2004janfeb

Membership Advantages for Metropolitan Physicians and their Practices AmeriPride Apparel and Linen Services is a locally owned and operated company offering rental and cleaning services of medical garments. Their organization is top notch with quality products and services. HMS and RMS members receive a discount. For a free price quote, contact Steve Severson from AmeriPride at 612-362-0334.

SafeAssure Consultants recently partnered with HMS and RMS to offer the required OSHA compliance training for our members and their staffs. Our members receive a discount. To meet or exceed the Minnesota OSHA and the Federal OSHA requirements talk with SafeAssure Consultant, Jim Peterson at (320) 231-3803, or visit their website at www.safeassure.com.

Berry Coffee Service is a valued partner of RMS and HMS and offer our members up to 25% off of their wide array of coffee and hot beverage services. If you are interested in trying their service, contact Bob Dilly at (952) 937-8697. If you are an existing customer of Berry Coffee Service, be sure that you are receiving the discounted pricing.

DAMARCO Solutions offers HMS and RMS members the ability to outsource OSHA compliance needs as they relate to the management of Material Safety Data Sheets. Members of HMS and RMS receive a discount for this service. To find out more information, contact Gary Graczyk at (612) 617-0997.

Call HMS or RMS at 612-623-2889 for details.

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2004 Winter/Spring Activities Continuing Professional Development 16th Annual Burn & Wound Care Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . February 5- 6 Pre-conference Workshops: Compression Dressings and Vacuum Assisted Closure: Tricks of the Trade Wound Care Product Selection and Care Plan Development

18th Annual Family Medicine Today . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . March 11-12 Post-conference Workshop: Skin Biopsy and Lesion Removal Techniques

Managing the Pain Patient: A Multidisciplinary Approach . . . . . . . . . . . . . . . . . . . . . . . . . . April 16 22nd Annual OB/GYN Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . April 22 - 23 Psychiatry Update: Selected Topics for the Non-Psychiatrist . . . . . . . . . . . . . . . . . . . . . . . . April 30 View our website – http://ime.healthpartners.com For further information contact Center for Continuing Professional Development.

Telephone 952/883- 6225 • Fax 952/883 -7272

Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

Physician Co-editor Y. Ralph Chu, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Charles G. Terzian, 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 Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

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. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: bauerfamily@earthlink.net.

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.

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. For subscription information, contact Doreen Hines at (612) 362-3705.

MetroDoctors

CONTENTS VOLUME 6, NO. 1

2

JANUARY/FEBRUARY 2004

EDITOR’S MESSAGE

Steps to Becoming Politically Active

3 4 5

Grass-roots Participation Key Component for Legislative Success New Rules for Medicaid Managed Care Contracts PUBLIC POLICY

Minnesota’s Health Care System — an Important Issue for the 2004 Legislative Session

7

PUBLIC POLICY

Health Care Cost Containment a Top Priority for 2004 Session

9

MINNESOTA PERSPECTIVE

No Shortage of Health Challenges for Minnesota to Address

11

COLLEAGUE INTERVIEW

Paul Matson, M.D.

14 17 20

Medicare Reform: The Long, Hard Slog Medical Group Quality Data: A Reality Disease Management: A Leap of Faith to Lower-Cost, Higher-Quality Health Care RAMSEY MEDICAL SOCIETY

24 25 26 27 28

President’s Message RMS in Action RMS Winter Gala and Annual Meeting Caring Hearts/RMS Election Results/ RMS Board/RMS Winter Gala RMS Alliance HENNEPIN MEDICAL SOCIETY

29 30 31 32

Chair’s Report HMS in Action/Charles Bolles Bolles-Rogers Award New Members/In Memoriam HMS Allianc

The Journal of the Hennepin and Ramsey Medical Societies

On the cover: The Minnesota Legislature reconvenes in February. Will health care be on the agenda? Articles begin on page 2.

January/February 2004

1

EDITOR’S MESSAGE

Steps to Becoming Politically Active: Your Time has Come Attention Physicians: Your Patients Need your Involvement ASAP! Very shortly, a number of issues intimately related to the care that we are able to provide as physicians will be under consideration in the political arena. Health care financing, disparities in care and outcomes, quality in medicine, prescription drug coverage, Medicare and Medicaid payments, MinnesotaCare, the provider (“sick”) tax, and tort reform are just a few of the examples that are likely to be up for discussion by our elected officials. They will be making important de-

January/February Index to Advertisers Central Medical Building-Wirth Co.......... 22 Classified Ad. ............................................ 23 Crutchfield Dermatology .......................... 18 Healthcare Billing Resources ..................... 23 HealthEast Vascular Center ...........................

Inside Back Cover Health Partners Continuing Education...........

Inside Front Cover Medical Billing Professionals ....................... 6 MMIC ............................. Inside Front Cover Parent Professional Properties LLC............ 10 ProSource Medical Services ......................... 8 RCMS, Inc....................... Inside Back Cover U of M CME ................. Outside Back Cover Weber Law Office ....................................... 9 Whitesell Medical Locums Ltd.................. 10

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January/February 2004

following four steps to increased involvement:

cisions concerning a number of these issues within the next year or two.

The question is what groups or individuals are going to have the most influence on legislators as they consider these issues?

Health insurers? Lobbyists? Industry groups?

Pharmaceutical companies? It is unlikely that they will be putting the needs of your patients at the top of their priorities. It is also unlikely that they will be putting a strong consideration of what you need to deliver quality care anywhere near the top as well.

The responsibility for this really falls on physicians. There is a compelling need for physicians to become more involved in the political process on behalf of our patients in order to ensure the best possible outcomes of the legislative process. While for some this is a very familiar and invigorating activity, most of the rest of us have not been engaged in the political process, even at a city council level. Because of a lack of experience and opportunity, many of us feel awkward and ill equipped, and therefore choose to remain outside of the process.

I would encourage every physician to become more involved with advocating for our ability to treat patients well. I suggest the MetroDoctors

STEP 1: Become Informed Thanks to the Internet, taking the initial steps to being more informed and participative is extremely easy. Through the Web site www.leg.state.mn.us you can access all the pertinent state-related information on what bills are under consideration, what committees they are being considered by, and the corresponding companion bill in the House or Senate. If you are unsure who your Representative or Senator is, you can access the link “District Finder” and find contact information on your State Representative, State Senator, U.S. Congressman, and U.S. Senators (www.leg.state.mn.us; click on “House;” click on “Who represents you;” click on sidebar “District Finder”). Once you get to the State Representative or Senator links, they will typically have an easy way to send them an e-mail.

Information on city government officials and issues are also typically easy to find. City Web sites tend to .mn.us or be of two types: www.ci. .org. For example, Minneapolis www. is www.ci.minneapolis.mn.us and St. Louis Park is www.stlouispark.org. Smoke-free ordinances are now being considered at a city level, so information pertaining to progress in your community would be included there.

STEP 2: Decide to Act Once becoming informed of whom to contact, contact them with the specifics of your concern or issue. The more physicians who contact, the greater the result, so recruit others in your voting district to contact that official as well. The method of contact you The Journal of the Hennepin and Ramsey Medical Societies

use — letters, phone calls, e-mails, personal meetings in their office — will depend on what you are comfortable with. The important thing is to make the contact.

STEP 3: Work Together The next level of activity above individual contact is working with a group or organization to carry a message through the grassroots or legislative process. At one end of the spectrum, a small, informal group of three to six physicians working together on a certain issue can have a significant impact on that particular issue. The other end of the grassroots spectrum is working cooperatively through the Hennepin or Ramsey Medical Societies or the MMA on a particular healthcare-related issue.

Another opportunity to work with others on a common issue is with communitybased groups such as the American Cancer Society, the American Lung Association, or the American Heart Association.

STEP 4: Be Visible in Public Opportunities It only requires a small number of physicians who are willing to testify during city council meetings and legislative subcommittees, speak at press conferences, and present information at community group events. The only requirements are some basic information, some basic public speaking skills and, most importantly, a real passion for the issue.

If public speaking is not your forte, you can

go a long way to support those who are getting out into the public light.

What you do and how you do it is not as important as doing something. Physicians are seen by local government officials as a trusted source of reliable information on a number of topics. Please use that position to help influence legislation that will positively affect your patients. Regardless of what we do or don’t do, the legislation is going to be considered, and whatever group has the most convincing voice will likely win the day. Your patients are relying on you to help win it on their behalf. ✦ Peter Dehnel, M.D. is a MetroDoctors editor and a member of the Hennepin Medical Society Board of Directors.

Grass-roots Participation Key Component for Legislative Success EVERY YEAR THE LEGISLATURE makes

decisions that affect you, your practice, and your patients. Health care costs, professional liability tort reform, health care taxes, and tobacco control issues will be just a few of the health care issues discussed during the 2004 legislative session. Grass-roots participation in the political process is a key component for success at the Capitol. The MMA, HMS, and RMS work hard to effectively represent physician’s interests at the Capitol but lawmakers also need to hear from you as a physician and a constituent on these issues.

The MMA, HMS and RMS know that you are busy, but there are a few easy steps you can take now to increase physician’s power at the Capitol during the 2004 legislative session.

Step 1 Become a grass-roots advocate by Joining The MMA Legislative Action Network!

The MMA, with your help, is creating the Legislative Action Network to help build the grass-roots network needed to increase physician’s power and voice at the legislature.

MetroDoctors

The goal of the Legislative Action Network is to have a well-informed and active group of physicians in each legislative district in the state that is ready to contact their legislator on issues important to Minnesota physicians.

The MMA will provide you with all the tools that you need to be an effective advocate with your lawmakers. You will be invited to attend a training session, be provided with briefings on legislative priorities and strategies, and be given tools to help you effectively communicate with your legislators.

If you decide to become a member of the Legislative Action Network, your responsibilities will include: ✓ Getting to know your state legislators or strengthen your relationship if you already have one. They do want to hear from you! ✓ Explaining the MMA’s position on key issues to your legislators. ✓ Responding to legislative alerts during the legislative session. ✓ Providing the MMA with your legislator’s position on issues. ✓ Participating in their political campaigns.

The Journal of the Hennepin and Ramsey Medical Societies

To sign up, contact the MMA Center for Physician Advocacy at (888) 662-6774 or e-mail wodonnell@mnmed.org. By joining the Legislative Action Network you can use your power as a physician and a constituent to inform your legislators on issues important to Minnesota physicians. It is a small time commitment that will provide significant returns at the Capitol.

Step 2 Your first responsibility as a Legislative Action Network member is to establish (or strengthen) a relationship with your legislators.

It is important that legislators hear from their constituents even when the legislature is not in session. Now is the perfect time to establish (or strengthen) a relationship with your legislators. By establishing the relationship now, it will be much easier and more effective when you discuss critical issues with them during the legislative session. Contacting your legislator now lets them know that you are interested and engaged.

(Continued on page 4)

January/February 2004

3

Grassroots Participation (Continued from page 3)

Opportunities to meet your legislators include 1. Set up a one-on-one meeting with your legislator at a local coffee shop.

2. Attend town meetings or other functions where your legislator is scheduled to speak.

Make sure to introduce yourself and tell them you are a physician.

3. Invite them to your clinic or hospital for a tour.

4. Invite them to your medical society or hospital staff meeting.

5. Attend fundraisers and contribute or volunteer time to their campaign.

Setting up your meetings 1. If you are unsure who represents you, contact the MMA at 612-362-3745.

2. Contact your legislators at home. Home numbers can be found on the state legislature’s Web site at www.leg.state.mn.us

or by calling Senate information for your Senator’s number at 651-296-0504 or House information for your Representative’s number at 651-296-2146.

3. Address your legislator as Senator if they are a member of the Senate or Representative if they are a member of the House of Representatives. Do not refer to them as Congressman.

4. Introduce yourself and inform them you are a physician and you would like to meet with them.

When meeting with your legislator 1. Contact the MMA prior to your meeting to get issue briefs and talking points on priority issues (soon to be on mmaonline.net).

2. Tell your legislator who you are, what you do, and what issues are important to you.

3. Offer to be of assistance to them. For example, you can be a resource for them on health care issues and/or you can be politically involved in their campaign.

4. If a legislator asks a question and you are unsure of the answer, tell them that you are unsure but you will look into it and follow up with them. It is better to tell them you don’t know than to give them wrong information.

5. Be respectful and polite if they disagree with you. Try to respect their views also.

Following your meeting 1. Contact the MMA Center for Physician Advocacy at (888) 662-6774 or e-mail wodonnell@mnmed.org and let them know how your legislator responded to issues you discussed.

2. Keep building and strengthening your relationship!

Acting on these two steps will help position the MMA for a successful 2004 legislative session. Your legislators do want to hear from you.

These steps don’t take long to accomplish and will help physician’s be successful on important health care policy issues at the Capitol. ✦ Erin Sexton is an MMA Lobbyist.

New Rules for Medicaid Managed Care Contracts

T

THE FINAL COMPLIANCE DATE for

states to amend their Medicaid managed care contracts to comply with the Balanced Budget Act (BBA) requirements was August 13, 2003.

The changes impact over 23 million Medicaid beneficiaries enrolled in every state except Alaska and Wyoming. Providers covered by the managed care contracts are directly affected by the mandatory changes as well.

CMS regulations implementing the BBA requirements were published on June 14, 2002.

States had until August 13, 2003 to comply.

The scope of the regulations is broad and addresses all aspects of managed care including state responsibilities, enrollee rights and protections, quality assessment and improvement, and grievance systems. The regulations outlined the new requirements for actuarially

4

January/February 2004

sound capitation rates paid to managed care plans as well.

The regulations implemented new protections for enrollees. For example, enrollees must be provided information on the services and providers available to them within a managed care organization and how to access such care.

The regulations also require managed care organizations to implement written policies regarding enrollee rights including the right to privacy, freedom from restraint, right to participate in health care decisions, and the right to request medical records.

