practice, psychiatrists were eager to provide inpatient services, even at lower reimbursement rates, in order to bring new patients into their practice. Now, the demand for child and adolescent psychiatric services is so great that most psychiatrists spend their management efforts trying to figure out how to limit their own workload in order to prevent professional burnout, rather than trying to recruit new patients. An additional recent factor has been the EMTALA requirement. Because the emergency room physicians are (correctly) concerned about an EMTALA violation if they release an unstable psychiatric patient, the inpatient psychiatrists are often swamped with patients to a point beyond their reasonable capability. This has led many psychiatrists to move from inpatient care to the somewhat more controllable workload of outpatient care. Some current figures may help put the shortage in perspective. The Minnesota Society for Child and Adolescent Psychiatry (MSCAP) has about 100 members. Virtually
The Journal of the Hennepin and Ramsey Medical Societies
all practicing child and adolescent psychiatrists in Minnesota belong to the organization. MSCAP covers a slightly larger geographic area than just Minnesota. Minnesota residency programs typically produce six to eight new child and adolescent psychiatrists each year. While certainly child and adolescent psychiatrists could be recruited from other areas of the country, there continues to be a national shortage as well. The American Academy of Child and Adolescent Psychiatrists (AACAP) has approximately 6,700 members. In 1999, 23 percent were age 30 to 39 and 11 percent were age 60 to 69. Nearly five percent were age 70 to 79. These figures indicate that at the present time, more child and adolescent psychiatrists are leaving the field than coming into it. There may be greater demand for child and adolescent psychiatric services than ever before. The recent study from Mayo Clinic finding of ADHD in 7.5 percent of 8,548 Olmsted County school children studied indicates the high need. (Interestingly, the study found that among children felt not to meet criteria for ADHD, only 0.2 percent were getting stimulants, so evidence of widespread over-prescribing of stimulants was not supported.) The most frequently suggested long-term solution to the shortage of child and adolescent psychiatrists is to recruit more to the field. This has become the number one priority for AACAP, and is included as part of their program for reducing barriers to mental health care for children. This recruiting process is somewhat difficult at a time when the council on graduate medical education (COGME) is still recommending cutting back the total number of physicians graduating from medical schools, and still recommending more generalists than (Continued on page 12)
May/June 2002
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Shortage of Psychiatrists (Continued from page 11)
specialists. Despite this recommendation, the current number of child and adolescent psychiatrists is so far behind the need that going against this overall trend seems warranted. Additional solutions, such as providing forgiveness of government loans for individuals working in underrepresented specialties, are being proposed.
In the short run, patients must still be served. Pediatricians and family physicians provide most child and adolescent psychiatric care. Greater collaboration between child and adolescent psychiatrists and primary care providers could increase the number and complexity of patients beyond what the primary care providers could handle. Improved collaboration is the goal of an upcoming meeting of MSCAP to be held in St. Cloud in May of this year.
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This collaboration could take the form of more telephone consultation between the primary care provider and the psychiatrist, having the psychiatrist hold some office hours at the primary care location, and providing more detailed documentation and instruction for patients evaluated by the child and adolescent psychiatrist but referred back to the primary care physician for ongoing treatment. Telemedicine consultation, especially in urgent cases, is another possible solution. Certainly, the help provided by adult psychiatrists who also take care of adolescent patients helps a great deal. Hospitals have begun to recognize child and adolescent psychiatrists as an “underrepresented specialty.” They have also taken steps to reduce the pressures on child and adolescent psychiatrists to see too many inpatient cases, and therefore have reduced the attrition due to professional burnout. Child and adolescent psychiatrists remain an appropriate source of expertise and treatment for complex cases, and for patients who fail to respond to initial treatment regimens. Improved collaboration among child and adolescent psychiatrists, pediatricians, and family physicians could help more patients with difficult problems obtain appropriate care, while allowing the more routine cases to be handled by the primary care providers. Long-term resolutions are in the pipeline. In the meantime, greater collaboration between colleagues will help serve our child and adolescent psychiatric population. ✦
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
Mental Health and Public Health
T
THE RECENTLY RELEASED U.S. Surgeon General’s report on mental health outlines the scope and nature of mental health problems in the U.S. It notes that these problems, in addition to causing immense human suffering and family disruption, are financially costly to society. In fact, mental health disorders are the second most disabling conditions, second only to cardiovascular disease. The report clearly defines these disorders as public health issues, requiring public health approaches to prevention, early identification and coordinated treatment. A review of the literature on the recognition of mental health problems and the provision of mental health services clearly indicates that the majority of children, adolescents and adults who have mental health problems receive no treatment. The vast majority of those treated are treated by primary care physicians. Various studies describe a significant degree of unrecognized and untreated psychiatric and chemical health problems in the primary care population. A number of studies note that approximately 25 percent of patients seen by primary physicians have a psychiatric disorder, such as anxiety or depression. (This compares to 18 percent of the general population.) Some studies have noted even higher percentages. As many as 20 percent of patients seeing primary care physicians have alcohol abuse or dependence. Unfortunately, primary care physicians do not have a good track record of diagnosing mental health and chemical health problems. One study noted that only 10 percent of patients meeting criteria for substance abuse were recognized by their primary care physician. Only 20 to 30 percent of patients with emotional distress, family problems, behavioral problems or sexual dysfunction are noted to communicate
BY WILLIAM DIKEL, M.D.
MetroDoctors
these issues to their primary care physician. Another study noted that general physicians missed half of the psychiatric disorders seen in their clinics. Family practice residents were noted to miss 85 percent of cases of depression of at least mild severity, and 70 percent of cases with severe depression. Medical patients receiving care financed by prepayment were significantly less likely to have their depression detected or treated during their visits than were similar patients receiving fee-for-service care. In a University primary care clinic, 25 of 87 randomly selected patients were noted to have an anxiety disorder based on a structured clinical interview, but when medical charts were reviewed only one of the 25 patients had documentation of anxiety. It has been estimated that one of every eight patients in primary care have an undetected psychiatric disorder. Medical problems are often missed by mental health professionals as well. Up to 18 percent of patients thought to have psychiatric disease have an underlying medical cause of their psychiatric symptoms. One study indicated that nearly 75 percent of organic illness was first unrecognized by mental health professionals but was finally diagnosed by judicious attention to history, physical examination and screening laboratory tests. The most common psychological manifestation of organic disease is depression. This is of great concern, since the majority of people who have mental health disorders receive their care from primary care physicians. In one study, only 17 percent of psychotropic prescriptions were written by psychiatrists. Contributors to inadequate mental health care include physicians’ lack of training about mental health diagnosis and treatment, the relatively brief treatment appointments, poor financial compensation for treatment of mental health problems, and physicians’ attitudes.
The Journal of the Hennepin and Ramsey Medical Societies
Patients who have mental health disorders have higher health care costs. Patients diagnosed as depressed have higher annual health care costs ($4,246 versus $2,371) than patients without depression. Eleven million Americans suffer from depressive disorders, costing the U.S. economy 44 billion dollars a year. Medical patients often receive unnecessary medical care while their underlying mental health disorders remain untreated. For example, clients who have panic disorder frequently seek medical treatment for their episodes of shortness of breath, heart palpitations, dizziness, etc., only to have extensive and expensive medical assessments by pulmonary specialists, cardiologists, neurologists and primary physicians that do not identify their very treatable and disabling disorder. Also, research on the topic of cost offset indicates that there is evidence that increased awareness and treatment of mental health disorders frequently results in decreased costs in medical treatment. Thus, the use of effective screening tools by primary care physicians can result in a significant cost savings in medical expenditures. Screening tools can identify both the presence of mental health and chemical health disorders and the level of their pathology. For example, the PRIME-MD can be administered by paraprofessionals, takes approximately eight minutes to fill out, and identifies several mental health disorders including anxiety and mood disorders. The Zung self-rating depression scale and the CAGE Alcoholism screening tool are other very effective screening tools for primary care physicians. These statistics support general screening of all primary medicine patients. Even if general screening of primary medicine patients is seen as too time intensive or not cost effective, screening could focus on clients most likely to have mental health or chemical health disorders. (Continued on page 14)
May/June 2002
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Mental and Public Health (Continued from page 13)
A number of medical symptoms are highly correlated with depression. For example, complaints that discriminate between depressed and nondepressed patients include sleep disturbance, fatigue, multiple complaints, nonspecific musculo-skeletal complaints, back pain, shortness of breath, amplified complaints and vaguely stated complaints. Another study noted that the most common physical complaints associated
with depression are insomnia, appetite changes, impaired concentration, weakness, drowsiness, headaches, agitation and excessive perspiration. Other common symptoms include chest pain, low back pain, polymenorrhea, slurred speech, sexual dysfunction, and chronic pain. Substance abusers often present with telltale signs, symptoms and laboratory findings. Patients with Obsessive Compulsive Disorder frequently present with eczematoid hands, trichotillomania (hair pulling), nail picking, gingival bleed-
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MetroDoctors
ing or tics. Children who have ADHD frequently have academic and behavioral problems. A number of policy recommendations have been made regarding guidelines for mental health treatment and referral by primary care physicians. In December 1989, Congress mandated that medical disorders with high frequency and cost be reviewed, and guidelines be established to improve the quality of care nationally for patients being treated with these disorders. One of the seven mandated disorders was Depression in primary care. Clinical guidelines have been established for treatment of Depression by primary care physicians. These guidelines assume a reasonable degree of diagnostic sophistication by the primary care physician and the ability to distinguish between primary mood disorders and mood disorders related to secondary issues such as general medical disorders, concurrent medication, substance abuse, and causal, non-mood psychiatric disorders. They also expect the primary care physician to recognize the different types of disorders such as Major Depression, Dysthymia, Bipolar I and Bipolar II Disorders, Cyclothymia and Depressive Disorder Not Otherwise Specified. Although these recommendations are commendable, they will not be able to be successfully implemented unless there is a greater emphasis on training of mental health issues to primary care physicians, the use of effective screening tools, establishment of equitable insurance reimbursement rates for treatment of Depression, and effective oversight by governmental and medical agencies. Although the business community has resisted parity coverage for mental health treatment, recent studies indicate that there is actually a cost benefit to employers in ensuring that mental health disorders are recognized in primary care. The Twin Cities StarTribune recently featured a front page article noting that most people who suffer from Depression get their treatment from primary care doctors at community clinics, the disease goes unrecognized half the time, and is properly treated only onefourth of the time. It described a recent study by the Rand Corporation that measured how quality improvement programs affected the diagnosis and treatment of 913 patients at 46 primary care clinics in five states. In addition to significant improvement in depressive symptoms, there was a 5 percent increase in patients who were maintaining employment in the quality improvement group. Given that worker absenteeism from serious depression costs emThe Journal of the Hennepin and Ramsey Medical Societies