The regulations also established new protections for providers. The new rules prevent managed care plans from discriminating against providers solely on the basis of license or certification. If a managed care organization MetroDoctors

declines to include a provider in its network, it must give the affected provider written notice of the reason for its decision. The rules also prohibit a managed care plan from restricting health care professionals from advising their patients on alternative treatments, information needed to decide among treatment options, and the risks, benefits, and consequences of treatment or nontreatment.

CMS, state Medicaid agencies, and Medicaid managed care plans have been cooperating to ensure that final compliance with the rules is completed on time. For more information on the managed care regulations and requirements, go to http://www.cms.gov/ medicaid/managedcare. ✦ Reprinted with permission, the Pulse of CMS, fall 2003, Volume 1, Issue 1.

The Journal of the Hennepin and Ramsey Medical Societies

PUBLIC POLICY

Minnesota’s Health Care System — an Important Issue for the 2004 Legislative Session Editor’s Note: Senator John Hottinger, Senate Majority Leader, and Representative Steve Swiggum, Speaker of the House, accepted the invitation of MetroDoctors to submit articles describing their perspectives of Minnesota health care on the 2004 legislative agenda. In addition, an article by Minnesota Department of Health Commissioner, Dianne Mandernach, details her health care priorities.

T

THE ISSUES THAT REVOLVE around health

care access, quality and costs are re-emerging in the public policy arena — and it’s about time.

Over the last four years, health care costs and health insurance rates have quadrupled the general inflation rate, and have grown three times faster than personal and business income.1 It is the single largest factor in the growth of state government expenditures, and it is an increasingly difficult issue for business and labor to confront. Paying for health care has emerged as the number one issue for collective bargaining in both the public and private sectors. In these days of NAFTA and market globalization, American manufacturers must compete not only against foreign firms that often pay employees a tiny fraction of American wage rates, but also operate in countries that offer government-sponsored health care.

What’s driving health care costs? Our population and our genius. Minnesotans, along with the rest of America are getting older — and staying older. This represents a ticking time bomb of health care costs. Be-

BY SENATOR JOHN HOTTINGER

MetroDoctors

tween 2000 and 2030, Minnesota’s over-60 population will more than double.2 As age rises, so does health care utilization. In 1995, the 12.8 percent of the population that was age 65 or older accounted for over one-third of personal health care expenditures.3 You can see the implications when this ratio of this group of citizens doubles by 2030.

Innovative research, much of which originates at public universities, is finding its way into the marketplace in the form of pricey new drugs, treatments and diagnostic tools. In other words, our ability to treat and cure medical problems grows at a rate unprecedented in the history of humankind. The prospects are that this happy factor will only continue to accelerate, but innovation must be paid for.

It gives many pause to reflect that the ability to really handle medical conditions is pretty much a function of the last 60 years. It wasn’t so long ago that medical services were dispensed by nuns or other charitable people who offered their services for free or for very little compensation. When coupled with public health initiatives of the last century — like sewage treatment and immunizations, we have extended the life expectancy for newborns from 48 years in 1900 to over 79 years in 2000.4

The Journal of the Hennepin and Ramsey Medical Societies

The administration of care is another significant cost factor. The number of people employed in health care administration in the U.S. grew from 18.2 percent in 1969 to 27.3 percent in 1999. Meanwhile, during the same period in Canada, the number of administrative workers grew from 16 percent to 19.1 percent — and those figures don’t include people employed in the health insurance industry.5 Overall, administration accounts for 31 percent of U.S. health care expenditures.6 Referring again to the bygone days of health care, the sisters who ran a lot of health facilities back in the day may have lacked the administrative polish and up-to-date methods of modern-day graduates from the Carlson School of Management, but they sure did work cheap.

Administrative costs rise as complexity increases. Our “many-payer” system is one of multiple contracts, payment rates, claim forms and continuous negotiation and red tape handling. It employs lots of people, but they are not involved in direct patient care.

So, we have a fast-growing aging population that uses health care at three times the rate of the rest of the population, an ever-increasing ability to keep us all alive and operating at higher levels of function, and an increasingly complex delivery and payment system.

But these irresistible forces are met by a growing inability to pay for it at the same rate of growth. Something’s got to give.

If I get my way, health care will be the most important issue for the 2004 legislative session. It’s time for a non-partisan discussion on Minnesota’s health care system that will lead to action that will hold down costs, increase access, and improve health care quality. Health care costs are driving our economy — out-ofpocket costs are hurting families, premiums (Continued on page 6)

January/February 2004

5

Minnesota’s Health Care System (Continued from page 5)

are overwhelming employers, and millions are being priced out of health care.

To that end, I applaud Governor Pawlenty’s appointment of the Minnesota Citizens Forum on Health Care Costs to explore these issues and report back to the Governor and the Legislature in January. While the membership of the panel — weighted heavily towards corporate, health care, and insurance executives — is wanting, in my view, for real consumer participation, I eagerly anticipate their recommendations and would strongly urge that Senate committees give consumers and health care professionals additional input on their recommendations.

Arriving at solutions that will pass both houses of the legislature and be signed into law will require that we all set aside partisan considerations in the interests of the greater good of Minnesota citizens.

The plain fact is that Canada does a better job negotiating prices for their citizens than is even possible under our current system. That’s just good business. For years, I’ve been ďŹ ghting

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January/February 2004

for passage of the Fair Drug Pricing Act, which would use the state’s buying power to buy drugs at the discounted price currently given to us by drug companies for Medicaid patients. Minnesota consumers would in turn, be able to buy at those reduced prices. It’s the least we can do to bring costs under control — and at no cost to the state.

The claim that undermining America’s underwriting of the world’s pharmaceutical market leads to reduced research and innovation is the most misleading of all. The pharmaceutical industry beneďŹ ts from over $15 billion spent annually by the NIH on biomedical research, as well as a host of other public sector and public domain research.7 What the pharmaceutical industry has done, at questionable beneďŹ t to patients but certainly increased costs to everyone, is spending billions on marketing, advertising and administration. The numbers are staggering.

According to Families USA, drug companies spent more than twice as much on peddling drugs as it did on research and development, $44.5 billion in 2001 or 26 percent of revenues, vs. just 11 percent on R & D. ProďŹ ts amounted to 18 percent, or $30.6 billion.8 Consumers pick up the costs of marketing in more ways than one. Much of pharmaceutical marketing also leads to higher costs in the health care system as consumers, egged on by slick TV ads, inquire their physicians about “purple pillsâ€? or cures for that current modern scourge, toenail fungus. (Which is treatable, by the way, with a twelve-week course of Lamisil, at $10 per pill.9 If there’s a hideous yellow monster partying with his friends under your toenail, it must be worth the price!)

With Canadian imports, drug companies will continue to be the most proďŹ table in health care, and innovation will continue unabated.

The history of science and medicine has proven time and again that there is a far more important underpinning to medical innovation than mere proďŹ ts. It’s the nature and dedication of the people who enter the ďŹ eld and dedicate their lives to advancing medicine. To suggest otherwise is an insult.

As legislators, we should avoid easy answers and promising too much, which some might say is against our very nature. Health care reform has long been a place where highminded nostrums have been offered up as cures, while ignoring the contraindications. “Single-payer� medicine, a laudable goal to MetroDoctors

me, is frequently discussed without much discussion regarding the many thousands of folks who would lose their jobs in the insurance industry. Similarly, the current buzz around “personal responsibility� sounds very sensible and certainly meets with our shared values, but doesn’t necessarily mean that the health care system will save money. To begin with, we’re all mortal; and disease, injury and eventual death will get us all, the careful and virtuous along with the careless and ornery.

And, as the cigarette industry once famously asserted, “dying young is cheaper.�

We must keep an eye out for solutions that produce sustainable cost savings. It’s sobering to reflect that every cost-cutting strategy in the last 40 years — the institution of Medicare/Medicaid in the 1960s, wage and price controls in the 1970s, voluntary cost containment in the 1980s, and managed care in the 1990s — were followed by a return to the previous rate of ination.10 To produce sustainable savings, the choices are going to be more difďŹ cult and come with consequences for both policymakers and stakeholders. These range from rationing health care to cutting the number of people who have their ďŹ ngers in the ďŹ nancial pie, such as the insurance industry.

With a shared commitment to our values, open minds, and a rational approach to analysis of our problems and solutions, we can improve access to care and cut costs. Mercy, we don’t have many decent alternatives to that. âœŚ Senator Hottinger is the Senate Majority Leader and represents Senate District 23 (D-St. Peter).

(Footnotes) 1 Minnesota Citizens Forum on Health Care Costs Fact Sheet: Rising Health Care Costs 2 Minnesota Department of Health, Health Economics Program Issue Brief 2203-05: Minnesota’s Aging Population: Implications for Health Care Costs and System Capacity, August 2003 3 http://ucsfagrc.org/module_one/section_three/04_ healthcare_utilization.html 4 McMurry, Martha, Minnesota Life Expectancy in 2000, Minnesota Planning State Demography Center, April 2002 5 Woolhandler, StefďŹ e, M.D., M.P.H., Campbell, Terry M.H.A., and Himmelstein, David U., M.D. Cost of Health Care Administration in the United States and Canada New England Journal of Medicine 349:768775 6 Ibid 7 http://ugsp.info.nih.gov/bioresearch/budget.htm 8 Mahan, Dee ProďŹ ting from Pain: Where Prescription Drug Dollars Go; Families USA; July, 2002 9 http://www.buy-my-online-rx.com/_buy_lamisil.html 10 Altman, Drew E. and Levitt, Larry “The Sad History of Health Care Cost Containment As Told In One Chartâ€?, i>Â?ĂŒÂ…ĂŠ vv>ÂˆĂ€Ăƒ]ĂŠĂ“Ă“ĂŠ >Â˜Ă•>ÀÞÊÓääÓ

The Journal of the Hennepin and Ramsey Medical Societies

PUBLIC POLICY

Health Care Cost Containment a Top Priority for 2004 Session

M

MINNESOTANS ENJOY some of the best

health care in the world, but right now, soaring costs are threatening all aspects of our system. That’s why a top priority for House Republicans in the 2004 legislative session is health care cost containment. We want to continue to expand health care access for all Minnesotans, but at the same time, remain fiscally responsible.

Currently, we are awaiting a report from the Minnesota Citizens Forum on Health Care Costs, Governor Tim Pawlenty’s blue ribbon task force chaired by former U.S. Senator Dave Durenberger. The report, due in January, will make recommendations for short-term cost control measures. After that, the task force will develop a “Vision 2010” plan charting a long-range cost control strategy for the future of health care in Minnesota. We look forward to considering the recommendations issued in these reports, and believe that they will add to our health care reform efforts for the 2004 session, which are substantial.

One area my House Republicans colleagues and I plan on taking a close look at during the 2004 session is medical malpractice litigation, which is a leading contributor to skyrocketing health care costs.

House Republicans will likely push some sort of tort reform during the upcoming session to address the excessive lawsuit awards that have driven medical liability insurance premiums through the roof. Florida recently adopted a cap on claims for non-economic damages, which are usually awarded for pain and suffering claims. Undoubtedly, this will be a hard, emotional fight, but we believe it

BY REPRESENTATIVE STEVE SVIGGUM

MetroDoctors

could seriously reduce the cost of liability insurance.

We also think it is important to encourage and reward “best practices” so we can protect patients and physicians. Along this line, we would like to continue to work on the strongly supported “adverse affects” law of last session.

Prescription drug purchasing assistance is another top concern for House Republicans.

Our seniors face prohibitive cost barriers in a world where our neighboring countries provide the same drugs for a fraction of the price.

Last session, we enacted two important prescription drug laws.

The new RxConnect program, up and running now, is a telephone hotline service (1-800-333-2433) that matches eligible Minnesotans to free or discounted prescription drugs offered by over 100 pharmaceutical companies.

And beginning in January of 2005, the Prescription Drug Discount Program will help thousands of Minnesotans without drug coverage who are earning less than 250 percent of the federal poverty guideline.

The Journal of the Hennepin and Ramsey Medical Societies

In the 2004 session, we’ll continue to examine initiatives tackling the prescription drug cost crisis, including re-importing drugs from Canada, an effort being led by Gov. Pawlenty and Congressman Gil Gutknecht, R-Rochester.

Another issue driving up health care costs that we’ll be looking into during the 2004 session is wasteful regulations and paperwork. It’s ridiculous, for example, that hospitals have to pay upwards of $2,000 to fly physicians who they want to hire from other states into Minnesota for a 15-minute interview with the Board of Medical Practice. Allowing teleconference interviews for migrating physicians would be a common-sense cost-saving measure, and is one example of the simple kind of cost-saving regulatory reforms we’ll be looking at this session.

We’d also like to increase competition among health plans in our state. Right now, Minnesota has just three major health insurance providers. This session, House Republicans plan on examining and addressing the barriers that keep additional providers out of Minnesota.

We’ll do our best again this session to protect Medical Assistance reimbursements.

The state’s largest budget deficit ever required us to make some very difficult decisions last session in this area. Nevertheless, we increased health and human services funding by over 11 percent and preserved long-term care providers by making sure that there were no reductions in Medical Assistance reimbursement rates to Minnesota nursing homes, even though the

(Continued on page 8)

January/February 2004

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Health Care Cost Containment (Continued from page 7)

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DFL-run state Senate sought to reduce these rates.

We’ll be looking at reauthorizing the Emergency Health Powers Act during the 2004 session, as well. This 2002 law will expire on August 1, 2004 unless it is reauthorized this session. The law grants the governor certain powers during a public health emergency, including the power to isolate and quarantine, so we would like your input on its reauthorization.

Finally, I once again will personally support legislation this session to eliminate the health care provider tax — or “sick tax” — by replacing the funds this tax generates with a $1 a pack cigarette tax hike. I believe that this would be a win-win situation for our state. It would end a tax that hurts health care providers and the people they care for, and also economically encourage people to stop smoking.

I must note, however, that this is my own personal position on this controversial legislation. As a whole, the House Republican Caucus is deeply divided on this issue. My caucus has long supported getting rid of the sick tax, but many of our representatives do not support raising another tax to do it.

Thank you for working every day to improve the lives of Minnesotans. I look forward to working with you during the 2004 legislative session and beyond. Together, we need to encourage such things as best practices, consumer empowerment and healthy lifestyles.

If you have questions about any of the issues I’ve brought up in this column, please don’t hesitate to contact me. My e-mail address is rep.steve.sviggum@house.mn, and my Capitol phone number is 651-296-2273. Also, don’t hesitate to drop by my office located in Room 463 of the State Office Building, which is across the street from the Capitol. My door is always open to you. ✦

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

MN PERSPECTIVE

No Shortage of Health Challenges for Minnesota to Address

W

of getting the disease. Diabetes costs the state an estimated $2 billion per year in medical costs and lost productivity. The human and economic costs of chronic diseases such as diabetes are staggering. The Centers for Disease Control and Prevention estimates that 75 percent of the $1 trillion we spend on health care every year goes to treating chronic disease.

Many of these diseases could be prevented if people made healthier choices. At MDH, we’re helping to coordinate a number of comprehensive, collaborative efforts to address diseases such as diabetes, asthma, arthritis, cancer and

WHEN I ATTEND MEETINGS outside of

Minnesota, I’m often asked how we manage to consistently rank as one of the healthiest states in the country. After I brag about our wonderful health care providers, our strong commitment to public health, and our excellent medical facilities, I point out that we still have our share of challenges.

In the best tradition of Minnesota, we try to address those challenges head on. Although the Minnesota Department of Health (MDH) often leads the charge, neither MDH nor any other single entity can manage these challenges alone. The public health community, health care providers, government officials, non-profit organizations and others must work together to ensure a healthy Minnesota.

Although we face routine challenges everyday in public health — such as keeping our drinking water safe, tracking infectious diseases, and promoting healthy habits — the following challenges need special attention.

Eliminating Health Disparities Minnesota’s overall good health masks some of the worst health disparities in the country. Populations of color and American Indians have poorer health outcomes in many areas, including diabetes, heart disease, infant mortality and injury. MDH launched its “Eliminate Health Disparities Initiative” in 2001 to begin reducing these disparities. We’ve awarded grants to more than 40 community-based organizations across the state, and we’re working with them to tailor programs to reduce disparities in their communities. Disparities won’t be eliminated overnight; however, we’re confident we’re on the right track. This issue will remain a priority

BY DIANNE MANDERNACH, Minnesota Commissioner of Health

MetroDoctors

(Continued on page 10)

until all Minnesotans have an equal opportunity to enjoy good health.

Preparing for Health Threats The state’s ability to respond to public health threats must remain strong — because new threats, such as West Nile virus, SARS and bioterrorism can emerge at any time. MDH will continue providing leadership to ensure that communities across the state are prepared to effectively respond to public health emergencies. Thanks to grant money from the federal government, we’ve been able to enhance numerous parts of our response system, including disease surveillance, information technology, lab capacity and communications. We’ve involved numerous partners in this effort, including hospitals and health care providers from across the state. One of the issues we still need to resolve is how to handle the surge of patients that will show up at clinics and hospitals if an unexpected emergency occurs.

Preventing and Managing Chronic Diseases We recently announced that one in ten Minnesotans either have diabetes or are at high risk

The Journal of the Hennepin and Ramsey Medical Societies

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MetroDoctors

No Shortage of Health Challenges (Continued from page 9)

cardiovascular disease. Preventing chronic diseases and helping people with those diseases to effectively manage their condition will not only promote better health; it will help address the following challenge, too.

Containing Rising Health Care Costs Our Health Economics Program issued a report last September showing that Minnesota private health care costs jumped 16 percent in 2002. That kind of increase is likely to repeat itself over and over if we don’t take action soon.

Governor Pawlenty understands this is a huge challenge; that’s why he appointed the Citizen’s Forum on Health Care Costs in September.

The 18-member forum, led by former U.S. Senator David Durenberger, held public meetings across the state in the fall to hear from Minnesotans about their views on health care costs. The forum’s workplan calls for them to present an initial set of short-term recommendations to the 2004 legislature. Once that is done, they will turn their attention to creating a Vision 2010, a long-term plan for keeping health care affordable into the next decade. I look forward to reviewing their recommendations and working together with them on this critical issue.

Ensuring Quality Care in Long-term Care Facilities Minnesotans residing in long-term care facilities deserve quality care. MDH is reviewing its role in regulating these facilities to ensure that the regulations are not overly punitive and that they contribute to — rather than detract from — quality care and a comfortable living environment. I’ve created a working group, including facility administrators and advocates for the elderly and disabled, to help us find the right balance of regulation and proactive improvements that will produce quality care in these facilities.

There are other challenges we must address in the future, including mental health and rural health. If you’d like more information about any of the challenges I’ve outlined above, I encourage you to visit our Web site at www.health.state.mn.us, or contact me by e-mail at commissioner@health.state.mn.us. ✦ The Journal of the Hennepin and Ramsey Medical Societies

COLLEAGUE INTERVIEW

Paul Matson, M.D.

Editor’s Note: Paul C. Matson, M.D., President of the Minnesota Medical Association, is a board certified orthopedic surgeon. A native of Minneapolis, Dr. Matson received his B.A. at St. Olaf College, and his medical degree from the University of Minnesota. His internship was served at HCMC and he completed his orthopedic residency at the University of Minnesota. In addition, Dr. Matson completed an AO Fellowship at the University of Basel/Switzerland and served as a medical missionary in Kenya and in Cameroon, West Africa. He is a fellow in the American Academy of Orthopaedic Surgeons and the American College of Surgeons. He practices at The Orthopaedic & Fracture Clinic, P.A. in Mankato, Minnesota.Questions were provided by: Andrew J.K. Smith, M.D.; Douglas J. Pryce, M.D.; Lee Beecher, M.D.; Michael Ainslie, M.D.; E. Duane Engstrom, M.D.; and Lyle Swenson, M.D.

Q A

What goals do you hope to achieve during your term as president?

The three main goals that I would hope to achieve during my term as president involve the basic themes of the professionalism of medicine to our colleagues, to the legislature, and to the public at large. A portion of my inaugural speech and review of some of the accomplishments of the medical association during these past 150 years highlighted the struggles that physicians have endured. The times bring different struggles, which require different responses, but the central theme was that physicians of each time worked together for the common good of the association and the public to overcome these challenges. It is only by continually stressing the professionalism that physicians bring to the care of their patients that we can continue to enhance the ability of physicians to provide the high quality of medical care that Minnesotans have come to expect.

The second goal I have set is to use the outstanding communication vehicles and staff that the MMA has to promote volunteer opportunities to underserved areas in the United States and abroad. As I had stated in my speech, most physicians receive tremendous personal satisfaction from their medical activities. Volunteer opportunities allow physicians to take a step back from the bureaucratic hassles present in our current medical environment and get back to the reason that many of them entered medicine in the first place. We have the tools and an opportunity through our association to foster and nurture those activities. I am very excited with the enthusiasm that the staff has brought to this project.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

The third goal is to work diligently to increase the sense of the organization’s benefits to physicians throughout the state. Many activities of the medical association are behind the scenes and the benefits are not immediately visible or recognized. The value that the medical association brings to physicians in our state needs to be better communicated.

How do we get more physicians involved in organized medicine?

The Membership Task Force, which I had the opportunity to chair, brought forth 29 recommendations to encourage physicians to become more involved in organized medicine. One of the central tenets of the Task Force’s recommendations is that members are more important than money. While it is true that the organization must have a revenue stream to enable it to carry out the activities that the members would like, we feel it is even more important that total membership be stressed even more than a specific revenue stream. Recommendations were also made to target membership to organizations in which we do not currently have high penetration levels, as well as mentoring young physicians to foster an interest and continued participation in the medical association policy making structure.

(Continued on page 12)

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Colleague Interview (Continued from page 11)

What are the most important issues facing physicians in Minnesota?

I believe the most important issues facing Minnesota physicians are loss of autonomy and sense of professionalism. This loss of autonomy erodes the patient-physician relationship, forces the physicians to be perceived as technocrats performing a specific function within a system and may foster a sense that physicians are interchangeable. All of this further erodes that bond that people seek when they come to see “their physician.” The payment systems that have evolved within Minnesota have placed some challenges on maintaining that relationship, which I believe most people want with their caregivers.

The long-term issues that we have had with the legislature, specifically the repeal of the provider tax, although currently hampered by budgetary constraints, are no less important than they have been.

We continue to press for substitution of this regressive tax with a more appropriate funding mechanism, as well as increasing cigarette taxes to discourage youth smoking.

Liability reform, though not an immediate threat to Minnesota physicians, could easily become a crisis and we want to lay the groundwork with the legislature before this happens so we do not become another crisis state.

How can the MMA increase its influence with Minnesota legislators?

I believe that the most important activity that Minnesota physicians in general can engage in is personal contact with their legislators. Physicians still enjoy good relationships and the respect of members of their communities but do not do enough to foster those relationships with our legislators. This includes writing or calling the legislators on issues of importance to us, as well as maintaining a general dialogue with the MMA. We have excellent lobbyists and staff, but all of them have said many times over that legislators respond to physician constituents at a higher level than they do to lobbyists. We must continue to work and expand these contacts. One of the Task Force’s recommendations was to increase the physician advocacy grass-roots network. The MMA has established a position of a grass-roots advocacy coordinator to assist in this important part of our mission. I would hope that physicians would respond when the call goes out to them to engage their legislators.

well as, collaboration with county and specialty societies. To that end, regular meetings will be scheduled both at the staff level with the county and any staff specialty societies, as well as meetings at the leadership level. In addition, the MMA will meet with organized groups of any type including large clinics, educational facilities, and anyone else with whom dialogue and cooperation would further activities for physicians and patients in the State of Minnesota. The grass-roots advocacy network described above is important to encourage our members to collaborate and interact with their local legislatures.

The county medical societies, particularly the staffed medical societies in the metro area, Lake Superior and Rochester, have an integral role in setting MMA policy through the House of Delegates, as well as encouraging physician participation both at the county level and at the MMA level through committee structures. The committee structure is the process where issues and initiatives are debated and acted upon. The county and specialty societies bring issues forth, as well as provide essential information and advocacy activities. It cannot be overemphasized how important and effective the cooperative advocacy of county and state organizations can be.

How can the MMA help improve access to health care for uninsured people?

The MMA has been an advocate for improved access for both uninsured and the marginally insured working poor for well over a decade. The MMA has prepared white papers and legislation encouraging a pluralistic entry point system for health care access based on income level. While we have argued about funding mechanisms for MinnesotaCare, that program combined with GAMC and Medicaid, has provided Minnesota with among the lowest uninsured population in the country. The recent budgetary problems have dropped 38,000 people from insurance programs, which is of concern to us. There is no question that the current health care funding system is approaching the breaking point and a private-public partnership has been the best mix of programs to decrease the number of uninsured. Whether this mix will be sustainable as business continues to decrease its participation in the traditional employer based system remains to be seen. The funding mechanisms may change, but the MMA continues to advocate for a system that allows full access to the health care system.

MMA needs to improve its grass-roots, legislative network and collaboration with county and specialty societies.

What are the MMA’s plans to do this?

Even though the MMA has developed principles to guide the development of a health care system that covers all Americans, and the AMA has developed a plan for Universal Health Insurance, no significant progress has been made towards these goals. What do you think the role of the physicians of the MMA should be to achieve affordable health care for all Americans?

The Task Force recommendations, which are very sweeping and encompass activities on many fronts, seeks to address the necessity of cooperation and advocacy at the grass-roots level as I had mentioned above, as

No one system has emerged as the obvious choice to provide universal access to health care. Any system that is designed must accept the reality that we can no longer pay for all the care that people would like,

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January/February 2004

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

whether that system eventually will become a regulated utility model, such as the German or the Dutch system; a strict single payer system, such as Canada; a single payer with supplemental private insurance, as in England; a system that allows individual insurance and MSAs, or a hybrid of all of these, is difficult to say. The MMA and the AMA have a very diverse membership and have always advocated for a system that allows flexibility and purchasing options for individuals within whatever system is created. As I stated above, there is no question that the current system in the United States, which has significant cost shifting among various segments of the population, is approaching an unsustainable level.

The Minnesota Medical Association is currently participating in the Governor’s Citizen’s Forum on Health Care Costs, as well as meeting with key legislators, such as Representative Fran Bradley, Chair of Health and Human Services Committee. Both of these groups have been supplied with an extensive list of short- and long-term cost containment recommendations, which will be forwarded to these and other groups.

We intend to remain fully engaged with agencies struggling with the difficult task of improving access to health care at an affordable cost.

Do you see ways to utilize the experience and time of retired physicians in serving the citizens of Minnesota?

Retired physicians in Minnesota are a large untapped resource. In my opinion, it would be in Minnesota’s best interest to foster and utilize these physicians’ talents for the good of the state. As we struggle with rising costs and uninsured, we will have to look to volunteer care to fill gaps for underserved people. That would require a type of insurance indemnification program, perhaps run through the state, providing physicians with liability coverage for their activities that benefit society.

As physicians’ practices slow down and their families are grown, they have more time to devote to organized medicine, as many of them do now, which provides this association with the great contribution of wisdom and experience of our older members.

How do you envision the construction and monitoring of regular meetings with Minnesota health plans and regulatory agencies?

The MMA currently has regularly scheduled meetings with the health plans, the Minnesota Council of Health Plans, as well as regulatory agencies. We are attempting to keep the agendas focused and productive, letting each group know the issues and activities planned so that in areas of agreement we can work collaboratively. Where disagreement exists, we attempt to negotiate solutions before involving the legislature for we all know there is the law of unintended consequences whenever the legislature gets into the mix. Where fundamental disagreement occurs, certainly we use all of our resources to advocate on behalf of physicians, including legislative and legal relief.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

During your inaugural speech, you talked with great passion regarding your experiences in medical missionary work. Please describe what benefits this important work brought to you and your family. Do you have recommendations to make to your colleagues or individuals in medical schools and residencies?