ployers 17 billion dollars a year, Dr. Kenneth Wells, the study’s lead researcher stated, “If that finding were extrapolated across all of those disabled by depression, it would move the stock market.” Public health should have a primary role of overseeing mental health issues for the following reasons: 1.) Most mental health treatment is provided by primary care physicians, whose mental health screening, diagnostic and treatment efforts are not overseen by the Mental Health Division of the Department of Human Services (DHS). 2.) DHS has an even narrower focus in regards to oversight of mental health disorders, even when treatment is provided by mental health professionals. Its focus, in adults, is on addressing only four mental health disorders: Depression, Bipolar Mood Disorder, Schizophrenia and Borderline Personality Disorder. This is an arbitrary group of disorders, outlined by legislation, and does not reflect the epidemiological impact of other disorders. The Department of Health functions on a model that addresses all health disorders without using these arbitrary distinctions. 3.) DHS tends to focus on individuals served in the public sector, whereas the Department of Health addresses health problems in the general population. 4.) Human Services agencies at the state and local level tend to have a high threshold for services, and tend to focus services on the most seriously disabled individuals. Many of these individuals would not have reached this level of severity if earlier interventions had been utilized. Public Health operates on a model that emphasizes early identification, intervention and prevention efforts. Addressing the most severely disturbed individuals does not tend to have an impact on mental health problems on a societal level. Generally, most of the severely disturbed individuals do not receive services, and many do not request them. A public health model that emphasizes early intervention efforts, with research-based epidemiological models of services, would have a much greater impact on mental health issues in the state. 5.) Research indicates that there is a biological basis for the severe and chronic mental health disorders such as Depression, Bipolar Mood Disorder, Schizophrenia, Obsessive Compulsive Disorder, Panic Disorder, Attention MetroDoctors
Deficit Hyperactivity Disorder, etc. As noted above, many medical disorders also have psychiatric manifestations. Psychiatric disorders are public health problems, and need to be addressed as such. Although social problems such as poverty and prejudice can result in adjustment related psychological problems, putting the oversight of mental health in the social services realm tends to blur the distinctions between these social problems and primary mental illness. 6.) For many patients, there is a significant stigma attached to mental health problems, seeing mental health professionals, etc. They are more comfortable addressing mental health issues, at least initially, with primary health care providers. Other patients are interested in seeing mental health professionals, but have limited access to them. Since health professionals either are generally the referral source for treatment by mental health professionals, or provide the treatment themselves, oversight of mental health issues has to be provided by an agency that provides oversight to these professionals. 7.) Health programs already mandate mental health screening, although at the present time
it is rarely done effectively. For example, EPSDT (Early and Periodic Screening, Diagnosis and Treatment) is a mandated service for children ages 0-21 covered by Medical Assistance or MinnesotaCare. It is supposed to include a mental health screen and a comprehensive mental health history. Research studies indicate that 25-30 percent of children and adolescents on Medical Assistance have mental health problems. However, Minnesota data indicates that only 1-4 percent of those screened by EPSDT are referred for mental health assessments. If mental health screening was addressed like other public health screening interventions, and overseen by the Health Department, one would expect a significantly higher early recognition of these disorders, with a markedly positive societal impact in the education, social services and correctional systems as well as the health and mental health systems. 8.) As noted above, there is a significant cost offset benefit resulting from treating mental health disorders. In other words, medical care costs decrease when mental health treatment is (Continued on page 16)
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The Journal of the Hennepin and Ramsey Medical Societies
May/June 2002
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Mental and Public Health (Continued from page 15)
provided. When mental health is “carved out” of the health care system, it is difficult to track this cost offset effect, and difficult, if not impossible, to address program planning and development issues related to cost effective mental health treatment provisions. 9.) Public Health nurses across the state repeatedly note that mental health problems are the number one unserved or underserved issues in their patient population. This results in a significantly negative impact on their patients’ physical health. 10.) Mental health professionals are an essential component in the provision of high quality mental health services. Health Department oversight of mental health issues can result in increased training to health professionals regarding criteria for referrals to mental health professionals, payment for mental health consultation to primary care physicians, cooperative relationships between mental health professionals and primary care providers, and increased sensitivity to unaddressed medical problems in individuals with mental health disorders. 11.) The Surgeon General’s report indicates that half of individuals who have mental health disorders have problems with chemical abuse or dependency. The reverse is also true. Thus, these health issues also need to be addressed as primary health problems by the Department of Health. The issues outlined above provide a compelling argument for mental health issues to be addressed on a societal level as public health issues, with oversight provided accordingly. The need to address these issues effectively should drive system change, support access to funding, and overcome resistance to system redesign.✦
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William Dikel, M.D., is an associate clinical professor of psychiatry at the University of Minnesota and an adjunct professor at Hamline and the University of Minnesota Graduate Liberal Studies programs. He is board certified in general psychiatry and in child and adolescent psychiatry, and is an APA fellow. Editor’s Note: The article above can be viewed in its entirety, including recommendations to the Minnesota Department of Health proposed by Dr. Dikel and a list of references, on the MetroDoctors website: www.metrodoctors.com.
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The Journal of the Hennepin and Ramsey Medical Societies
Public Academic Liaison: Medical Centers’ Relationship to their Communities
O
OVER THE LAST 15 YEARS, academic medical centers in the United States have participated in constructive collaborations with state or county systems with increasing regularity. This type of partnership—variously called Public Academic Liaison (PAL) or other acronyms— has provided important opportunities for medical schools and community centers alike. In Minnesota, there are substantial opportunities for the University of Minnesota to play a larger role in mental health issues than it has in the past. As has been seen around the United States, the University and its community counterparts will need to recognize that their progress will come through partnership. To provide a framework for such partnership, this article will review some of the historical background of the relationship of medical centers to state and county communities, describe changes over the last 25 years involving medical school and community interactions, and conclude with strategies that the University of Minnesota can pursue with its community partners. These potential collaborations are not meant to be exhaustive, but to provide initial discussion points for a better future for mental health treatment in Minnesota.
A History of Mutual Suspicion As medical school Departments of Psychiatry blossomed following World War II, they frequently emerged in settings separate from their state and county colleagues. Whether this was secondary to elitism, different models of psychotherapy, or goals of treating patients with different types of diagnoses, the collaborative spirit in the United States was generally low. As is well known, the system of state hospitals placed their institutions at a great distance from
BY S. CHARLES SCHULZ, M.D.
MetroDoctors
most urban medical centers, thus imposing a physical as well as philosophical difference between the two groups. Also, the research and teaching missions of medical schools frequently focused on patients without the severity of psychiatric illnesses of patients served in state hospitals. As years went by, mutual suspicion increased as community systems of care felt research departments were not relevant for their patients or that there might be actual harm from research studies. Added to this mix was the absence of consumer advocacy groups in psychiatry—groups that may have had the potential to bring universities and community services together. State Systems and Universities Discover Each Other It is an over-generalization to say that universities and community systems never worked together—examples of outstanding collaboration include University of North Carolina and the Dorothea Dix State Hospital, which was the site of a National Institute of Mental Health (NIMH) Clinical Research Center. However, many psy-
The Journal of the Hennepin and Ramsey Medical Societies
chiatrists feel that the “Maryland Plan” initiated a new era of university and state systems working together. The Maryland Plan included a close relationship between the University of Maryland and the Maryland State system with a focus on young graduate psychiatrists playing a meaningful role in the state system. Many observers (including me) noted a dramatic rejuvenation of Maryland’s state system and felt that it paved the way for the placement of new leadership at the Maryland Psychiatric Research Center (MPRC). The success of this plan signaled potential to other states, which followed suit—such as the collaboration between Yale and its nearby community mental health center. As clinical trial research expanded during the 1980s and the NIMH changed its focus to prioritize research of the most seriously psychiatrically ill patients, and initiated the Public-Academic Liaison program (PAL). I was fortunate to have been assigned the lead in this project to design ways that the public sector and universities could collaborate on research for seriously ill patients. Opportunities for research for patients previously refractory to medication treatment became common after this project started. Also during the mid-1980s, consumer groups and family advocacy/self-help organizations began to play a larger role in the agenda of mental health care. Some academic medical center investigators made efforts to bridge the gap between these groups and university departments, so that yet another academic-community relationship began. Looking back, it is hard to imagine that medical schools did not generally have strong relationships in the community just a generation ago. However, the initiatives described
(Continued on page 18)
May/June 2002
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Public Academic Liaisons (Continued from page 17)
above point to the success of such programs around the country and the potential for collaboration in Minnesota. Opportunities for Partnership in Minnesota The Department of Psychiatry at the University of Minnesota has identified the partnership with the community as one of its leading strategies. This collaboration is meant to provide partnership with state, county, and consumer entities. Such partnerships rely upon the development of plans recognizing the needs and expertise of all parties. As long as communities and medical centers can both prosper, the likelihood for success is enhanced. I would like to briefly discuss ways in which the University of Minnesota could collaborate with its community counterparts.
Collaborations between medical schools and state hospital systems have probably been the most frequently described partnership. It is well known that the University of Texas has forged an outstanding relationship with its state hospital system to construct a medication algorithm program (T-MAP). Not only has this program led to more standardized service for seriously ill patients in Texas, but it also has provided the framework for sophisticated outcomes research and for teaching at a number of the medical schools in Texas. Other states, such as Ohio, have embarked upon collaborative relationships where a full-time faculty member from a nearby medical school serves as the medical director for a state hospital. By allowing some “protected time” for faculty at the state hospital, new and empirically oriented psychiatrists have been drawn to the state setting. Here in Minnesota, teaching collaborations had been initiated years ago at Anoka State Hospital. Clearly such teaching relationships can be
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expanded. In addition, the University of Minnesota and the State Hospital System have made preliminary plans to collaborate with leaders of the Texas Medication Algorithm Plan for discussions regarding a similar model in Minnesota. Over the last two decades, collaborations between community mental health centers (CMHCs) have become quite common. Furthermore, as empiric research has increased in departments of psychiatry, CMHCs have become collaborative partners. Such collaborations have substantial potential for the University of Minnesota and its affiliates—but have, as yet, to be fully realized. In the Twin Cities area of Minnesota, strong consumer and advocacy groups exist. Whether focused on the issue of suicide (Suicide Awareness/Voices of Education, or SA/VE), the seriously mentally ill through NAMI (Nationally Alliance for the Mentally Ill) or other groups (NMHA), the parents of patients and consumers themselves play an important role in advocating and setting the agenda for mental health care. Community provider organizations such as People, Inc. have reached out to the University of Minnesota and the VA to develop collaborations. Another opportunity exists here for the academic department to establish a partnership and dialogue. Mutual needs of education and research, along with expert clinical care, can also clearly enhance both groups. Conclusions In my opinion, universities benefit by “getting out of the building” and participating with community systems in order to help the seriously mentally ill people in our cities and throughout the state. These collaborations have emerged with vigor over the last 25 years and a number of instructive examples exist throughout the United States. New interest from the Department of Psychiatry at the University of Minnesota has led to initial discussions with the state system, counties, and consumer groups for a partnership in the service of the seriously ill. ✦ S. Charles Schulz, M.D., is professor and head of the Department of Psychiatry at the University of Minnesota Medical School.
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MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
The Effectiveness of Addiction Treatment
P
PATIENTS WITH SUBSTANCE USE DISORDERS (SUDs) often
evoke hostility and disgust from doctors and health care staff when they are noncompliant with medical treatments. Unfortunately, medical training often seems designed to create resentment and pessimism among physicians for these patients. As medical students and residents who receive much of our training in public hospitals, most physicians have been confronted with annoying, smelly, intoxicated patients who are rarely deferential to doctors. In addition to such negative training experiences, physicians reinforce such stereotypes of addicted patients due to their lack of training in techniques to manage SUDs in the context of medical practice. Two facts make this annoying situation tragic. First, much therapeutic pessimism stems from a misunderstanding of actual treatment compliance and outcomes for patients with substance use disorders and how SUD treatment outcomes compare to outcomes of treatment for other chronic illnesses. Second, treatment techniques that have been proven effective for SUDs in medical practice are not being widely implemented. We will address each of these below. Substance use disorders are similar to other chronic diseases in that there is a spectrum of illness that varies from mild and transient, to severe, chronic, and treatment resistant. Viewing most SUDs in this way helps to reframe treatment goals and expectations and to clarify misconceptions. Most people regard a positive treatment outcome for an SUD to be complete and permanent abstinence from use of the substance. Compared to outcomes for other chronic, relapsing illnesses, the SUD “cure� rate, or permanent full remission, is relatively high, on the order of 30 percent after one treatment episode. However, intermediate outcomes are very common. Therefore, in order to properly evaluate outcomes, it is essential to think in continuous terms, rather than a cured/ failed dichotomy. The same holds true for compliance. As illustrated in Figure 1, compliance and re-treatment rates for diabetes, hypertension, asthma, and SUDs are comparable. In fact, re-treatment rates are lower for SUDs than most other chronic illnesses. In recent years, several large, multi-site studies have demonstrated the effectiveness of treatment for SUDs (Hubbard et al., 1997; Project MATCH Research Group, 1997). Treatment outcomes for alcohol and cocaine dependence are shown in Figures 2 and 3. In any other serious chronic disorder, these would be regarded as very good outcomes.
Figure 1. Compliance and re-treatment rates for four chronic illnesses.
Figure 2. Treatment outcomes for alcohol dependence in two large multi-site trials.
Figure 3. Treatment outcomes for cocaine use in a large multi-site study.
(Continued on page 20) BY ZAHEER ASLAM, M.D. AND MARK L. WILLENBRING, M.D.
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
May/June 2002
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Addiction Treatment (Continued from page 19)
SUD treatment makes sense economically as well. Studies show that drug abuse treatment is cost effective for each and every day the patient is in treatment, due to reductions in crime and medical morbidity, even if the patients were to start using the day they left treatment. For example, Methadone maintenance is extremely cost-effective, with an incremental cost of only $6,000 per year of life saved. This compares favorably to the incremental costs of other common medical treatments (Figure 4). Figure 4. Incremental cost per quality-adjusted year of life saved.
Physicians need to query their patients and significant others about alcohol and drug usage patterns. In addition to diagnosing substance dependence in their patients, physicians are in a unique position to conduct secondary prevention among heavy, but nondependent drinkers. Current recommendations for safe levels of drinking are 14 drinks/week for men and 7 drinks/week for women. Multiple randomized controlled trials have demonstrated reductions in drinking lasting at least one year following brief interventions by a physician (Wilk et al., 1997; Babor et al., 1999). Such advice is likely to be most effective if it is delivered in a nonjudgmental, empathic style, compares the patient’s drinking with standards, and offers clear advice for desirable goals (abstinence or safe levels of drinking). Although even very brief (5-15) interventions have an effect, repeating advice over several visits increases effectiveness. Finally, care management has emerged as a new model for the management of chronic SUDs in primary care (Willenbring, 2001). The goals of care management are similar to those for other illnesses: slow the rate Table 1. Principles of care management for chronic SUDs.
• Monitor and record specific substance use at each contact by patient report (e.g., drinking days during the past month, days of any substance use during the past month, and typical and maximum number of drinks per occasion). • Monitor biological indicators (e.g., transaminase levels and urine toxicology screens). • Encourage abstinence or reduced substance use. • Educate about substance use and associated problems. • Recommend self-help groups. • Address or refer for social, financial, and housing problems. • Coordinate treatment with other care providers. • Monitor progress and periodically assess for possible referral to specialty care rehabilitation.
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of deterioration, reduce suffering, prevent and treat complications, educate and support the patient and significant others, limit relapses whenever possible and induce remission when possible. Care management does not imply giving up on patients, rather it is a way of engaging patients in a treatment, to reduce the severity of use with the ultimate goal of achieving long term remission. Principles of care management are summarized in Table 1. VA/DOD Clinical practice guidelines for the management of SUDs for primary care and specialty care are available over the Internet (www.oqp.med.va.gov/cpg), and address different treatment options in detail. Summary Research has shown good outcomes for the treatment of substance-related disorders. Although many physicians may lack confidence in mainstreaming SUD assessments and treatments, untreated SUDs are a negative factor in treatment outcomes for other medical disorders. Moreover, treatment results are comparable for other chronic, remitting conditions. Recognizing SUD as an illness with a chronic relapsing course helps decrease the frustration physicians feel while treating these patients. Brief interventions within the scope of primary care practice are very effective in reducing the severity of substance use. Care management is an efficient approach to improve the patient-doctor relationship and may lead to improved outcome as well. Referral should be sent to specialty care for patients with identifiable severe problems and who are willing to go to treatment. Physicians can access guidelines from the internet site to help them manage these patients. ✦ References Babor TF, Aguirre-Molina M, Marlatt GA, Clayton R. Managing alcohol problems and risky drinking. Am J Health Promot. 1999 Nov-Dec;14(2):98-103. Review. Barnett PG. The cost-effectiveness of methadone maintenance as a health care intervention. Addiction. 1999 Apr;94(4):479-88. Review. Hubbard, R. L., Craddock, S. G., Flynn, P. M., Anderson, J., & Etheridge, R. M. (1997). Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors, 11(4), 261-278. Project MATCH Research Group (1997). Matching Alcoholism Treatment to Client Heterogeneity: Project MATCH Posttreatment Drinking Outcomes. J Study Alcohol 58:7-29. Wilk AI, Jensen NM, Havighurst TC. Meta-analysis of randomized control trials addressing brief interventions in heavy alcohol drinkers. J Gen Intern Med. 1997 May;12(5):274-83. Willenbring ML: Psychiatric Care Management for Chronic Addictive Disorders. Am J Addictions 10:242-248, 2000.