One of the benefits of the inaugural speech, in addition to recognizing the achievements and 150-year history of the MMA, was the opportunity to utilize the communication vehicles to foster and assist physicians’ desires to perform volunteer medical missionary work in underserved areas of the United States and Africa.

As I said during this portion of the speech, the experience that I had in 1983, when Jodi and I were in Cameroon for a year, as well as the experiences that my family and I have had on medical missionary trips to Kenya, have had a profound influence on my children. Besides a keen appreciation of the humanity and generosity of people who have less than we do, the trips have also fostered a desire in all of my children to become involved in medical and global initiatives, in whatever field they choose. While I was working at the hospital, they were volunteering in projects at the primary school or at feeding stations and, in fact, spent more time with the Kenyan people and learned their language better than I did. I am very excited about the Web initiative of the MMA. There are a multitude of organizations that perform this work that are fragmented across religious, organizational and governmental lines.

The Web site will allow physicians not only access to each of these organizations and their Web sites but also vignettes regarding each of the locations provided by Minnesota physicians and a contact person to answer any further questions that people would have regarding language, geography and whether the location is family friendly or not.

As an aside, I would also like to see an effort within the University of Minnesota and its residencies to encourage younger people during their periods of training, when they have perhaps fewer family responsibilities, to take a rotation or a period of time in one of these regions. I can say categorically that you will get more out of it than you give and the experiences will last a lifetime. To those whom much is given, much is expected. I hope that this MMA initiative will encourage physicians to spread the talents that they have been given to those who are less fortunate and I am enthusiastic about MMA’s commitment to the project. ✦

January/February 2004

13

Medicare Reform: The Long, Hard Slog

sion to take on the issue of major Medicare Reform. They made this decision even though the Majority party in the House had only a 23 vote margin (229 – 205, with one independent who regularly votes with the Minority) and the Majority party in the Senate had only a two vote margin (51 – 48, with one independent who regularly votes with the Minority). As a result, there were two Medicare Reform bills before the Congress — the House version H.R. 1, the Medicare Prescription Drug and Modernization Act of 2003, and the Senate version, S.1, the Prescription Drug and Medicare Improvement Act of 2003. (Go to http: //thomas.loc.gov for copies of the bills and status summaries.)

The House Medicare Reform version was sponsored by Speaker Dennis Hastert (R-IL14th) and is 747 pages long. The chief architects of the House Medicare Reform bill were Ways and Means Committee Chairman Bill Thomas (R-CA-22nd) and Energy and Commerce Committee Chairman Billy Tauzin (R-LA-3rd). The

Senate Medicare Reform Bill was sponsored

by Senator Majority Leader Bill Frist, M.D. (R-TN), a general and cardiac surgeon, and is 1,044 pages long. Its key architect was Finance Committee Chairman Chuck Grassley (R-IA).

When the two bodies produce and pass bills that are not identical but address the same issues, both bills are sent to a conference committee, where the two bills are hammered out and then resubmitted to both bodies for approval. In this instance Congressman Thomas was the chairman of the conference committee detailed to hammer out the final version of the Medicare Reform bill with Senator Grassley being the Vice-Chairman.

The two documents differed in many respects but most notably, the Senate version kept Medicare as primarily a federal government financed and administered program whereas the House version maintained federal financing of the program but, beginning in 2010, competed the administration of the program by the federal government with the private insurance industry.

While discussing the pros and cons of this process would be a very challenging intellectual exercise, that is not the purpose of this monograph. Instead, we would like to focus on five issues of importance to the physician community and suggest ways in which physicians in the Twin Cities of Minneapolis and St. Paul could go about influencing the ever-continuing Medicare Reform process in Washington.

The issues we would like to discuss are: the 1.5 percent physician payment update, the geographic payment adjustment floor, the incentive payment enhancements for rural providers, the gradual phase-in of electronic prescribing standards, and the reimportation of prescription drugs, all of which are being considered for inclusion in the final Medicare Reform Bill,

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Editor’s Note On Saturday, November 22, the U.S. House of Representatives adopted the Medicare Conference Report to H.R. 1 by a vote of 220 to 215. Votes of the Minnesota delegation were as follows: • Voting in favor – John Kline R-2nd District, Jim Ramstad R-3rd District, Mark Kennedy R-6th District, Collin Peterson D-7th District.

• Voting against – Gil Gutnecht R-1st District, Betty McCollum D-4th District, Martin Sabo D-5th District, James Oberstar D-8th District.

On Monday, November 24, the U.S. Senate approved the Medicare Conference Report to H.R. 1 by a vote of 54 to 44. Votes of the Minnesota Senators were: Norm Coleman voted in favor; Mark Dayton voted against. As of press time, the bill is awaiting the signature of President Bush.

The next issue of MetroDoctors will include a comprehensive analysis of the Medicare legislation from the Minnesota Senior Federation and from the AMA .

F

FRONT AND CENTER in last year’s Congressional debate was the problem of Medicare, or rather the reform of Medicare. Without stating specific numbers, suffice it to say that Medicare, America’s single payor system for its senior citizens, costs a lot, and with the baby boomers of the 1940s, 1950s, and 1960s coming of age it will cost even more, and the pool of available money per beneficiary will be even less. Indeed, one pundit recently argued that today, for every one Medicare beneficiary there are three taxpayers available to pay the bill, and that sooner than we want to admit the pyramid will invert and, for every one paying taxpayer, there will be three Medicare consumers!

Being more than aware of this fiscal dilemma, as well as more than aware of the fact that American seniors consistently vote, the Congressional leadership decided last ses-

BY JOEL ARNEY, M.D. AND JAMES SIEBEN, J.D.

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January/February 2004

currently before the Medicare Reform Conference Committee. It is our view that all of these provisions are essential to genuine Medicare reform and must be included in any Medicare reform bill. The provisions are summarized as follows: 1.5 Percent Physician Payment Update

The House bill provided a modest minimum 1.5 percent physician payment increase for each of the 2004 and 2005 updates. Medicare payments to physicians and other health professionals were cut by 5.4 percent on January 1, 2002, and Congress narrowly averted a similar cut for 2003. The Center for Medicare and Medicaid Services (CMS) recently announced an additional 4.2 percent cut on January 1, 2004, and projects further cuts until at least 2007. Over the last 10 years, Medicare fees increased an average 1.1 percent per year. Data from the Medical Group Management Association (MGMA) indicates that the cost of operating a group practice rose by an average 4.1 percent per year over this same period. In fact, in just the last year, new MGMA data shows that operating costs increased approximately 7.5 percent. Although better than the scheduled cuts, the trend of decreasing reimbursements relative to practice costs and inflation continues unashamedly, forcing further cost shifting to private payors. The discrepancy between real costs and Medicare reimbursements is just plain unsustainable.

Geographic Payment Adjustment Floor

Both bills included provisions setting a floor to the geographic adjustments to physician payment rates, although the Senate bill set a floor for more of the components of the payment rate formula. Currently, these adjustments unfairly attribute higher costs to urban areas outside of rural states, such as Minnesota, by using proxy data that does not accurately reflect the costs of delivering medical services in most areas of the state. A classic example of this lies in our own backyard, with the average Medicare reimbursement per enrollee in Minneapolis being $3,431 and in Miami, $8,414. By establishing a floor for the geographic practice cost indices in the formula, rural states such as Minnesota, will be able to better compete in the national

MetroDoctors

AMA Celebrates Passage of Historic Medicare Bill Statement Attributable to: Donald J. Palmisano, M.D., J.D., AMA President “Today’s Senate passage of the Medicare bill is a historic victory for Medicare patients and their physicians. This Thanksgiving, Congress and the Bush Administration have given America’s seniors a Medicare bill for which they can be truly thankful.

“There are so many positive provisions in this bill. All Medicare patients will be eligible for a long overdue prescription drug benefit, and the neediest patients will receive the most assistance. All Medicare patients will receive a greater choice of health plans. Health savings accounts, which empower patients to have greater control over their health care decisions, will become a more attractive option for all Americans.

“This truly significant legislation also enhances access to care for seniors by halting Medicare cuts to physicians and other health professionals for the next two years. Instead of cuts, the Medicare bill provides at least a 1.5 percent increase in payments in 2004 and 2005. For next year, this represents a 6 percent difference in Medicare payments at a time when physician practice costs are on the rise.

“Patients also will benefit from a comprehensive package to strengthen health care in rural and underserved areas. This bill will reduce payment disparities in parts of the country where physician services are in great need and short supply. It also provides regulatory relief, so physicians can spend more time with patients and less on paperwork.

“The AMA applauds Congress for giving America’s seniors and disabled greater access to prescription drugs and medical care and increased choice under Medicare. We look forward to President Bush’s signature on this historic bill and to a stronger Medicare program for our nation’s seniors.”

market for medical professionals. They will also be better able to acquire technology to provide equitable care for their Medicare patients. A genuine Medicare reform bill must contain a geographic payment adjustment floor.

Incentive Payment Enhancements for Rural Providers

Both bills also included incentive payment enhancements for rural providers. These enhancements include increased government notification to providers in health professional shortage areas as well as a new 5 percent incentive payment to providers in primary and specialty care scarcity areas. Both provisions will enhance the ability of physicians, in rural states like Minnesota, to provide quality care.

However, the net effect will be to stop the reimbursement cuts relative to practice costs for only about a year. A genuine Medicare reform bill must contain incentive payment enhancements for rural providers.

The Journal of the Hennepin and Ramsey Medical Societies

Gradual Phase-in of Electronic Prescription Standards

Both bills encouraged electronic prescribing as a way of reducing medical errors and improving patient safety. However, because the current technology is in its infancy and remains unproven, the conferees must adopt the Senate framework, which is to develop uniform standards without a requirement to receive or transmit prescriptions electronically. Additionally, these standards must be developed as a result of a deliberative process, which includes input from practicing physicians to ensure the new, voluntary standards are workable and appropriate.

Reimportation of Prescription Drugs

HR 2427, the Pharmaceutical Marketing Act of 2003, authored by Congressman Gil Gutknecht (R-MN-1) and passed by the House (Continued on page 16)

January/February 2004

15

Medicare Reform (Continued from page 15)

by a margin of 243 – 186 must be included in the final Medicare conference report thereby allowing the reimportation of FDA-approved drugs made in FDA-approved facilities in order to give seniors and other Americans access to low-priced prescription drugs. States such as Minnesota, Iowa, Wisconsin, and Illinois have already taken steps to lower their prescription drug bills through reimportation. The conferees must not produce a conference report that does not have real reimportation provisions.

While this is a stopgap solution to the prescription drug problem, and the potential response of the major drug manufacturers should be of concern, unless and until a viable prescription drug benefit is incorporated into the Medicare program, this will have to suffice.

Regional and metropolitan medical centers, as well as ambulatory surgery centers, in the greater Twin Cities area treat a large percentage of Medicare patients who, because of their advanced age, are among the most vulnerable patients and the patients most in need of care. As a result, if, at minimum, the five Medicare “fixes” identified above are not enacted, groups may be forced to reduce the number of physicians in their practices and, either hand-off more of their Medicare patients to less trained non-physician providers who are already in short supply, or reduce the number of Medicare patients treated at the facilities they service. Either response provides a quality and an access problem for Medicare, as well as our non-Medicare, patients.

Some readers may believe that since these fixes do not correct Medicare long-term, that they should not waste their valuable time advocating them to their federal Senate and House members. Although these reforms are limited and do not solve the longer-term Medicare problems, they are politically achievable. Real Medicare reform is unlikely to occur until we, as a nation, are facing a cataclysmic event. The political reality is that physicians gain or lose control of the health care system by political incrementalism. If we fail to fight the tactical battles (the five “fixes” identified above) along the way, then we will surely lose the strategic goal of shaping a health care system that our patients value and in which we enjoy working.

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What can we do to continue to encourage the inclusion of the 1.5 percent physician payment update, the geographic disparities floor, the incentive payment enhancements for rural providers, the gradual phase-in of electronic prescribing standards, and the reimportation of prescription drugs, in the final Medicare Reform Bill? Three things — educate ourselves on these issues, communicate our positions to Senators and members of the House of Representatives, and provide political support to those members of the Senate and House of Representatives who are in positions of authority on these issues and demonstrate a desire to be helpful to us.

Three ready sources of education on these Medicare Reform issues are easily accessible.

They are the Medical Group Management Association (MGMA) Web site at http:// www.mgma.com, the American Medical Association (AMA) Web site at http://www.amaassn.org/ama/pub/category/6583.html, and the Medicare Justice Coalition (MJC) Web site at http://www.mnseniors.org/.

The best way to communicate positions on issues to Senators and members of Congress is to mail (and simultaneously fax — the U.S. Capitol Complex still has mail problems) them a position letter (not an e-mail), 1-2 pages maximum in length on personal (not business — unless you are a business) stationery, outlining who you are, where you practice, what issue(s) you are concerned with (bill numbers are preferred), what your positions on the issues are, and how these issues will affect your practice. Make sure you thank them for taking the time to review your letter and provide them with a phone number where they can contact you, should they have follow-up questions or comments. You should then reinforce your letter by a personal contact of some type — visit their offices, talk to them at a town hall meeting, meet them at a public event — or, better yet, attend an organized medicine sponsored leadership conference in Washington, D.C. and visit them on their own turf!

The best way to show your political support for any elected official is to contribute money to their re-election campaign. With the demise of the political parties, and the rise of direct candidate to consumer political advertising, the American electoral process

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has changed from being a solemn decision making process to a continuous media event.

Therefore, the cost of candidates to get their messages separated out from all the other messages is astronomical.