Zaheer Aslam, M.D., is a staff psychiatrist in the Addictive Disorders Section of the Minneapolis VA Medical Center and Assistant Professor of Psychiatry at the University of Minnesota. Mark L. Willenbring, M.D., is director of the Addictive Disorders Section of the Minneapolis VA Medical Center and Associate Professor of Psychiatry at the University of Minnesota. For correspondence, please contact: Mark L. Willenbring, M.D.; MHPSL (116A); VA Medical Center; One Veterans Drive; Minneapolis, MN 55417; Tel: 612-725-2000 x3967; Fax: 612-725-2013. MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
PHYSICIAN'S SOAP BOX
Mind-Body Medicine
M
MENTAL HEALTH AND PHYSICAL HEALTH are closely and
inexorably intertwined. Through the use of integrative health care models, we are better able to address the complexity of our patients’ needs medically, psychologically, socially, and spiritually. An encompassing model will view patients as whole human beings in body, mind and spirit. Approaching patients holistically within an integrated health care system is better health care. It can empower patients to be active participants and partners in their care, and improve therapeutic outcomes through improved compliance and willingness to institute lifestyle changes, both of which are critical in achieving wellness. At the basis of many mind-body integrative modalities is the relaxation response. In the 1960s, Harvard cardiologist, Herbert Benson, M.D., began to appreciate the usefulness of the relaxation response in the etiology of cardiovascular disease, and its therapeutic usefulness in the intervention of cardiac disease in patients. It turns out to have wide applicability in ameliorating many other disease processes. Robust data and scientific literature exists about the efficacy of the relaxation response in anxiety, depression, chronic pain, chronic fatigue, headaches and gastrointestinal disorders. The relaxation response is a state of resting wakefulness and increased attention, in conjunction with widespread brain quieting, diminished blood pressure, diminished heart rate, diminished respiratory rate, and slowing of the brain wave rhythms. It can be profoundly healing and is simple to induce with focused attention on the breath or a singular word, similar to the practice in many spiritual meditative traditions found cross-culturally in all of the world’s major religions. In essence, we possess an innate, evolutionarily, old neurobiologic apparatus that we can access and voluntarily control. At the heart of mind-body integrative medicine is this neurobiologic apparatus that we can intentionally access and voluntarily control, turning on our body’s innate healing processes through the psychoneuroendocrine-immune systems. It is powerful and elegant in both its simplicity and complexity. Used judiciously with surgery, medication and other traditional modalities, therapeutic outcomes can be amplified and improved through the use of the relaxation response. We are all familiar with pain
relief achieved by acupuncture. The modalities of mind-body integrated medicine have the potential to amplify the body’s response to medication, reduce the need for anesthetic agents, promote wound healing post operatively, and even perhaps reduce the number of hospital days. Obviously, this is cost effective. It is simple to employ and empowers patients. It is interesting to know that the words medicine and meditation share the same root meaning. So do the words wholeness and healing. Meditation means to perceive the right inward measure of one’s being. Medicine is the practice of restoring right inward measure, and medicine can utilize meditation to bring about healing and wholeness. This has scientific validity and a neurobiologic basis as noted above through the rich, complex multiplicity of psychoneuroendocrineimmune interconnections. We are able to access these pathways via the relaxation response that is akin to meditation. Wholeness and social connectivity are part of our most fundamental human attributes. Connectivity is crucial for physical and psychological health. This connectivity is part of why the physician-patient relationship is sacred and so powerful in healing. Healing may not always involve cure; many chronic illnesses have no definitive cure. But healing involves recognizing our intrinsic wholeness and connectivity, both from within our beings and from without. Healing utilizes the patient-physician relationship to achieve wholeness and wellness. It is exciting to know that we now have knowledge of the scientific basis and neurobiological pathways that support what we have always known. In the fullest meaning of the word, medicine brings about healing and wholeness and restores the right inward measure of our bodies, minds and spirits. ✦
BY KAREN DICKSON, M.D. Private Practice, Nystrom & Associates, Ltd.
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Parallel Missions of Medicine and the Courts
T
THERE IS A STORY about a doctor, minister and lawyer who were marooned on an island surrounded by shark-infested waters. As the days went on, they became increasingly despondent, each day lessened hope that they would be found, and as the days passed there was less water and food. Every morning the minister would arise and say a prayer for the trio’s salvation. One morning, as the minister raised his head after the morning prayer, he looked out upon the waters and saw a sailboat. The sailboat would surely save the trio, but it was also far enough away in the shark-infested waters to present serious danger to anyone who might try to swim to the boat. The minister awoke his colleagues, pointed out the boat, and proclaimed that they had been saved. Almost simultaneously, however, the minister said he could not swim to the boat because he was the chief spiritual officer of the island and his congregation needed his presence. The minister then turned his attention toward the doctor. The doctor, too, rejoiced about the prospect that the trio had been saved, but said that he was the chief medical officer of the island and he, like the minister, was in no position to abandon his patients and try to get the boat. Both the minister and doctor looked at the lawyer. Without apparently giving the issue much thought, the lawyer walked to the water and began swimming toward the sailboat. Immediately the sharks converged upon the lawyer, but amazingly they escorted him to the sailboat. The minister, seeing all of this, dropped to his knees and exclaimed, “Lord, you’ve saved us with a second miracle,” to which the doctor replied, “hell, no, it’s professional courtesy.” Aside from providing material for jokes, close working relationships between the profesBY THE HONORABLE KEVIN S. BURKE
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sions—the clergy, the legal and medical professions—has at best been spotty. However, for civilized society, the professions are integral to the health of individuals and the advancement of community. Leaving the clergy out of the discussion for the time being, there is great opportunity for the medical profession and the judiciary in this community to work effectively together to deal with some of the most critical issues that affect our community’s health and well-being. Indeed, unless new ways of approaching some of the critical problems that face the community are tried, it is hard to be optimistic about our potential for problem solving. There is something about being a professional that can unfortunately limit our willingness to think outside the box of our own profession. In this case to radically think outside the box is to envision the medical profession and the judiciary establishing a forum for dialogue, that is hopefully more than conversation, and a commitment to work together on specific issues of mutual concern. There are a lot of reasons why there has been little direct dialogue between our professions in the past. For the judiciary, one impediment is the type of personality that gravitates
toward law school. Judges went to law school because we didn’t want to spend our professional life working for anyone and then we went on the bench because we wanted to get rid of our partners. Judges are not natural coalition builders. One might surmise that many people go to medical school because they, too, do not want to work for anyone, because doctors, like judges, are not natural coalition builders either. A second impediment to coalition building is, by tradition, the judiciary has viewed its role as solely to adjudicate cases. Despite being an elected official, judges were not public people. In the past, we did our work in the obscurity of a courtroom and thought that whatever impact our decisions had shouldn’t influence judges since our proper role was simply to “apply the law.” Historically for the judiciary, process improvement was a phrase from a foreign language. For the judiciary, a commitment to precedent is important. No one can seriously argue for the creation of a wildly activist judiciary. Goofy judicial activism is not the point. There is a new era in state courts—and a good one. The judiciary of today is not only expected to decide cases, but in many cases to also solve the underlying problem. Increasingly the language of the judiciary is process improvement. Sometimes process improvement takes the form of the creation of problem-solving courts—drug courts, mental health courts, domestic violence courts are current well-known examples, but the commitment of the modern judiciary is to process improvement. Each of our professions—medicine and the judiciary—is filled with people whose initial attraction to the profession was that during their lifetime they could make a real difference for people. There are new and serious challenges for each of our professions. At times those challenges threaten the core of the profession. Does
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The Journal of the Hennepin and Ramsey Medical Societies
managed care and cost containment threaten what it means to be a doctor? Does the caseload of 7,800 cases per year threaten any reasonable chance for judges to decide cases objectively? While these or other threats are real, there is also a great opportunity for us to learn from each other. We learn if we talk to each other. We limit our potential if we ignore that opportunity. As a starting point, there are four areas of public concern for dialogue between our professions: chemical dependency, mental health, domestic violence, and the health of children. There is a fifth concern that is more private to our professions—can we learn from each other on how to approach and deal with the individuals we serve? Chemical dependency and mental illness are major health issues. Very few people in the medical profession are not aware of the devastating impact that drug abuse can have both on individuals and the community. Drugs can destroy not only individuals, but can also incapacitate spouses to be caring spouses and effective parents. When chemical dependency is dealt with solely in a medical context, there is diagnosis and rapid intervention. Doctors who diagnose do not delay entry into treatment. To be sure, managed care has at times created barriers that have unjustifiably denied mental health or chemical dependency treatment. But there is no doubt that doctors recommend prompt treatment upon diagnosis. Historically, getting people rapidly into treatment is not the approach that the judiciary has taken. Indeed, in the past, months could go on between when the police arrested a defendant and a judge ordered the defendant into treatment. We have learned from medicine. Now in the Hennepin County Drug Court, people who should receive chemical dependency treatment enter treatment within 24 hours of their arrest. We recognize that there is no reason to believe that chemical dependency treatment is more effective if it is delayed for several months after competent people make the diagnosis of chemical dependency. We are now reviewing how the judiciary deals with defendants who have serious mental illness. Although the Hennepin County District Court is recognized by some nationally, we still need the knowledge of the medical profession in dealing with the specifics of effective chemical dependency and MetroDoctors
mental health treatment. The number of Americans seeking help for depression has skyrocketed, with a tripling of treatment rates, according to a recent study in the Journal of the American Medical Association. Our community can benefit from a joint voice of judges and doctors advocating for sound public policy for those in need of chemical dependency and mental health treatment. To its credit, the medical profession is more vocal about domestic violence. The Minnesota Medical Association has launched its Stop the Violence Campaign to help physicians recognize the signs of domestic abuse and to know where to refer their patients for help. Doctors are increasingly aware of the devastating impact that violence can have not only upon the victim, but also on children who are raised in violent households. Children raised in such an
My hope for the future is that some day...judges and doctors know how to learn from each other... environment are exponentially more likely to repeat violent behavior when they are parents. Prevention of domestic violence is as important a challenge to our community as any public safety issue. Each of our professions has separate roles in dealing with domestic violence, but surely there is a place for us to speak with one voice. The Hennepin Medical Society most recently was led by a very able physician, Dr. Virginia Lupo. I met her the first time because of her work with crack babies, and it was she who graciously honored me by the invitation to speak at the annual Board Dinner. It would be inappropriate to neglect recognizing her work on behalf of children, but more importantly, Dr. Lupo is an example of how the medical profession can have an impact on the judiciary when it comes to the fourth issue of common con-
The Journal of the Hennepin and Ramsey Medical Societies
cern—the health of children. Each year judges deal with the fate and future of thousands of children. Our professions give us the opportunity to do good things for those children, but also present a challenge of not being there when kids needed us most. The fifth issue is the umbrella for future dialogue. Can we learn from each other on how to approach and deal with the individuals we serve? What is common to our professions is a thirst for knowledge and an eagerness to learn. Let me offer one example. There is sound social science research that has found that people coming to court have a far better understanding that they may not win than judges believe. Moreover, even if they lose, if people believe that the judge listened, people are more likely to obey the judge’s order. Assuming that research to be sound, then learning how to listen better makes for a better judiciary. Our bench is now in the forefront of trying to learn to listen better. Although I know of no research to support the similar point when it comes to medicine, it seems reasonable that doctors, like judges, could learn to listen better. Good listening skills make for a better profession. Nearly everyone assumes that learning to speak is a skill that can be improved. Why do we not assume the same to be true of listening? Someone once said experts are people who know a great deal about very little, and who go along learning more and more about less and less until they know practically everything about nothing. Lawyers, on the other hand, are people who know very little about many things, and who keep learning less and less about more and more until they know practically nothing about everything. Judges are people who start out knowing everything about everything, but end up knowing nothing about anything, due to their constant association with experts and lawyers. My hope for the future is that some day people will say that whatever else they know, judges and doctors know how to learn from each other, that they can draw upon the strengths of the respective professions to help the other and that on occasion they can speak strongly with a common voice to advocate for a better community. ✦ Kevin S. Burke is the Chief Judge of Hennepin County.
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PRESIDENT’S MESSAGE P E T E R H . K E L L Y, M . D .
Ending the Shell Game RMS-Officers
President Peter H. Kelly, M.D. President-Elect Michael Gonzalez-Campoy, M.D. Past President Robert C. Moravec, M.D. Secretary Jamie D. Santilli, M.D. Treasurer Peter J. Daly, M.D. RMS-Board Members
Kimberly A. Anderson, M.D., Specialty Director John R. Balfanz, M.D., Specialty Director Victor S. Cox, M.D., Specialty Director Gretchen S. Crary, M.D., At-Large Director Charles E. Crutchfield, III, M.D., At-Large Director Laura A. Dean, M.D., At-Large Director Thomas B. Dunkel, M.D., MMA Trustee James J. Jordan, M.D., Specialty Director Robert V. Knowlan, M.D., At-Large Director Charlene E. McEvoy, M.D., At-Large Director Ragnvald Mjanger, M.D., Specialty Director Kenneth E. Nollet, M.D., Ph.D., At-Large Director Stephanie D. Stanton, Medical Student Lyle J. Swenson, M.D., MMA Trustee Charles G. Terzian, M.D., Specialty Director David C. Thorson, M.D., Specialty Director Russell C. Welch, M.D., At-Large Director RMS-Ex-Officio Board Members & Council Chairs
Brenda Andrewson, Alliance President Brent R. Asplin, M.D., AMA Young Physician Section Blanton Bessinger, M.D., MMA Past President Kenneth W. Crabb, M.D., AMA Alternate Delegate Robert W. Geist, M.D., Ethics & Professionalism Council Chair *Michael Gonzalez-Campoy, M.D., Education Resource Council Chair Frank J. Indihar, M.D., AMA Delegate William E. Jacott, M.D., U of MN Representative Melanie Sullivan, Clinic Administrator Donald B. Swenson, M.D., Sr. Physicians Association President *Lyle J. Swenson, M.D., Public Policy Council Chair *Russell C. Welch, M.D., Communications Council Chair *Also elected RMS Board Member RMS-Executive Staff
Roger K. Johnson, CAE, Chief Executive Officer Doreen M. Hines, Membership & Web Site Coordinator Sue Schettle, Director of Marketing & Member Services
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May/June 2002
I
IF YOU WALK DOWN the streets of New York City you may come across a small crowd gathered around a small table. At the table will be a man with three cups (or shells) and a ball. He places the ball under one of the shells and rapidly shifts the shells around. He then takes bets from the crowd to see if anyone can tell where the ball is. Funny thing is the man with the shells and the ball usually wins the bet, mostly because there is slight of hand at work. I think that it is mandatory for senior executives in health care plans to go to New York to learn how to play this game because reimbursement for physicians has become a huge shell game. It has become all but impossible to follow the reimbursement ball. Much of physician reimbursement is based on Relative Value Units (RVUs). This concept was originally devised by Harvard economists who wanted to reign in Medicare costs and, at the same time, level reimbursements between various physician specialties. The RVU actually has three separate components: work, overhead and malpractice units. RVUs for any CPT or ICD code are determined by a federal commission, which has representation from the AMA. There can be changes in the number of RVUs assigned for any particular code by changing the absolute number of RVUs/code or by changing the individual components of the RVU. RVUs will vary by region because of perceived overhead and malpractice differences per region. Add to this that total reimbursement may also be changed by a Geographical Adjustment Factor, which also increases or decreases reimbursement by regions. (This represents a sort of double tax in that geographic adjustments are made both within and outside of the RVU schematics.) Medicare or the health plans will then determine or negotiate a conversion factor (the amount paid per RVU) and this will ultimately determine the final reimbursement for any particular service. So at any given time there are as many as six variables that can be manipulated to determine reimbursement. An example of what can happen is the recent attempt by a local health plan to eliminate the overhead comMetroDoctors
ponent of the RVU for surgical services. This would decrease reimbursement by as much as 25 percent. While this has not been enacted, a senior health plan executive recently told me that this potential change in the RVUs might be revisited in the near future. All of this makes it nearly impossible for physicians to determine their true reimbursement and this is compounded by the fact that this information is not easy to obtain from the health plans. None of this is probably news to most of you, so why do I bring it up at this time? Because recently a Fair Contracting Bill was introduced in the legislature (Minnesota Fair Healthplan Contracting Act HF 2925, SF 2532). The bill was drafted and supported by the Ramsey Medical Society, the Hennepin Medical Society, Minnesota Medical Group Managers Association, Metropolitan Medical Practice Forum as well as other organizations. A key component of that bill was a section requiring health plans to make available to the public their reimbursement schedules. The bill as drafted was not supported by the MMA, which objected to this section on reimbursement disclosure. The reasons given by the MMA leadership were concerns for potential price fixing between physician groups or between health care plans. Though I can appreciate their concerns I think it is short sighted and the MMA’s initial neutrality on this bill helped lead to its ultimate demise during this legislative session. There is a clear need to begin to revamp the current reimbursement model and full disclosure will help start that process for a couple of reasons: 1. Current fee schedules of physicians and hospitals are pure fantasy, but this is what patients see on their bill. They will see a bill from a surgeon for $1,200 for an appendectomy not realizing that the average reimbursement is $500. They will see a hospital bill for thousands of dollars and The Journal of the Hennepin and Ramsey Medical Societies
2002 Supply Drive THE TENTH ANNUAL “Caring Hearts for Homeless People,” sponsored by Ramsey Medical Society, Ramsey Medical Society Alliance and HealthEast Care System, began on Friday, February 8, 2002 and concluded on Monday, February 25, 2002. This year’s drive was very successful considering the impact of September 11! Fourteen medical clinics, 35 churches, HealthEast Care System, and many volunteers from the Ramsey Medical Society Alliance, and many other organizations (4-H clubs, girl scout troops, high school youth groups, elementary class groups) pitched in to collect and sort over $31,000 worth of hygiene and medical supplies for the Health Care for the Homeless clinics, Listening House, and SafeZone. In addition, more than $1,000
Many volunteers help complete the sorting of all the items donated.
in cash contributions was collected. These organizations rely heavily on donated medications, hygiene supplies, toys, juice and monetary donations to help meet the physical, emotional and mental health needs of their clients. This drive contributes the majority of supplies needed for the entire year. Carole Nimlos coordinated the activities of the RMS Alliance members who worked hard picking up the supplies from 14 participating medical clinics. Thank you to the clinic managers, staff, and physicians of the following clinics that participated: Allina Medical Clinic -Shoreview American Red Cross - North Central Blood Services/St. Paul Chapter Cardiovascular Consultants, Ltd. Dermatology Consultants, P.A. Hamm Memorial Psychiatric Clinic Metropolitan Urologic Specialists, P.A. Minnesota Medical Joint Services Organization Parkway Family Physicians Partners Obstetrics and Gynecology, P.A. Physicians Neck & Back Clinic, P.A. Ramsey Family Physicians St. Croix Orthopaedics, P.A. St. Paul Eye Clinic, P.A. St. Paul Internists, P.A. ✦
A Call for Resolutions The Delegates of RMS will be representing you at the MMA House of Delegates Annual Meeting September 25-27. Over the next several weeks, the Delegation will be identifying issues and developing resolutions to carry to the House where MMA policy is established. The RMS Delegation will caucus at 7:00 a.m on Wed., May 22 at United Naseff Heart Hospital and again on Tues., June 4 at the United Hospital Heart and Lung Bldg. Please help us to assure that your interests are accurately conveyed by contacting RMS staff to submit resolutions: phone: 612/362-3799; fax: 612/ 623-2888; e-mail: rjohnson@metrodoctors.com.
MetroDoctors
The committee that devotes many hours of planning to coordinate this event each year, from left: Jodi Monson, HealthEast Communications Specialist; Helene Frient, Health Care for the Homeless; Kim Swanson, HealthEast Bethesda Pharmacy; Mari Uutula, Listening House; Cindy Rudh, HealthEast Spiritual Care; Jodie Butwinick (front), Health Care for the Homeless; Heather Schwartz, HealthEast Organizational Communications Intern; Sister Marian Louwagie, HealthEast Spiritual Care; Vontrell McSwain, SafeZone; Carole Nimlos, Ramsey Medical Society Alliance; and Doreen Hines, Ramsey Medical Society. Not pictured: Sarah McCullough, HealthEast Public Relations and Communications Specialist.