When contributing to office holders, avoid the three biggest mistakes in political giving — only giving to people in your own district or state, only giving to office holders of your own political party, and never giving to an office holder who at one time or another may have supported a position contrary to yours.

Remember what former California Assembly Speaker Jesse Unruh once said, “If I’d slain all of my political enemies yesterday, I wouldn’t have any friends today.” (California Journal’s Political Action Handbook, California Journal Press, Sacramento, 1995 at 17.)

The real issue ultimately is not whether to contribute, but how much to contribute and who to contribute it to. Treat your political portfolio like your stock portfolio. Always contribute to your blue chip office holders in reasonable amounts but don’t be afraid to take some occasional risks and give to a Senator or member of Congress who might not be your idea of a blue chip office holder — in hopes that the person will be of assistance on some future issue at some point.

The bottom line of all political activity is that being a policy wonk is great, but unless you can transform your ideas into realities, in the current political system as it is, your ideas will be just that — ideas, and, as we all know, ideas are like sphincters — everyone has at least one! ✦ Joel Arney, M.D., is currently the Chief of Anesthesia at Fairview Ridges Hospital in Burnsville and is a partner with Ridges Anesthesiology, P.A., the physician anesthesiology practice group serving Fairview Ridges Hospital. Dr. Arney may be reached at joelarney@hotmail.com.

James Sieben, J.D., is admitted to practice before the Minnesota Supreme Court as well as at all levels of the federal judiciary, including the US Supreme Court. He is currently the Government Relations Attorney for Health Billing Systems, L.L.C., a health professional practice management firm located in Minneapolis. Mr. Sieben may be reached at jsieben@hmadoc.com.

The Journal of the Hennepin and Ramsey Medical Societies

Medical Group Quality Data: a Reality

M

MINNESOTA’S MEDICAL GROUPS and health plans are working together to make Minnesota the place to receive top quality health care. This new, collaborative approach to quality measurement will provide Minnesota medical practices with better quality of care information than has previously been available. The idea for the project started in 2001 when health plan sponsors of the Institute for Clinical Systems Improvement (ICSI), along with the Minnesota Council of Health Plans (MCHP), began discussing a collaborative approach to health care quality improvement.

The result is the Minnesota Community Measurement© Project. In addition to supporting medical group quality improvement work, goals of the project include: • reduce reporting-related work at clinics; and • maintain the ability to report by health plan as required by law.

Project Structure Funding is through MCHP, and in part, through a grant from the Center for Disease Control and Prevention. Overall direction has been developed by a steering committee that includes medical directors from each health plan, two medical group practices, representation from the National Council on Quality and Accreditation (NCQA) and MCHP. An operations committee with measurement and data expertise provides technical know-how and works out the many complexities involved. A Medical Group Advisory Board (medical directors and quality leaders representing medical group practices) provides input on project policy, direction and communication.

As with any change, questions arise. Here are answers to some of the most common quesBY GAIL M. AMUNDSON, M.D., AND JOHN FREDERICK, M.D.

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tions from physicians regarding the Minnesota Community Measurement© Project.

Q. Why do health plans need to review medical group work?

A. The review is required by law. In order to be licensed in Minnesota, health plans must report to regulators on many issues. Among these reports is a requirement that health plans document the care health plan enrollees receive from medical groups.

Q. What is different about this reporting?

A. Until now, medical practices have not had useful data on their quality-of-care performance. Collected data was specific to individual health plans but not specific to medical group performance. This overview provided little guidance where care is delivered — in individual medical practices.

Q. Why was diabetes the focus of the first report?

A. Outcomes for patients with diabetes can be dramatically improved when treatment targets are met. Because of this, diabetes was selected by the physicians with the Institute for Clinical Systems Improvement (ICSI) as its focus for improving care. It made sense to support the effort of ICSI. The purpose of the pilot was to test a technique of measuring and reporting that would yield reliable information for medical practices.

Q. Overall, how and why were the measures selected? Some measures haven’t been proven to be cost-effective.

A. HEDIS measures that could be reported using the Community Measurement attribution methods were selected for reporting in 2003,

The Journal of the Hennepin and Ramsey Medical Societies

in addition to the ICSI standards for diabetes care. While HEDIS measures are not perfect and not where we believe future performance measurement needs to be, HEDIS measures are current industry standard measures for assessing quality. We believe the Community Measurement project’s emphasis on quality of care will encourage more physicians to practice evidenced-based medicine. Ultimately, improving the quality of care is cost-effective.

Q. How is the measuring and reporting accomplished?

A. Physicians and medical groups need support to improve care. To be successful, it was necessary to develop common methodology across health plans as well as a common way of describing medical groups and the patients under their care. A data sampling method that takes into account the wide variation in the size of Minnesota practices was also developed.

Q. How do we know the data is statistically valid?

A. NCQA, a nationally recognized leader in health care quality, approved the methodology and selected the sample. An independent statistician is providing the numbers.

Q. Why aren’t public medical group comparisons available now?

A. We needed two years to develop, test and retest the technique to make sure the data is fair, accurate, reliable and credible. Currently, blinded medical group-by-medical group results are provided to participating medical groups. In fall 2004, we anticipate the information will be reported publicly.

(Continued on page 18)

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Medical Group Quality Data (Continued from page 17)

Q. How were the participating medical groups selected?

A. Medical groups with 60 or more patients with diabetes, the number needed to create a valid sample, were included in the 2002 pilot.

Q. There are more than 50 medical groups in the state. How can my clinic become part of the project?

A. Right now, the project is focusing on primary care groups that meet minimum sample size for diabetes.

Q. Will results be available on individual doctors or specific clinic locations?

A. Medical group practices with more than one clinic will receive one report. For example, Allina, Park Nicollet, Fairview, or other large systems will receive one report, not a separate report for each clinic location. The goal of the project is to help medical groups implement

system-wide changes including registries, procedures, training, computer systems, etc. to help improve care. Physician-specific information is not collected.

Q. What results are available to medical groups now?

A. Participating primary care groups received the pilot results listed below in January 2003 either by mail or during an in-person presentation. The pilot report was based on 2001 data.

Participating medical groups received the latest results, based on 2002 data, at a November 19, 2003 meeting. Medical groups not represented at the meeting received the results via mail.

• percentage of patients with HbA1c less than or equal to 8.0 • percentage of patients with LDL-Cholesterol less than 130.

• percentage of patients with blood pressure less than 130/85 • percentage of patients over age 40 taking aspirin • percentage of patients known to be nonsmokers

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• percentage of patients with annual screening for kidney and eye complications • Percentage of patients with optimal diabetes care.* *Note: The optimal diabetes care rate means individual patients reach all of the first five targets.

An optimal care rate using modified ICSI Diabetes Guideline treatment goals was also reported in 2003 (HbA1c at or below 7.0, LDL-Chol less than 100 and blood pressure less than 130/80).

Along with the second year of diabetes data, many medical groups received data on common preventive and chronic condition care measures. These are nationally recognized HEDIS measures and include: • Children’s Health: childhood and adolescent immunization rates; well child visit rates; • Women’s Health: breast and cervical cancer and Chlamydia screening rates; and • Hypertension, asthma and depression treatment rates; All participating medical groups did not receive results on all measures because some groups do not have enough patients to meet valid sampling requirements. Publicly, results will be reported at a statewide level and will include low and high details. Medical groups will not be identified this year.

The measures reported are standard HEDIS definitions. These measures are collected as required by the state. The Community Measurement project is reporting the information back to medical groups, a step that has not happened in the past. Although HEDIS may not be the measures that the provider community or the Community Measurement Project wants to focus on long term, it is what is currently collected. This type of data collection is required to take place each year and reflects the current state of quality measurement. Measuring and reporting quality is a work in progress; it is not perfect. Community Measurement Project participants believe that medical groups deserve to see that the information is reported based on the care they deliver. Through collaboration and time, the project’s Steering Committee and Medical Group Advisory Board hope to improve measures so that they are more clinically useful than the current HEDIS set.

The Journal of the Hennepin and Ramsey Medical Societies

Q. How is product mix/risk adjustment communicated in the results?

Q. Does this project have the support of Minnesota’s physicians?

A. Medical groups were given the distribution of patients in their sample in commercial managed care, Minnesota’s Medicaid program, (Minnesota’s General Assistance Medical Care, MinnesotaCare), Medicare or the Minnesota Senior Health Options products.

A. The Minnesota Medical Association’s Quality of Care and Practice Committee fully supports the project, as did the MMA’s executive committee. The ICSI board formally endorsed public comparative performance reporting.

ICSI is very interested in the results as it will be a large part of assessing the effectiveness of ICSI to sponsoring health plans and participating medical groups. NCQA also supports the project, as does the Center for Disease Control and Prevention.

Q. What is a reasonable goal for optimal diabetes care or HEDIS measures?

A. Of course, 100 percent is not achievable for the optimal diabetes care; patients may decline tests or treatment, goals may not be reachable despite ideal therapy or a patient may not have a prescription benefit, for example. Minnesota’s best performing medical group is at 25 percent, the benchmark.

Q. How do medical groups use the data?

A. Medical groups are using the information in employee orientation and training programs to help spur improvements in the health care system. This type of data is also helpful as computer and other office systems are updated.

More details on use of the data will be available as the project matures.

Q. How should consumers use this information when it’s available to them in 2004?

A. Consumers are encouraged to talk to their physicians and work with their health care providers to get the best possible care outcomes.

Q. What specific steps are taken to ensure patient privacy?

A. The data does not include any information that could identify patients.

Q. How and when will the information be available to purchasers? What should they do with the information?

A. We expect medical group-specific information will be available in the Fall 2004. Currently, information is available on a statewide level. Employers may use the information to help teach employees about what it means to receive quality medical care. For example, a company newsletter could highlight the key elements of great diabetes care and how individuals can work with their physicians.

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Q. Why will it be released publicly if it’s for improving care provided by physicians?

A. The best quality improvement work takes place when you know where you are, and where you are in comparison to others. Also, in an effort to make sure the data is released fairly and accurately, the Community Measurement Project will release the results itself versus having numbers come from various organizations

at different times. No medical group-specific information will be released until the fall 2004, reporting 2003 data.

Q. How will this be used to determine reimbursement or physician pay?

A. Health plans and others may use the results as they would use any other information available to them. Medical groups and health plans would need to discuss this issue during contract negotiations. One organization not involved in the project has already asked medical groups to submit their first round of diabetes results so that awards can be given for top-quality care. ✦ Supported in part by contract # 200-95-0957; task order 052 from the Centers for Disease Control and Prevention.

Gail Amundson, M.D., is the associate medical director of quality utilization management at HealthPartners. John Frederick, M.D., is the medical director at PreferredOne.

Minnesota Community Measurement© Project Leadership Steering Committee Gail Amundson, M.D., HealthPartners; Dawn Blomgren, M.D., Northwest Family Physicians; Janny Brust, Minnesota Council of Health Plans; Craig Christianson, M.D., UCare Minnesota; Charlie Fazio, M.D., Medica; John Frederick, M.D., PreferredOne; Doug Hiza, M.D., First Plan of Minnesota; Arthur Puff, M.D., Metropolitan Health Plan; Steve Richards, M.D., Blue Cross and Blue Shield/Blue Plus of Minnesota; Joachim Roski, NCQA; and David Yauch, M.D., Aspen Medical Group Dr. Linda Walling is newly elected medical group Steering Committee representative replacing Dr. Dawn Blomgren.

Medical Group Advisory Board Richard Gebhart, M.D., Camden Physicians; David Tilstra, M.D., CentraCare; Tom Rolewicz, M.D, Columbia Park Medical Group; Linda Walling, M.D., HealthEast; Julie Blehm, M.D., MeritCare; Wanda Hanson, MeritCare; John English, M.D., MN Health Care Network; Bruce Penner, North Star Physicians; Latania Carey, M.D., Pilot City Health Center; Tom Nelson, M.D., St. Mary’s Duluth; Hugh Renier, M.D., St. Mary’s Duluth; Andrea Carruthers, Affiliated Community Medical Center; Burnell “BJ” Mellema, M.D., Affiliated Community Medical Center; Bruce McCarthy, M.D., Allina; and Mary Michener, M.D., Winona Clinic.

Participating Health Plans Blue Cross Blue Shield/Blue Plus of Minnesota, First Plan of Minnesota, HealthPartners, Medica, Metropolitan Health Plan, PreferredOne, and UCare Minnesota.

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2004

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Disease Management: A Leap of Faith to Lower-Cost, Higher-Quality Health Care With managed care’s promise to reduce costs and improve quality waning, employers and health plans are exploring more targeted ways to control rapidly rising health costs. Disease management programs, which focus on patients with chronic conditions such as asthma and diabetes, are growing in popularity, according to findings from the Center for Studying Health System Change’s (HSC) 2002-03 site visits to 12 nationally representative communities. In addition to condition-based disease management programs, some health plans and employers are using intensive case management services to coordinate care for high-risk patients with potentially costly and complex medical conditions. Despite high expectations, evidence of both disease management and case management programs’ success in controlling costs and improving quality remains limited.

Rising Costs Set Stage for Disease Management In response to employers’ requests to slow rapidly rising health care costs in the early 1990s, many managed care plans limited patients’ choice of physicians and hospitals and required prior approval for certain high-cost services.

But consumers and physicians rebelled against tightly managed care, prompting a powerful backlash. Faced with a tight labor market in a booming economy, many employers moved away from tightly managed care and directed health plans to expand provider networks and ease restrictions on care. Due in part to these changes, health spending and insurance costs began rising rapidly again in the late 1990s.

BY ASHLEY C. SHORT, GLEN P. MAYS, AND JESSICA MITTLER

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January/February 2004

The retreat of tightly managed care, coupled with the economic downturn, has left employers with few tools to rein in costs other than increased patient cost sharing. Many employers admit that shifting health care costs to workers is a temporary fix at best, and they are seeking other options. As a result, more employers and health plans are exploring disease management and intensive case management as potential tools to help control costs and improve quality.