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May/June 2002
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Ramsey Medical Society
not understand that the reimbursement for this care is a fraction of what is billed. The public has no clue as to the real costs of health care. As there is more of a push to consumer driven health care it will become more imperative to know the true costs so that both patients and physicians can have an honest discourse regarding these costs. 2. In contract negotiations with many health plans reimbursement is based on the conversion factor per RVU. Not taken into account is the fact that the number of RVUs/code may have decreased. In recent negotiations with a health plan I was told my reimbursement was being increased by 10 percent because of an increase in the conversion factor. When I pointed out that many of our high volume procedures were having the number of RVUs/code decreased thereby canceling any effect that the increase in the conversion factor may have I was told that I could not expect the health plan to be able to calculate this effect for all physician groups. Thus, the health plans are claiming that some of their costs are rising by 10 percent or higher because of an increase in the conversion factor to physicians when in fact the increase may be much lower than that. While disclosing reimbursement rates will not solve all of these problems, it will open the door for discussing an overhaul to the current reimbursement system. It will ultimately be easier to negotiate a fair contract if there is a less complex and a more above board reimbursement structure in place, one that will end the shell game we are now dealing with. ✦
R M S U P D AT E
New Members RMS welcomes these new members to the Society. Schools listed indicate the institution where the medical degree was received.
Active Cathryn S. Angel, M.D. University of Minnesota Pediatrics Central Pediatrics, P.A. Mark J. Austin, M.D. University of Minnesota Diagnostic Radiology St. Paul Radiology, P.A. John W. Copenhaver, Jr., M.D. University of Minnesota Diagnostic Radiology St. Paul Radiology, P.A.
Timothy V. Myers, M.D. University of Missouri Diagnostic Radiology St. Paul Radiology, P.A. Mary Jo Nelson, M.D. University of Cincinnati Diagnostic Radiology St. Paul Radiology, P.A. Lon Peterson, M.D. University of Wisconsin Family Practice Regina Medical Group Tammi S. Plotnik, M.D. University of Minnesota Pediatrics Pediatric & Young Adult Medicine Rajbir S. Sarpal, M.D. University of Saskatchewan Anesthesiology Twin Cities Anesthesia Associates, P.A. Gary S. Schwartz, M.D. Boston University Ophthalmology Associated Eye Care
In Memoriam
Hien Quang Dam, M.D. Med & Pharm U, Vietman Psychiatry
Saeed Raza Shaikh, M.D. Khan Medical College, Pakistan Internal Medicine/Cardiovascular Disease St. Paul Heart Clinic, P.A.
George F. Edeburn, M.D. University of Minnesota Diagnostic Radiology St. Paul Radiology, P.A.
James H. Sullivan, M.D. University of Minnesota Diagnostic Radiology St. Paul Radiology, P.A.
James H. Jacobs, Jr., M.D. Mayo Medical School Diagnostic Radiology St. Paul Radiology, P.A. Morteza Jahangir, M.D. Northwestern University Diagnostic Radiology St. Paul Radiology, P.A. Muhammad A. Khan, M.D. DOW Medical College, Pakistan Internal Medicine/Infectious Disease St. Paul Infectious Disease Associates John A. Kollitz, M.D. University of Minnesota Anesthesiology Associated Anesthesiology Nina C. Kostraba, M.D. State University of NY at Buffalo Internal Medicine/Emergency Medicine St. Joseph’s Hospital
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Julia D. Gonsoski Michael J. Gruba Matthew R. Hallman Catherine K. Hart Jennifer F. Iverson Calley A. Kennedy Ann M. Knapp Christopher M. Lloyd Melissa A. Moore David J. Polga Matthew E. Prekker Scott T. Roethle Sereen D. Sharp Iberia R. Sosa Amanda N. Spielman Stephanie D. Stanton Ty D. Weis Brian A. Weisenberg Janet M. West Nicholas J. Wills ✦
OTTO K. BOSCH, M.D. died at the age of 75 on March 11. Dr. Bosch graduated from the University of Innsbruck in 1952. He was a general practitioner in Austria until he came to the U.S. in 1966. Dr. Bosch completed an anesthesia residency at the University of Minnesota. He then practiced with Anesthesiologists, Ltd. until his retirement in 1991. He joined RMS in 1972. WILBERT J. HENKE, M.D. died on February 13. He was 70 years old. Dr. Henke graduated from the University of St. Louis in 1956. He practiced at Highland Internal Medicine clinic prior to retirement. Dr. Henke joined RMS in 1962.
1st Year in Practice Timothy J. Kroshus, M.D. University of Minnesota Cardiovascular Surgery Cardiac Surgical Associates Keith H. Wittenberg, M.D. University of Boston Diagnostic Radiology St. Paul Radiology, P.A.
CYRIL R. TIFFT, M.D. died on April 2 at the age of 95. He graduated from the University of Minnesota in 1931 and completed an internship at St. Mary’s Hospital in Duluth. He practiced family medicine and general surgery. Dr. Tifft served in WWII as a surgeon in the Army Air Corps and was discharged with the rank of Major. He was founder of the Arcade Clinic. Dr. Tifft was a past president of the Ramsey County and Minnesota State Chapters of the Academy of Family Practice. He joined RMS in 1933. ✦
Emeritus William F. Dickes, M.D. Albany Medical College Obstetrics/Gynecology
Medical Student (University of Minnesota)
Luke W. Albrecht Janef M. Bruner Jennifer L. Burger Stephanie C. Cintora MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
RMS ALLIANCE NEWS BRENDA ANDREWSON
A
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but one recurring theme as to why each of us joined this organization has been PEOPLE. The delightful stories I have heard about making friends with some amazing, talented, intelligent and caring individuals have been heartwarming. These are people who have encouraged us, taught us new ways to see things, pushed us to learn something new about ourselves — people who care about us and our families. In my last update, I discussed the feeling of disconnectedness that many sociologists claim is afflicting America. Many people feel powerless to implement change within their communities. Our Alliance has learned that much can be done when we unite together and that sometimes, small steps can lead to greater gains. We offer our members an opportunity to connect with others within the larger medical community. We’ve learned that where we don’t have the strength or numbers to do something, we can collaborate with others to
accomplish our goals. Our strength lies in the people behind our organization; the people who care enough to get involved. You are those people, and I thank you for caring enough about our Alliance to continue to make it the strong organization it is. On May 8 a new group of leaders will step forward to lead our Alliance as Becky GonzalezCampoy and her officers are installed for the 20022003 year. Becky brings enthusiasm, energy, and experience to our organization. I hope you will join me in wishing them success as they lead us in the new year. And I hope you will continue to support our Alliance and its causes. Our strength lies in each and every one of you, our members. ✦
RMS Membership Value-Added Advantages for Physicians and their Practices NEW! Business AdvantEdge is a local company offering a wide array of discounts on products and services including: • Office Depot - 50-75% discount on a full-range of office supplies • Compaq Computers - 9% discount on computers • Sprint Cell Phones - Discounts on cell phones and plans • Savin - Discounts on copiers and fax machines • Payroll Processing - Up to 20% discount on ADP payroll processing
• Courier Services - Discounts on materials and services
Products and Services Offered to RMS Members by RCMS, Inc. For more information call 612-362-3704.
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May/June 2002
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Ramsey Medical Society
AS I WRITE THIS, my year as president of the RMS Alliance is rapidly coming to a close. What a whirlwind year it has been. None of us could have predicted the changes that have taken place in our world during this past year; but reflecting back on this year makes me proud to be a part of this strong organization and thankful for all of the support and help I have received from everyone connected with this organization. Yes, we certainly have some challenges ahead of us. Membership will continue to be an issue in the future as we struggle to find ways to encourage other spouses of physicians to join our organization. Many of these spouses that we will target work outside of the home and all of these potential members are busy individuals with little time to spare for another organization. But perhaps the strength of our organization lies within this diverse membership base. We are all extremely busy and involved individuals. Our interests and concerns are many and varied and this diversity of interests allows our members to become involved in as many or as few of our projects as they choose. Some of us love being involved in our annual Body Language Health Fair every spring. Others prefer to help our community raise funds for HealthEast’s annual Festival of Trees or our Spare Key Butterfly Ball. Some wouldn’t miss our Holiday Auction for anything. Others value the friendships and bonds they have formed from our Trusted Friends interest group. And these are only a few of the ways our members can be involved in our Alliance. The opportunities for involvement are many and are driven by our members’ interests. Not many organizations can afford to be so flexible. One year you may be extremely active and another find that you need to cut back on your involvement as you help a child choose a college, help care for an elderly parent, become more involved with your church, or make the transition to retirement with your spouse. No one here will make you feel guilty for making those choices. We will support you. We have no minimum number of hours that you must commit to in order to join our organization. Throughout this past year I have asked many of you what you like and don’t like about our Alliance and where you see us headed in the future. Believe me, many opinions exist about our future,
CHAIR’S REPORT DAVID L. SWANSON, M.D.
A Pyrrhic Victory for the Plans HMS-Officers
Chair David L. Swanson, M.D. President T. Michael Tedford, M.D. President-Elect Michael B. Ainslie, M.D. Secretary Richard M. Gebhart, M.D. Treasurer Paul A. Kettler, M.D. Immediate Past Chair Virginia R. Lupo, M.D. HMS-Board Members
Michael Belzer, M.D. Carl E. Burkland, M.D. Jeffrey V. Christensen, M.D. Andrea J. Flom, M.D. Kathy Larson, Alliance President Ronald D. Osborn, D.O. James A. Rhode, M.D. David F. Ruebeck, M.D. Richard D. Schmidt, M.D. Leah Schrupp, Medical Student Marc F. Swiontkowski M.D. Michael G. Thurmes, M.D. D. Clark Tungseth, M.D. Michael J. Walker, M.D. Joan M. Williams, M.D. HMS-Ex-Officio Board Members
Paul F. Bowlin M.D., Senior Physicians Association Lee H. Beecher, M.D., MMA-Trustee Karen K. Dickson, M.D., MMA-Trustee John W. Larsen, M.D., MMA-Trustee Robert K. Meiches, M.D., MMA-Trustee Henry T. Smith, M.D., MMA-Trustee David W. Allen, Jr., MMGMA Rep. HMS-Executive Staff
Jack G. Davis, Chief Executive Officer Nancy K. Bauer, Associate Director
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May/June 2002
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THE HENNEPIN MEDICAL Society has been
very busy in the last months working with its partner across the Mississippi, as well as with the many members of the Health Care Contracting Coalition. We have actively promoted the passage of legislation designed to remedy many of the problems faced by physicians and their patients when dealing with health care contracts. The Minnesota Fair Healthplan Contracting Act was moved with the broad, strong support of legislators and interested parties, ranging from us to the Minnesota Nursing Association to the State Board of Medical Practice. The Act significantly changed the business of medicine in Minnesota for the better. It promised to make the Plans accountable for denial of services. It required streamlined means of communicating preauthorizations. It set rules for contracting that eliminated unilateral amendments, uncontested recoupments, and contract stacking. It prevented the arbitrary redefinition of reimbursement codes. It required open access to profiling data and a mechanism for physicians to appeal profiles. It went a long way toward redressing grievances that physicians have had for nearly a decade. We entered this legislative session with little doubt that the legislature would finally give the physicians who serve their constituency the relief that the providers deserve. Unfortunately, the Plans knew whom to lobby and succeeded in convincing Senator Linda Scheid, the vice chair of the Senate Commerce Committee, to deny allowing the bill to be heard. Her denial was much to the chagrin of the Committee. That denial may prove to be a Pyrrhic victory for the Plans. The following is excerpted from a letter written to Michael Scandrett, executive director of the Minnesota Council of Health Plans, by Senator Scheid and Representative Greg Davids (chair of the House Commerce Committee): “…the coalition of provider groups that proposed the bill made some compelling arguments to Legislators that some existing health contracting practices MetroDoctors
should be changed. During the Senate Commerce Committee hearing on this bill you acknowledged that there were problems and made a public commitment on behalf of your Member Organizations that you would work to address them. “We are writing to ask you to put that commitment into writing in the form of a letter to us. We also ask that you follow up by working with the provider groups during the interim and report back to us prior to the 2003 Legislative Session on the progress that is made.” We learned much about the collaborative work we have participated in. That work is far from over. I am very positive that it will reap rewards. With our partners, we plan to continue our activism on behalf of our physicians regarding contracting and intend to expand into other issues as well. The HMS will persevere in the tireless advocacy for its members. ✦ David L. Swanson M.D., HMS Board Chairman can be reached at: Swans045@umn.edu. A Call for Delegates If you are interested in serving as a Delegate, please contact HMS. A Call for Resolutions Resolutions are due by Friday, May 17. HMS Caucus Thursday, June 6; 7:00 – 8:30 a.m. MMA Annual Meeting Wed-Fri, September 25-27, 2002 Northland Inn, Brooklyn Park, MN Contact Kathy Dittmer, at 612-623-2885 or kdittmer@mnmed.org
The Journal of the Hennepin and Ramsey Medical Societies
HMS NEWS
Laurel L. Erickson, M.D. University of Minnesota Medical School Pediatrics Lakeview Clinic
Winston P. Cavert, M.D. University of Minnesota Medical School Infectious Diseases University of Minnesota
John Mogan Faust Jr., M.D. University of Mississippi School of Medicine Diagnostic Radiology Consulting Radiologists, Ltd.
Joseph Charles Cerny Jr., M.D. University of Michigan Medical School Urology/Urological Surgery Urology Associates, Ltd.
Markham J. Fischer, M.D. Washington University School of Medicine Radiology Abbott Northwestern Radiology
Active Ellen L. Abeln, M.D. University of Minnesota Medical School Diagnostic Radiology Suburban Radiologic Consultants, Ltd.
Bradley J. Close, M.D. University of Michigan Medical School Diagnostic Radiology Suburban Radiologic Consultants, Ltd.
Bonnie K. Adkins-Finke, M.D. University of Minnesota Medical School Anesthesiology Anesthesiology, P.A.
Gary Telfer Copland, M.D. State University of New York Upstate College of Medicine Pathology-Anatomic/Clinical Unity Hospital
Robert D. Fisher, M.D. State University of New York Downstate College of Medicine Urology/Urological Surgery Metropolitan Urologic Specialists, P.A.
Richard D. Belkin, M.D. Rush Medical College Radiology Minneapolis Radiology Associates, Ltd.
Lawrence D. Deal, M.D. University of Washington School of Medicine Family Practice Columbia Park Medical Group, P.A.
Eleanor M. Beltran, M.D. College of Medicine University of the East, Quezon City Internal Medicine Fridley Medical Center Multicare Assoc. of T.C.
Avani Sunil Desai, M.D. Topiwala National Medical College, Bombay University, Bombay, Maharashtra Internal Medicine HealthPartners (Bloomington)
Ellen M. Bendel-Stenzel, M.D. University of Minnesota Medical School Pediatrics Neonatology, P.A.
Tore Detlie, M.D. University of Minnesota Medical School Radiology Suburban Radiologic Consultants, Ltd.
Benjamin T. Gulli, M.D. Northwestern University Medical School Orthopedic Surgery Northwest Orthopedic Surgeons
Jule Richard Block, M.D., D.D.S. University of Minnesota Medical School Anesthesiology Ridgeview Anesthesia
Pamela D. Doorenbos, M.D. University of Iowa - College of Medicine Family Practice
Heather L. Haakenson, M.D. Medical College of Wisconsin Anesthesiology Northwest Anesthesia, P.A.
New Members HMS welcomes these new members to the Society. Schools listed indicate the institution where the medical degree was received.
Geoffrey R. Bodeau, M.D. University of Minnesota Medical School Diagnostic Radiology Consulting Radiologists Ltd. Craig Lyman Bowron, M.D. Southern Illinois School of Medicine Hospitalist Abbott Northwestern Hospitalists Services Brenda K. Brown, M.D. University of Minnesota Medical School Family Practice Andover Park Clinic
Timothy J. Ehlen, M.D. University of Minnesota Medical School Ophthalmology Northwest Eye Clinic David Jackson Eilers, M.D. University of South Dakota School of Medicine Ophthalmology Northwest Eye Clinic Karen J. Enockson, M.D. University of Minnesota Medical School Internal Medicine Park Nicollet Clinic Erik R. Ensrud, M.D. University of Minnesota Medical School Neurology Noran Neurological Clinic
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
Sean P. Flood, M.D., MPH University of Minnesota Medical School Family Practice Columbia Park Medical Group, P.A.—Columbia Park Clinic Thomas M. Golbert, M.D. University of Colorado School of Medicine Allergy & Immunology Fairview Northland Clinics David Allen Gross, M.D. University of North Dakota School of Medicine Diagnostic Radiology Consulting Radiologists, Ltd.
David B. Haugland, M.D. University of Minnesota Medical School Family Practice Lakeview Clinic - Chaska Michael D. Heaney, M.D. University of Minnesota Medical School Radiology Suburban Radiologic Consultants, Ltd. Maria D. Hoenack-Cadavid, M.D. Escuela de medicina Juan N Corpas, Bogota Internal Medicine HFA Hennepin Senior Care (Continued on page 30)
May/June 2002
29
Hennepin Medical Society
Richard J. Carr, M.D. University of Minnesota Medical School Anesthesiology Twin City Anesthesia
New Members (Continued from page 29)
Gerald Allen Holguin, M.D. University of California School of Medicine, San Francisco Anesthesiology, Pain Management Northwest Anesthesia, P.A. Andrew J. Houlton, M.D. University of Minnesota Medical School Anesthesiology Anesthesiology, P.A. Robert G. Jacoby, M.D. Washington University School of Medicine Neurology Noran Neurological Clinic, P.A. Robert J. Jaksa, M.D. University of Minnesota Medical School Anesthesiology Medical Anesthesiology, Ltd. James Erik Johanson, M.D. University of Minnesota Medical School Family Practice Lakeview Clinic, Norwood Timothy D. Johanson, M.D. University of Minnesota Medical School Pediatrics Metropolitan Pediatric Specialists, P.A. Dawn Johnson, M.D. University of Iowa - College of Medicine General Surgery Metropolitan Surgical Associates Dan T. Johnston, M.D. Vanderbilt University School of Medicine, Nashville Anesthesiology Northwest Anesthesia, P.A.
Scott E. LeBard, M.D. Loma Linda University School of Medicine Pediatric Anesthesiology Children’s Health Care -West
John T. Olsen, M.D. University of Minnesota Medical School Diagnostic Radiology Suburban Radiologic Consultants, Ltd.
Peter K. Lee, M.D.,Ph.D. University of Minnesota Medical School Dermatology University of Minnesota
Manuel R. Otero, M.D. Facultad de Medicina de la Universidad Nacional Autonoma de Mexico Cardiology Metropolitan Cardiology Consultants, P.A.
Nancy Ann Leitch, M.D. University of Minnesota Medical School Dermatology Allina Medical Clinic Alexander A. Levitan, M.D. University of Rochester School of MedicineDentistry Medical Oncology Jane H. Lisko, M.D. University of Minnesota Medical School Dermatology Associated Skin Care Specialists, P.A. Michael J. Lyons, M.D. University of Minnesota Medical School Anesthesiology Twin City Anesthesia Ann Hartigan McGinn, M.D. University of Minnesota Medical School Dermatopathology Associated Skin Care Specialists, P.A. David P. Miller, M.D. Washington University School of Medicine Pediatrics Southdale Pediatric Associates Mancel T. Mitchell III, M.D. University of Minnesota Medical School Family Practice
Christoper Albert Powers, M.D. University of Wisconsin Medical School Anesthesiology Metropolitan Anesthesia Network Jon L. Pryor, M.D. University of Minnesota Medical School Urology/Urological Surgery University of Minnesota Physicians Teresa E. Quinn, M.D. University of Wisconsin Medical School Geriatric Med-Family Practice Seniors Clinic - Regions Hospital John B. Rogers, M.D. University of Minnesota Medical School Orthopedic Surgery Columbia Park Medical Group, P.A.— Fridley Plaza Clinic Candace J. Sabers, M.D. Mayo Medical School Anesthesiology Northwest Anesthesia, P.A. Janet M. Schmitt, M.D. Michigan State University College of Human Medicine Family Practice Fairview Uptown Clinic Lisa J. Schneider, M.D. Creighton University School of Medicine Radiology Consulting Radiologists, Ltd.