Targeted Care Improvement In the U.S. health care system, about 10 percent of patients — typically those with chronic or complex medical conditions — account for about 70 percent of overall health care spending.1 At the same time, research shows significant gaps between best medical practices that follow evidence-based treatment guidelines and the care many patients — especially those with chronic conditions — actually receive.2 The lines between disease management and intensive case management programs sometimes overlap, and both target individual patients for interventions with a goal of ensuring they receive appropriate care. While the two approaches share this feature, they also differ markedly.

Disease management programs typically identify a population of patients with a specific chronic condition, particularly those such as asthma and diabetes, where well-established, evidence-based treatment guidelines exist and patient self-care and compliance are important factors in managing the condition. Disease management interventions include sending patients educational materials about their condition and reminding them to adhere to prescribed medications or seek a preventive screening. Interventions also often include MetroDoctors

educational efforts, treatment guidelines and reminders aimed at physicians and other providers.

In contrast, intensive case management programs are typically highly individualized and focus on coordinating the care of high-risk patients with multiple or complex medical conditions — typically patients most at risk for hospitalizations and other potentially costly care. These patients might be treated by multiple physicians and have complex drug regimens, putting them at risk of adverse medical events if care is not coordinated well among different providers.

Many Players in the Field Hospitals and medical groups sometimes develop disease management programs for patients, particularly if the providers bear financial risk for patient care through capitation, or fixed per member, per month payments. As capitation has declined, development of disease management programs has fallen more frequently to health plans, third-party administrators (TPAs) who administer self-insured employers’ benefit plans and, increasingly, specialty disease management vendors.

Employers that purchase fully insured products typically rely on health plans to decide whether to offer disease management programs and the range and nature of the programs. Health plans, in turn, choose whether to develop these programs in-house or to contract with vendors who specialize in disease management services. By contrast, self-insured employers decide directly which disease management programs, if any, to offer their employees and dependents. Self-insured employers can purchase disease management programs from health plans, TPAs or specialty vendors, allowing these employers to The Journal of the Hennepin and Ramsey Medical Societies

avoid purchasing programs unsuited to their particular workforces.

Disease Management Trends Continuing the trend noted in the last round of HSC site visits3, health plans in 2002-03 expanded their array of targeted, disease-specific programs (see Data Source). Plans in at least half of the 12 sites have added new disease management programs in the last two years or are preparing to do so. Several plans have increased outreach activities to boost participation by eligible members — a problem area noted by health plans two years ago. In Seattle and Greenville, two plans that already offered disease management in their health maintenance organizations (HMOs) have added the service to other managed care products.

Increasingly, many large employers have concluded that the traditional array of disease management programs may not address the most prevalent and costly conditions in their specific workforces. For example, two large private employers reported that their health plans’ standard disease management targets, such as congestive heart failure, were a poor fit for their younger workers’ needs. These two employers have now identified employees’ most prevalent conditions and negotiated with plans to offer programs targeted at these conditions, such as high-risk pregnancies.

Other public and private employers in at least four sites are examining their health claims experience to identify and target high-cost conditions unique to their workforces. One large New Jersey employer provides workers with evidence-based clinical management for about 40 serious conditions, resulting in one in five patients moving to more effective treatment plans. In pursuit of more customized programs, a few large, self-insured employers are purchasing programs directly from specialty disease management vendors. For employers, this arrangement has the added advantage of providing access for all of their employees, regardless of each employee’s individual health plan or location.

New Focus on Intensive Case Management Services Uncertain about the yield from conventional disease management programs, some plans and employers are looking at intensive case manageMetroDoctors

ment programs that focus on the individual health care needs of high-risk patients, often with multiple or complex conditions, such as lupus or cystic fibrosis. Increasingly, plans and a sophisticated subset of employers are identifying candidates prospectively for case management programs through predictive modeling applications that use health care claims data or surveys to identify patients who are likely to generate significant health care costs.

By identifying high-risk patients prospectively, plans and employers hope to lower future health care costs by avoiding delays in needed care, improving care coordination, eliminating redundant care and encouraging self-management of health conditions. Most health plans and employers have begun to experiment only recently with intensive case management and predictive modeling, and their approaches vary widely.

In northern New Jersey, one program focuses specifically on identifying and managing members who are at increased risk for hospitalization, while a plan in Cleveland identifies high-risk patients based on their expected future health care costs. Several health plans also actively encourage physicians to refer patients with complex health conditions to case management programs, particularly patients who have difficulty complying with treatment recommendations and self-care protocols. In some markets, such as Seattle and Syracuse, TPAs have implemented mandatory case management programs for selfinsured employers that are triggered when a patient’s health care claims exceed a specified cost threshold. In some cases, reinsurers have encouraged or required self-insured employers to use case management programs to reduce the cost of stop-loss coverage for high-cost patients.

In most cases, health plans have introduced intensive case management and predictive modeling applications alongside traditional disease management programs.

These plans view individually focused case management programs as “filling in the gaps” of their disease management offerings and improving service for patients with health care needs beyond existing treatment protocols.

In some cases, however, health plans have adopted intensive case management as an alternative to or replacement for traditional disease

The Journal of the Hennepin and Ramsey Medical Societies

Data Source Every two years, HSC researchers visit 12 nationally representative metropolitan communities to track changes in local health care markets. The 12 communities are Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. HSC researchers interviewed key individuals in each community, including representatives of health plans, employers and other stakeholders.

This Issue Brief is based on analysis of these individuals’ assessments of disease management and intensive case management activities in the 12 markets. management programs regarded as ineffective or benefiting only limited numbers of patients.

A Seattle health plan that discontinued most disease management programs, including ones for diabetes, asthma and cardiovascular disease, replaced them with an intensive case management program linked to predictive modeling.

One Miami health plan chose to emphasize intensive case management rather than disease management in its Medicare+Choice product because of the large number of elderly patients with multiple health conditions who potentially could benefit from more coordinated care.

Still other plans are moving to more flexible care management strategies that allow even fully insured employers to choose specific types of interventions for their workers. For example, one Seattle plan recently introduced a new line of products that allows employers to select from a range of disease management, case management and wellness education options.

Evidence of Cost Savings, Improved Quality Limited Although interest in targeted, condition-specific disease management programs is growing, evidence of their clinical and cost effectiveness remains limited. Like other innovations (Continued on page 22)

January/February 2004

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Disease Management (Continued from page 21)

in health care delivery and management, disease management programs are difficult to evaluate systematically because they are rarely implemented consistently across health plans and vendors and often evolve over time. Much of the research evaluating disease management programs has focused on programs targeting three conditions — diabetes, asthma and congestive heart failure. Several studies have demonstrated that specific disease management programs can improve patient care and reduce service utilization, but the evidence varies widely across health conditions and types of interventions.4 There are many challenges in evaluating the cost effectiveness of disease management.

Most health plans are interested in programs that can produce relatively short-term reductions in health care utilization and costs, because high membership turnover makes it difficult for plans to capture longer-term savings. Employers, however, may value longerterm results beyond those of interest to health

plans, such as reductions in absenteeism and work-related injuries and improvements in worker productivity and satisfaction. As a result, employers and health plans may reach different conclusions about the value of offering disease management programs.5 Many health plans’ current experience with disease management programs is still too preliminary to assess how well they work, while plans that have made such assessments report varying results. The Seattle plan that jettisoned most of its programs in 2002 found that only one initiative — a prenatal care program for high-risk pregnancies — produced a positive return on investment and improved patient outcomes. The plan’s other programs reportedly were expensive to administer and served only limited numbers of members.

Other plans in Seattle, Greenville and Miami have found that some disease management programs can improve clinical performance or patient outcomes, though some still lack clear evidence of an economic return on investment. One insurer — convinced of the cost effectiveness — began offering lower premiums to fully insured employers that include disease

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and/or case management programs in their health plans. These assessments suggest that disease management programs are achieving desired results in some, but not all, health plan settings.

Like health plans, employers have difficulty evaluating disease management effectiveness. A few large employers initiating disease management programs independently of health plans have found evidence of program achievements. One employer that offered an evidence-based program to manage workers’ serious medical conditions found that one in 16 patients was misdiagnosed, creating meaningful opportunities to improve care.

This employer also reported saving more than $2 in health care costs for every $1 spent on disease management.6 Overall, however, relatively few employers have been able to assess the performance of disease management programs for their specific employee populations. In part, this is because health plans often do not have enough participants from any single employer to support employer-specific assessments, and many employers have not attempted to model systematically the health or economic effects of disease management activities on their workforce. Lack of consistent evidence of improved quality and reduced costs has prevented more rapid acceptance of disease management programs, according to some employers.

Like disease management, the effectiveness of intensive case management programs remains to be seen. Even if plans and employers can identify high-risk patients prospectively and enroll them in case management programs, there is no guarantee they will be able to offer interventions that reduce costs or improve care. Moreover, if plans and employers do find ways to manage high-risk patients successfully, targeted case management faces some of the same pitfalls that more traditional disease management programs do — namely, that competing objectives and member turnover could undermine the business case for investment.

Implications In theory, disease management and intensive case management programs offer health plans and employers opportunities to reduce health care costs and improve quality without resortThe Journal of the Hennepin and Ramsey Medical Societies

ing to restrictive utilization management or benefit reductions. In practice, disease management programs must demonstrate cost savings if they are to help slow rapidly rising health costs.

As former Congressional Budget Office Director Dan Crippen told Congress in 2002, “By helping diabetics manage their own care and by detecting problems earlier, those interventions could prevent much more costly treatments such as hospitalization or surgery.

If the total savings from avoided hospitalizations exceeded the costs of additional screening tests plus the administrative costs of the disease management services themselves, then total health care costs would be reduced.”7 The potential for both reducing costs and improving care helps explain why so many health plans and employers have invested in disease management despite relatively limited evidence of effectiveness. The disease management industry is growing rapidly, with specialty disease management companies’ annual revenues increasing from $85 million in 1997 to more than $600 million in 2002.8 Without many attractive alternative mechanisms to control costs, many employers are adopting disease management despite the lack of evidence. With their resources on the line, employers will make judgments about the effectiveness of these programs, no matter how limited the data. Recognizing this fact, the Disease Management Association of America has identified ongoing evaluation of clinical and economic outcomes as a core component of disease management programs. Moreover, the National Committee for Quality Assurance and the Utilization Review Accreditation Commission, which both accredit disease management programs, have set standards for measuring and improving the quality of these programs.

The growing enthusiasm for disease management has encouraged policy makers to examine whether these programs can control costs and improve care in public programs, including Medicare and Medicaid. A number of state Medicaid programs are experimenting with various disease management approaches, while the federal government has several Medicare disease management demonstrations underway. The limited amount of evidence on effectiveness is likely to make public programs MetroDoctors

more hesitant to move beyond demonstrations than is the case for private employers. But public payers may be more inclined to invest in research needed to evaluate effectiveness.

Disease management and intensive case management may prove to be especially beneficial in Medicare, given the prevalence of multiple chronic health conditions among beneficiaries who use the most health care services. In addition, traditional fee-for-service Medicare would encounter little of the membership turnover that challenges commercial health plans.

A key question yet to be answered is whether disease management is best delivered through the traditional Medicare fee-for-service program or through competing private plans. Indeed, this issue has become prominent in the current debate over Medicare reform, where some advocates of a larger role for private plans in Medicare cite the opportunity to make better use of disease management tools as a key argument in favor of this approach. ✦ Notes 1. Berk, Marc L., and Alan C. Monheit, “The Concentration of Health Expenditures Revisited,” Health Affairs, Vol. 20, No. 2 (March/April 2001).

2. Institute of Medicine, Crossing the Quality Chasm: A New Health System for the 21st Century, National Academy Press, Washington, D.C. (2001).

3. Felt-Lisk, Suzanne, and Glen P. Mays, “Back to the Drawing Board: New Directions in Health Plans’ Care Management Strategies,” Health Affairs, Vol. 21, No. 5 (September/October 2002).

4. Norris, Susan L., et al., “The Effectiveness of Disease and Case Management for People with Diabetes. A Systematic Review,” American Journal of Preventive Medicine, Vol. 22, No. 4 (May 2002); Georgiou, Archelle, et al., “The Impact of a Large-Scale Population-Based Asthma Management Program on Pediatric Asthma Patients and Their Caregivers,” Annals of Allergy, Asthma, and Immunology, Vol. 90, No. 3 (March 2003); Discher, Cheryl L., et al., “Heart Failure Disease Management: Impact on Hospital Care, Length of Stay, and Reimbursement,” Congestive Heart Failure, Vol. 9, No. 2 (March/April 2003).

5. Leatherman, Sheila, et al., “The Business Case for Quality: Case Studies and an Analysis,” Health Affairs, Vol. 22, No. 2 (March/April 2003).

6. Appleby, Julie, “Firms Offer Medical Data Services,” USA Today, Money Section (Jan. 22, 2002).

7. Crippen, Dan L., “Disease Management in Medicare: Data Analysis and Benefit Design Issues,” testimony before the U.S. Senate Special Committee on Aging, Washington, D.C. (Sept. 19, 2002).

8. Foote, Sandra M., “Population-Based Disease Management Under Fee-For-Service Medicare,” Health Affairs, Web Exclusive (July 30, 2003).

This Issue Brief is reprinted with permission from the Center for Studying Health System Change, Washington, D.C., www.hschange.org.

The Journal of the Hennepin and Ramsey Medical Societies

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January/February 2004

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PRES IDENT’S MESSAGE J. MICHAEL GONZALEZ-CAMPOY, M.D., Ph.D.