John R. Kearns, M.D. University of Washington School of Medicine Orthopedic Surgery Orthopedic Medicine & Surgery, Ltd.
John A. Muellerleile, M.D. University of Minnesota Medical School Anesthesiology Northwest Anesthesia, P.A.
Jason John Koch, M.D. Mayo Medical School Pediatrics Southdale Pediatric Associates, Ltd.
Theodore C. Nagel, M.D. Cornell University Medical College, New York Obstetrics & Gynecology Reproductive Medicine Center
Paul R. Kollitz, M.D. University of Minnesota Medical School Radiology Suburban Radiologic Consultants, Ltd.
Mary Kathryn Norris, M.D. University of Minnesota Medical School Internal Medicine
Michael T. Schulenberg, M.D. University of Oregon Medical School-Portland Family Practice Ridgeview Clinics
Thomas A. Oas, M.D., M.P.H. University of Louisville School of Medicine Occupational Medicine North Memorial Clinic-Golden Valley Family Physicians
Sheila N. Seats, M.D. University of Michigan Medical School Family Practice Ridgeview Mound Clinic
Kevin R. Leach, M.D. University of Minnesota Medical School Radiology Suburban Radiologic Consultants, Ltd.
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May/June 2002
MetroDoctors
Lawrence E. Schroeder, M.D. University of Minnesota Medical School Anesthesiology Metropolitan Anesthesia Network
The Journal of the Hennepin and Ramsey Medical Societies
Michael G. Seryakov, M.D. Leningrad Institute of Sanitation and Hygiene Obstetrics & Gynecology Blaine Medical Center Multicare Assoc. of the T.C.
Patricia Ann Welsh, M.D. University of Minnesota Medical School Obstetrics & Gynecology Obstetrics & Gynecology West, P.A.
Kerry L. Sheehy, M.D. University of Minnesota Medical School Family Practice Ridgeview Clinics
Deyong Wen, M.D. 4th Military Medical University Xian City, Shaanxi, China Anesthesiology Regional Anesthesia Services
Derek B. Simons, M.D., FRCPC, FACC University of Manitoba Faculty of Medicine Cardiology Metropolitan Cardiology Consultants, P.A.
Kathleen M. Slukoski, M.D. University of Minnesota Medical School Pediatrics Metropolitan Pediatric Specialists Tierza M. Stephan, M.D. University of Minnesota Medical School Internal Medicine Abbott Northwestern Hospital Kendall J. Strand, M.D. University of Minnesota Medical School Diagnostic Radiology Suburban Radiologic Consultants, Ltd. Brian Thomas Sullivan, D.O. University of Minnesota Medical School Diagnostic Radiology Suburban Radiologic Consultants, Ltd. Mary E. Tahnk-Johnson, M.D. University of Minnesota Medical School Nephrology Kidney Specialists of MN, P.A. Thomas C. Tunberg, M.D., FACS University of Minnesota Medical School General Surgery Columbia Park Medical Group, P.A.—Fridley Plaza Clinic David R. Vandersteen, M.D. Stanford University School of Medicine Pediatric Urology Pediatric Surgical Associates Jeffrey Richard Vespa, M.D. Loyola University Stritch School of Medicine Emergency Medicine North Memorial Health Care
MetroDoctors
Mark A. Wilkowske, M.D. University of Minnesota Medical School Medical Oncology Park Nicollet Clinic - St. Louis Park Freeman E. Wong, M.D. University of Minnesota Medical School Internal Medicine Health Partners West Medical Center Donald Dwight Wothe, M.D. University of Washington School of Medicine Maternal & Fetal Medicine Abbott Northwestern Hospital S. Lyle Zuck, M.D. Mayo Medical School Oral & Maxillofacial Surgery Metropolitan Oral & Maxillofacial Surgeons, P.A. Gary H. Zupfer, M.D. University of Minnesota Medical School Anesthesiology Northwest Anesthesia, P.A. Annette E. Zwick, M.D. Case Western Reserve University School of Medicine Anesthesiology Metropolitan Anesthesia Network Residents Susan M. Daniels, M.D. University of Minnesota Medical School Pediatrics Pediatric Services, P.A. Mark A. Houghland, M.D. University of New Mexico School of Medicine Cardiology University of Minnesota Monte Everette Johnson, M.D. University of Minnesota Medical School Family Practice Creekside Family Physicians Clinic
The Journal of the Hennepin and Ramsey Medical Societies
Jay D. Mitchell, M.D. University of Minnesota Medical School Family Practice Creekside Family Physicians Clinic Joel A. Sagedahl, M.D. University of Minnesota Medical School Family Practice North Memorial Family Practice Clinic Mark R. Sannes, M.D. University of Minnesota Medical School Internal Medicine
Hennepin Medical Society
Janice M. Sinclair, M.D. University of Minnesota Medical School Ophthalmology Northwest Eye Clinic
James R. White, M.D. University of Minnesota Medical School Neurology MINCEP Epilepsy Care
Gerald T. McCullough, M.D. University of Minnesota Medical School Radiology
Students Debrah Dee Erickson Melissa A. Kulinski-Quast Marc S. McSherry Tori M. Myslajek Paul J. Odenbach Shane M. Swanson Steven A. ver Beek ✦
In Memoriam S. LANE AREY, M.D., a pediatrician, died April 9 at the age of 94. He graduated from the University of Minnesota in 1932 and completed internships at Minneapolis General Hospital and Chicago Children’s Memorial. Dr. Arey was the founder of the Hennepin Medical Society Senior Physician Association and served as its first president. His honors and awards included the Gold Headed Cane award in 1982, the Charles Bolles-Bolles Rogers Award in 1985 and the Harold Diehl award. Dr. Arey joined HMS in 1934. NORTHROP BEACH, M.D., a pediatrician, died February 10 at the age of 90. He graduated from Harvard University Medical School in 1938. He was one of the first doctors at Nicollet Clinic (later Park Nicollet Clinic). He was an associate professor of pediatrics at the University of Minnesota Medical School for many years. Dr. Beach joined HMS in 1943. LEONARD L. KALLESTAD, M.D., a general surgeon, died April 1. He was 97. He graduated from the University of Minnesota. He retired in Lauderdale-by-the Sea, Florida. Dr. Kallestad joined HMS in 1941. ✦ May/June 2002
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HMS ALLIANCE NEWS K AT H Y I V E R S O N
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THE MINNESOTA STUDENT Survey has been administered every three years since 1989 to public school students in Grades 6, 9, and 12. The latest survey, (administered, spring 2001) shows a decrease in tobacco use by teens in all age groups. It is believed that the dollars from the Minnesota Tobacco Endowment are leading this trend. Teens who abstain from smoking are much more likely to stay drug free, and we all benefit from fewer dollars being spent on tobacco-related health care. A dangerous pattern of alcohol use by teens, binge drinking, continues to be reported at the ninth and twelfth grades. Statewide, one out of six ninth graders have reported binge drinking in the past two weeks. Finally, almost 25 percent of ninth and twelfth grade Minnesota teens report marijuana use within the past 12 months. This continues to be at a higher rate than was reported in 1992. Clearly, the work of prevention must stay the course, yet we have to ask, are there some ways that it can be enhanced?
I just found out that the Minneapolis Department of Health and Family Support is collaborating with pediatricians to develop an assessment tool for alcohol, tobacco and other drug use by youth, that can be used by pediatricians, as a regular component of physical checkups. Why are we excited about this in the prevention field? First of all, the pediatrician carries a respected role in the community, and that role defines staying healthy. A health-based perspective to chemical use by teens, is much more likely to get a parent’s attention than a call into the principal’s office. The pediatrician can help thwart the biggest hurdle to accessing help for adolescent chemical use: denial and shame, by the teen user and sometimes, the parents of the teens. A health-based perspective, could include recent compelling research on the effects of chemical use on the adolescent brain. Physicians can share these findings with teens and parents to emphasize the importance of getting healthy to attain the teen’s greatest potential.
Early intervention has a far greater chance of impeding the likelihood of years of addiction. The assessment that a pediatrician completes can be coordinated with health insurance plans, and more efficiently gets the health benefits to the teen more quickly. Looking into the future, it could become a standard of care, to call for a visit to the pediatrician, when a teen is brought to the E.R., due to overdosing, or when a parent realizes “enough is enough,” or when the police cite a teen for chemical use at a party. Here the pediatrician could get an accurate picture of what’s really going on, without shame and blame attached. Does this mean that pediatricians will be called upon to “do the intervention”? There may be times when an individual physician will choose to do this, but it is the place (the medical office) and the person (the doctor) that will really give weight to the assessment. A referral system involving treatment programs, and chemical health coordinators in schools, can support the first step taken by the pediatricians with the family and teen. Perhaps the teens, who are likely to benefit the most from medical assessment and intervention, are the teens who come from homes where parents are also abusing alcohol or drugs. These teens are in pain, and will not have a supportive family to get them into treatment. For these teens, a medical assessment has the power to change their lives, and provide earlier opportunities for choosing a life of sobriety. Much has been learned about work in prevention and why it works. It is the right time to apply a health-based approach to assessment and treatment for children and their families. For more information about this development, please contact Patricia Harrison, Ph.D. at the Minneapolis Department of Health and Family Support: pat.harrison@ci.minneapolis.mn.us. ✦ Kathy Iverson is a member of the Hennepin Medical Society Alliance. She currently works as the Chemical Health Program Coordinator for the City of Edina. She can be contacted at: menze002@tc.umn.edu
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May/June 2002
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
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