Thoughts on the Major Epidemic of this Century…

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RMS-Officers

LAST WEEK WAS A FUN WEEK for me. I

President J. Michael Gonzalez-Campoy, M.D., Ph.D. President-Elect Peter J. Daly, M.D. Past President Peter H. Kelly, M.D. Secretary Jamie D. Santilli, M.D. Treasurer Charles E. Crutchfield III, MMB, M.D.

was in Chicago, at the invitation of Arthur Elster, M.D., co-moderating the AMA Working Group on Managing Childhood Obesity, at the AMA headquarters. Art brought together an impressive group of interested parties, including representatives from the CDC, American Academy of Pediatrics, American Academy of Family Physicians, American Cancer Society, American Diabetes Association, American Dietetic Association, American College of Preventive Medicine, American Heart Association, American School Health Association, National Association of County and City Health Officials, National Association of School Nurses, National Assembly on School-Based Health Care, National Association of Community Health Centers, National Conference of State Legislators, National Medical Association, National Parent Teacher Association, National Recreation and Park Association, National Young Men’s Christian Association, Robert Wood Johnson Foundation, Society for Adolescent Medicine, and the AMA. It is scary to see the epidemic of obesity moving rapidly to the lower age groups, without a seeming end in sight. Our kids’ generation will develop diabetes and cardiovascular disease at a younger age than our parents’ generation. With this prospect in mind, the overwhelming consensus from the AMA Working Group is that our American society must aggressively treat obesity in children.

The optimal approach is one which encourages physical activity and improved nutrition, while involving the family, the school community, and the local governments. We now have evidence that pharmacotherapy is effective in teenagers, and must strongly consider its use as well.

Last week I was also in North Carolina, giving a lecture on obesity management. It was a wonderful conference that my colleague Bob Tanenberg, M.D. organized through the Brody School of Medicine of East Carolina University. North Carolina has obesity problems like

RMS-Board Members

Victor S. Cox, M.D., Specialty Director Gretchen S. Crary, M.D., At-Large Director, and MMA Trustee Laura A. Dean, M.D., At-Large Director James J. Jordan, M.D., Specialty Director Robert V. Knowlan, M.D., At-Large Director Bradley C. Linden, M.D., Resident Physician Charlene E. McEvoy, M.D., At-Large Director Ragnvald Mjanger, M.D., Specialty Director Robert C. Moravec, M.D., At-Large Director Jane C. Pederson, M.D., M.S., Specialty Director Lon B. Peterson, M.D., At-Large Director Thomas D. Siefferman, M.D., Specialty Director Stephanie D. Stanton, Medical Student Charles G. Terzian, M.D., Specialty Director & MMA Trustee David C. Thorson, M.D., Specialty Director Peter B. Wilton, M.D., At-Large Director RMS-Ex-Officio Board Members & Council Chairs

Brent R. Asplin, M.D., AMA Young Physician Section Blanton Bessinger, M.D., AMA Alternate Delegate Kenneth W. Crabb, M.D., AMA Delegate Robert W. Geist, M.D., Ethics & Professionalism Council Chair *J. Michael Gonzalez-Campoy, M.D., Ph.D. Education Resource Council Chair Rebecca Gonzalez-Campoy, Alliance President Frank J. Indihar, M.D., AMA Delegate Neal R. Holtan, M.D., Community Health Council Chair William E. Jacott, M.D., U of MN Representative Mark Kleinschmidt, Clinic Administrator *Lyle J. Swenson, M.D., Public Policy Council Chair Wayne H. Thalhuber, M.D., Sr. Physicians Association President *Also elected RMS Board Member RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive Officer Tracey Hallin, Executive Assistant Doreen M. Hines, Membership & Web Site Coordinator Sue Schettle, Director of Marketing & Member Services

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Minnesota does. The medical community there is mounting an organized campaign against obesity. I shared with our North Carolina colleagues the Minnesota experience. I was sad to tell them that obesity care is often NOT covered by third party payers and HMOs in Minnesota. There is consensus about treatment, but in Minnesota there is no consensus on coverage. There is a big difference between Minnesota and North Carolina: we have a heavy HMO dominance of the market, and North Carolina does not. Oddly, this difference makes it so that we can’t move in the direction of obesity treatment as expediently as our colleagues in North Carolina can. In Minnesota third party payers have been obstacles to overcome, not willing participants. Fortunately, there are interested individuals within each of these institutions that DO see the benefit of early and aggressive interventions, helping people manage their weights.

My tenure as your president of the Ramsey Medical Society is fast coming to an end. I want to be on the record, using this written vehicle, inviting our HMO and third party payer physician leaders to be part of the solution to this obesity epidemic. Up until now, we have made good progress, but we still have a long way to go. Five years ago obesity care was universally cut out of third party payer plans.

Now HealthPartners has instituted weight management counseling, and has started to cover some obesity drugs. It provides pedometers to patients. I was delighted to hear from Ted Loftness, M.D., that Medica will now help its members follow a more active lifestyle by covering membership dues for health clubs.

ICSI has now agreed to do an obesity guideline, and I appreciate the role that Gary Oftedahl, (Continued on page 26)

The Journal of the Hennepin and Ramsey Medical Societies

RMS IN ACTION ROGER K. JOHNSON, RMS CEO

Dr. James Reinertsen gave a lecture

The HMS/RMS Metropolitan Hospital Physician Leadership Forum that includes medical directors, chiefs of staff, and VPMAs of metropolitan hospitals met on October 21. Dan McLaughlin, Center for Health and Medical Affairs at the University of St. Thomas, gave a presentation on health care financing. Dr. William Jacott updated the physician leaders on the Shared Visions/ New Pathways program of the JCAHO. Topics at future meetings will include EMTALA provisions in relation to consultant coverage in emergency departments and 24-hour coverage for OB-GYN. Senator Steve Kelley met with Roger Johnson and other representatives of health care organizations to discuss health care issues in the offices of Lockridge, Grindal, and Nauen on October 22. Senator Kelley reviewed the budget deficits and the reductions in health care expenditures and advised the group on

key legislation that would be considered in the 2004 Session.

The RMS Council on Ethics and Professionalism met on October 23 at

United Hospital under the leadership of Dr. Robert Geist. The Council is continuing to review the ethical perspectives of the physician patient relationship and the potential challenges to that relationship. The Council members adopted a full schedule of meetings for 2004.

MetroDoctors

Leadership Panel meetings of the Minnesota Citizens Forum on Health Care Costs led by former Senator Dave Durenberger are being held each month. Roger Johnson represented RMS at the October 27 meeting at Metro State University. The next meeting will be on December 15 from 12:30 p.m. to 5:00 p.m. at the Minnesota Department of Health in the Snelling Office Park at 1645 Energy Park Drive in St. Paul. The final Leadership Panel meeting is scheduled for January 12 at 12:00 noon. Governor Pawlenty and Republican leaders in the legislature appear to be looking to this panel to solve the problem of increasing health care costs.

On October 29, Jack Davis of HMS and Roger Johnson of RMS met with Lynn Gruber, president of the Minnesota Comprehensive Health Association (MCHA). Ms. Gruber explained the transi-

tion of MCHA from Blue Cross/Blue Shield to Medica for administrative services. She also reviewed legislative and other developments affecting patients covered in the MCHA program. An article will be prepared for a future issue of MetroDoctors.

Dr. Charles Terzian, East Metro Trustee, was joined by newly elected East Metro MMA Trustee Gretchen Crary, M.D. at the MMA Board of Trustees meeting on November 1. Dr. J. Michael Gonzalez-Campoy, RMS president, attended the Board meeting in his new position as president-elect of the MMA. Other RMS members participating in the meeting included Drs. Frank Indihar, chair of the Minnesota delegation to the AMA, Dr. Ken Crabb, AMA delegate, and Dr. Blanton Bessinger, AMA alternate delegate. Dr. William Jacott represented the dean of the University of Minnesota Medical School. Roger Johnson also represented RMS. Agenda items included a report from Dr. Nancy Nielsen, speaker of the AMA

The Journal of the Hennepin and Ramsey Medical Societies

House of Delegates, vacancies on the Board of Medical Practice, a report on the Minnesota Citizens Forum on Health Care Costs, and a strategic planning session.

Organizations in the Health Plan Contract Coalition met on November 3 to discuss strategy for the 2004 Session.

Legislation will be developed to carry on with the work of the Coalition to achieve the adoption of legislation to enact the Contracting Principles of the Coalition into law. Principles of Quality have also been developed by the Coalition. The Coalition now includes 16 member organizations with the addition of the Minnesota Pharmacists Association.

Jack Davis, HMS, and Roger Johnson, RMS, met with Kathryn Kmit of the Council of Health Plans on October 21 to discuss the Council’s position on the contracting legislation. The Council supported the bill in 2003 and it appears that support will continue in 2004.

AMA staff members from Chicago who direct the AMA Strategies for Teaching Ethics and Professionalism (STEP) initiative hosted a dinner

meeting on November 4 for representatives of MMA, HMS, and RMS. Drs. Peter Daly and J. Michael Gonzalez-Campoy and Roger Johnson represented RMS. The University of Minnesota Medical School will be implementing a STEP project that uses internetbased discussion groups for each clerkship to expose medical students to each specialty.

(Continued on page 26)

January/February 2004

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Ramsey Medical Society

sponsored by ICSI that was attended by Roger Johnson at the Airport Marriott on October 20. Dr. Reinertsen stressed the importance of physician involvement in improving quality of care and he cited examples of physicians working together and with patient care teams to improve the delivery of care by eliminating errors and by improving systems.

President’s Message (Continued from page 24)

M.D. has played there. We just kicked off the Diabetes Plan 2010, which highlights the need for us to foster healthy lifestyles. Obesity care equals diabetes prevention. As the momentum and the science build to justify my call to action on obesity, our medical societies will continue the dialogue with employers and HMOs to eventually bring all patients to care.

The naysayers tell me that covering obesity medical care would soon make it so they are paying for fad diets and charlatans.

Therefore, there should be NO coverage for ANY obesity care programs. This extreme point of view alienates you and me, the physicians directing the care of these patients. Let’s go through a useful exercise now. We did this when we formulated the diabetes plan for the

2004 RMS Winter Gala and Annual Meeting Saturday, January 31, 2004 6:00 p.m.

Held at Circus Juventas 1270 Montreal Ave. St. Paul (Highland Park)

Hawaiian Luau (Children are invited) We will be entertained with a circus performance by the students in training and a performance by the Saint Thomas Academy Crack Drill Squad.

Installation of Peter J. Daly, M.D. as the 134th President of the Ramsey Medical Society.

A Silent Auction benefiting Ramsey Medical Society Foundation will be held.

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State of Minnesota. Let’s ask where we would like to see obesity care 10 years from now — as the physicians in this state. I offer this vision for obesity care: • All patients with obesity will have access to their physician.

• Physician visits for obesity will be covered by employers and third party payers.

• Physician-directed ancillary services (dieticians, exercise physiologists, psychologists) will be covered by employers and third party payers.

• Medications for obesity will be accepted as a standard part of obesity care.

• Medications for obesity will be covered by employers and third party payers.

• Surgery for obesity will be covered.

• Patients will have incentives from employers and the government to stay slimmer and healthier (i.e. allow pre-tax dollars for programs such as Curves for Women, Health Clubs, or Weight Watchers).

• With less burden from obesity, we will have less sleep apnea, less coronary disease, less gall bladder disease, less degenerative arthritis, less hypertension, less diabetes, less dyslipidemia, less depression, less colon cancer, etc.

• Our medical societies will take the lead in keeping people healthy — preventive medicine is the best medicine.

• Minnesota will be a national and international model for obesity care, like it is now for diabetes care.

We are still early on in this journey. From every venue, be it our medical societies, the Minnesota Department of Health, and certainly our patients, coverage for obesity care is desirable. Indeed, it is also prudent, and frugal.

I dare say that aggressively treating obesity, and helping our patients be healthier, will result in incredible savings to our health system over the years to come.

I will part by thanking my colleagues at the Ramsey Medical Society for the privilege of leading this society over the past year. The RMS staff is uniformly of the highest work ethic, and they have made this journey a real pleasure. I look forward to continuing the working relationships I forged this past year.

And you all can expect my continued advocacy for obesity care in our Twin Cities, our state, and our nation. ✦ MetroDoctors

RMS In Action (Continued from page 25) Moving day for the RMS offices was Friday, November 7, 2003, as RMS, HMS, and the MMA offices moved one block to the second floor of the Broadway West building at 1300 Godward St. N.E. in Minneapolis 55413. The RMS suite number is 2200.

The RMS staff worked hard to prepare for the move and to “settle” in the new quarters.

The RMS Executive Committee, chaired by Dr. J. Michael Gonzalez-Campoy, met on November 11 to consider the 2004 RMS budget, the advocacy activities generated through the Joint HMS/RMS Advocacy Committee, the RMS election ballot for 2004, the 2004 Winter Gala and RMS Annual Meeting, the 2004 HMS/RMS Winter Medical Conference, and the Board Strategic Planning meeting on January 20, 2004.

Dr. Robert Moravec chaired the Ramsey Medical Society Foundation Board of Directors meeting on November 12.

Board members heard a report from Brett Oslund of Paine Webber regarding the RMSF Investment Fund and worked on an Investment Policy. Plans for the Silent Auction to be held to benefit the Foundation at the 2004 Winter Gala and RMS Annual Meeting on Saturday, January 31, 2004 at Circus Juventas in St. Paul were discussed.

Donations of goods and services that can be purchased at the Silent Auction will be solicited from members and businesses. Members of RMS and of the RMS Alliance are asked to call the RMS office at 612-362-3799 with donations and with prospects for donations.

On November 13, the RCMS, Inc. Board of Directors met to discuss a proposal from the Schwarz Williams Company regarding benefits, compensation, and human resources consulting to physician practices. The Board is chaired by Dr. Robert Moravec and includes Drs. Ken Crabb, Peter Bornstein, and John Balfanz and clinic administrators Joe Drannen and Christine Morgan. The 2004 budget was approved and the portfolio of products and services offered to physician practices was reviewed. ✦ The Journal of the Hennepin and Ramsey Medical Societies

RMS UPDATE

Supplies and Clinic Participation Needed! hygiene supplies and over-the-counter medications and socks from February 1 through February 29, 2004. Some of the urgent supplies needed are ibuprofen, cough drops, feet ointments, diapers, deodorant and razors.

The committee is looking for clinics in the East Metro to participate in the drive. If every employee in your clinic donates items, what a difference you can make in supporting this much-needed supply drive. Arrangements will be made for all donations to be picked up at your location and delivered to the drop-off location at St. Joseph’s Hospital.

Call the RMS office at 612-362-3705 for more information or to let us know your clinic would like to participate in this supply drive.✦

2004 Ramsey Medical Society Election Results Congratulations to the newly elected RMS leaders

PRESIDENT Peter J. Daly, M.D. Orthopaedic Surgery Summit Orthopedics, Ltd.

PRESIDENT-ELECT Charles G. Terzian, M.D. Internal Medicine (Hospitalist), United Hospital

DIRECTOR-AT-LARGE Todd D. Brandt, M.D. Urology, Metropolitan Urologic Specialists, P.A.

MMA DELEGATES Richard L. Baron, M.D. Blanton Bessinger, M.D. Amy L. Gilbert, M.D. Frank J. Indihar, M.D. Lyle J. Swenson, M.D. DIRECTOR-AT-LARGE Lon B. Peterson, M.D. Family Practice, Regina Medical Group

MetroDoctors

FAMILY PHYSICIAN SPECIALTY TRUSTEE David C. Thorson, M.D. Family Practice, MinnHealth Family Physicians, P.A.- Banning

SURGERY SPECIALTY TRUSTEE Victor S. Cox, M.D. Otolaryngology, Otolaryngology Head & Neck Surgery, P.A.

The Journal of the Hennepin and Ramsey Medical Societies

Dr. John P. Frederick, Chief Medical Officer and Executive Vice President, PreferredOne, discusses “The Minnesota Community Measurement Project: making quality measurement work” with RMS Board members at the meeting on December 2, 2003. Photo from left: Peter Daly, M.D.; John Frederick, M.D.; Michael Gonzalez-Campoy, M.D.; and Charles Terzian, M.D.

RMS 2004 Winter Gala and Annual Meeting Silent AuctionDonations You are invited to help keep the mission of the Ramsey Medical Society Foundation alive! Donations to this event’s silent auction are tax deductible.

So whether you have tickets to a theatre, services you can provide, artwork, week long or weekend use of your vacation property, gift certificates, sports tickets or memorabilia, an unused appliance, or a priceless Ming Vase, we encourage you to donate to help support the RMSF. All donations should be in good condition. If you have a favorite restaurant, store, hotel, etc. that you would like to ask to donate an item, please call and we can provide you with the necessary form for them to fill out.

If you are interested in donating an item, please call Doreen at the RMS office at 612-362-3705.

January/February 2004

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Ramsey Medical Society

MORE THAN 7,250 HOMELESS people walked through the doors of the Dorothy Day Center in downtown St. Paul last year, according to their mandatory registry. This year their number of registered homeless people has more than doubled to 14,800. The Caring Heart for the Homeless People supply drive is asking you to double your efforts to help those less fortunate.

If you’re planning to stay in a hotel over the holidays or have any sample size hygiene supplies laying around the house, please remember the Caring Hearts for the Homeless People supply drive. HealthEast, the Ramsey Medical Society, and Ramsey Medical Society Alliance are collecting unopened, small sized

RMS Board Meeting

RMS ALLIANCE NEWS REBECCA GONZALEZ-CAMPOY

Fighting Obesity

O

OBESITY. IT’S ON EVERYONE’S mind. In fact, when Ramsey Medical Society President Mike Gonzalez-Campoy (my spouse) asked what I was going to write about for this issue, I told him I thought I’d cover the Alliance efforts to address obesity. Turns out great minds think alike. Be sure to read his column about the obstacles to treating obesity like any other disease.

So what’s the Alliance up to regarding prevention and public awareness of obesity?

The American Medical Association Alliance (AMAA) declared obesity its next focus topic.

However, it’s the Minnesota Medical Association Alliance (MMAA) that’s actually taking the lead in creating useful classroom materials to help educate elementary students about how to make more thoughtful — and healthful — food choices. Specifically, MMAA President Harriet Hodgson wrote and published the Food Label Detective, a workbook for 3rd and 4th graders that several Alliances have distributed during health fairs — including Ramsey Medical Society Alliance. RMS joined several other

medical societies and alliances in helping to pay for this project. Harriet has since created two more workbooks designed to help kids lead more healthful lives. RMSA will distribute those materials as well.

Meanwhile, back to the Food Label Detective. Our daughter, Aimee, a sophomore at Henry Sibley High School in Mendota Heights, is leading a class on nutrition and physical activity with 3rd and 4th grade students at our local elementary school, using the Food Label Detective as part of her curriculum.

Folks from around the country are requesting this workbook for distribution in their local schools. Mike’s dad just finished translating the booklet into Spanish, so we’ll be able to reach a broader population. The idea is to teach the kids, who will, in turn, teach their parents about how to make better lifestyle choices.

I wear many hats, as I’ve made pretty clear in previous columns. One of them is writing patient education material for Mayo Foundation. I had just finished a booklet about beverages when Harriet of the MMAA suggested we

Special Thank You from RMSF The Ramsey Medical Society Foundation thanks Dr. Frank Indihar and Dr. Robert Geist for their purchase of Ramsey County Medical Society china, along with a generous contribution to RMSF. If you are interested in acquiring a keepsake of the historical RCMS china and making a tax-deductible contribution to RMSF, please call the RMS office at 612-362-3799.

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MetroDoctors

create a card aimed at helping teenagers make better choices in what they choose to drink. I’ll get that put together in the next week. You can expect the card to be ready for use come early winter.

There are many ways you can be part of the obesity prevention team. Get creative and look for ways to use the MMAA resources, first of all. Join or initiate a committee in your school district that focuses on how to improve child nutrition. Also, on the school front is the Walk to School Day, an event that usually takes place in the fall. For more information, contact the Alliance in Rochester. They helped with this event in their community.

Check out the Diabetes Plan 2010 at www.health.state.mn.us/diabetes/2010plan/ plan.pdf. This is a statewide effort to address the growing diabetes epidemic. Obesity, of course, is at the core of much of the prevention efforts. There are ideas for everyone from physicians to community volunteers to get involved.

As for childhood obesity in particular, the MMA and the Alliance are founding members of the Minnesota chapter of Action for Healthy Kids. Check out what’s going on in our communities by going to www.actionfor healthykids.org and click on Minnesota. This group is looking at ways to increase physical activity for kids before and after school as well as how to improve school lunches, among other things. This site is a great place to learn about what efforts work.

And, perhaps, most important, increase your own physical activity and eat more healthy foods that are high in fiber and rich in nutrients. Maybe there IS something to the old adage, “An apple a day…” ✦

The Journal of the Hennepin and Ramsey Medical Societies

CHAIR’S REPORT MICHAEL B. AINSLIE, M.D.

What Crisis?

HMS-Officers

HMS-Board Members

Abdhish R. Bhavsar, M.D. Carl E. Burkland, M.D. Eric G. Christianson, M.D. Peter J. Dehnel, M.D. Donald M. Jacobs, M.D. Alisa Lee, Medical Student Jan Musich, Alliance President Ronald D. Osborn, D.O. Frank S. Rhame, M.D. David F. Ruebeck, M.D. Richard D. Schmidt, M.D. Jan H. Strathy, M.D. Thomas C. Tunberg, M.D. D. Clark Tungseth, M.D. HMS-Ex-Officio Board Members

Roger W. Becklund, M.D., Senior Physicians Association Lee H. Beecher, M.D., MMA-Trustee Karen K. Dickson, M.D., MMA-Trustee David L. Estrin, M.D., MMA-Trustee Kenneth B. Heithoff, M.D., MMA-Trustee Karin M. Tansek, M.D., MMA-Trustee Barbara Daiker, MMGMA Rep. HMS-Executive Staff

Jack G. Davis, Chief Executive Officer Kathy R. Dittmer, Executive Assistant Sue Schettle, Director, Marketing & Member Services

MetroDoctors

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WE HAVE BEEN TOLD TIME and time again that heath care is in crisis. Costs are spinning out of control. Many millions have no health insurance. We can’t “afford” quality medical care; it must be rationed. But we must keep the “quality.” We spend 17 percent of our GDP on health care, and it keeps going up. All this is supposed to work us into a frenzy that something must be done about it. Of course, the only solution is for the government to take over health care and have only a “Single Payor.” I would answer all these problems with a Bronx cheer.

If we have a crisis, it’s of our own making.

As Pogo observed: “We have met the enemy and he is us.” The “crisis” has been here since we took the costs of health care out of the patient’s hands (who ultimately controls costs) at least 75 years ago. Physicians have given up their role as businessman and abrogated this to insurance bureaucrats, and now pay a large percentage of their dollar to them.

For example, when I first joined St. Louis Park Medical Center years ago, my salary was 70 percent of my bookings; this last year I took home less than 20 percent of my bookings.

This net loss of more than 50 percent is eaten up by health plans and clinic administration.

Quality depends on the best care that I can give. I need time and resources to do this. It can’t be hurried or cook booked to an end. If we spend 17 percent of the GDP who cares?

I don’t. If we spend 50 percent who cares? In any other economic sector, they would kill to be getting more of the GDP. You think General Motors wouldn’t like to have 17 percent? The percent is whatever patients want to spend on their health care.

If costs are spiraling out of control, the answer is not more price controls than we have now. They haven’t worked and will never work.

I hope all of you will remember Econ 101; or

The Journal of the Hennepin and Ramsey Medical Societies

if you didn’t take it, get Harry Haslett’s book Economics in One Lesson, or Tom Sowell’s Basic Economics. You’ll see that all the schemes being discussed now cannot and will not work.

Someone must bear the costs; someone must pay the piper.

We have so detached from a free market that we don’t even recognize one that stares us in the face. Many plastic procedures are pay as you go. Some are expensive; some are cheap. I don’t see any starving plastic surgeons, nor lack of patients who are willing to pay the market price. Lasik surgery is another good example.

Costs for the procedure have gone from well over $1,000 per eye to now the low $100s.

Patients still seem to want to have it done.

The current debate is healthy, if one keeps an open mind. If we follow the politicians who call for a single payer like Mark Twain said of statistics, “A mathematical straight line from an unwarranted assumption to a forgone conclusion.” It seems to me that the current discussion is to railroad us into socialized medicine. It may work for a while, but economics cannot be ignored for long. Someone must pay the costs.

I hope and pray that it won’t be my children or grandchildren. It is time to look at the economic forces in medicine, and bring back the best and most efficient system the world has ever seen — the Capitalist system. ✦

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Hennepin Medical Society

Chair Michael B. Ainslie, M.D. President Michael B. Belzer, M.D. President-elect James A. Rohde, M.D. Secretary James F. Peters, M.D. Treasurer Paul A. Kettler, M.D. Immediate Past Chair T. Michael Tedford, M.D.

HMS IN ACTION JACK G. DAVIS, CEO

HMS in Action highlights activities that your leadership and executive office staff have participated in, or responded to, between MetroDoctors issues. We solicit your input on these activities and encourage your calls regarding issues in which you would like our involvement.

Jack Davis and a group of other provider representatives, met with Representative Matt Entenza, minority leader of the Minnesota House of Representatives. The focus of the conversation was health care issues to come forward in the 2004 session.

In preparation for the 2004 legislative session, Jack Davis and Roger Johnson (RMS CEO) met with Senator Dallas Sams

Michael Ainslie, M.D., MMA treasurer, Karen Dickson, M.D., Kenneth Heitoff, M.D., Lee Beecher, M.D., and David Estrin, M.D., trustees, attended the November 1 meeting of the Minnesota Medical As-

and Senate Majority Leader John Hottinger to discuss the Minnesota Health

Plan Contracting Act. A few members of the Fair Health Plan Contracting Coalition also attended.

Governor Pawlenty established the Minnesota Citizens Forum on Health Care Cost led by (former) Senator David

Durenberger. Jack Davis attended the initial brief of the Forum and its first meeting.

sociation Board of Trustees.

Michael Ainslie, M.D., HMS chair, Michael Gonzalez-Campoy, RMS president, Paul Matson, M.D., MMA president, Peter Daly, M.D., RMS president-elect, Roger Johnson, RMS CEO, and Jack Davis met with representatives of the AMA to discuss the implementation of a new AMA program— “Strategies for Teaching and Evalu-

HMS wins tobacco-free communities grant. The Hennepin Medical Society

applied for, and won, a grant from the Minnesota Department of Health, which will fund locally driven tobacco prevention activities in the Minneapolis area. Peter Dehnel, M.D., HMS member and board member, advocated for this project. The Society has established a coalition, which currently includes the Smoke-Free Coalition, Asian Media Access, Hispanos en Minnesota, University of Minnesota Cancer Center, Greater Minneapolis Council of Churches, and Children’s Physicians Network. Additional community organizations may be added to the coalition.

David Estrin, M.D., past HMS Chair and recently elected alternate delegate to the AMA House of Delegates, and Jack Davis met with Ted Loftness, M.D., medical director for Medica, to discuss issues related to pediatric patients. Dr Loftness recognized the importance of the issues.

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ating Professionalism” (STEP). The

program is an initiative designed to develop and enhance the latest teaching principles, educational resources and evaluation tools for promoting ethics and professionalism in medical education. The AMA is supporting this initiative by providing grant funding.

New HMS Address. The Hennepin Medical Society, along with the Ramsey Medical Society and the Minnesota Medical Association, moved on November 7 to 1300 Godward Street N.E. The move was from the Broadway East building across the parking lot to the Broadway West building. The phone numbers and e-mail addresses will remain unchanged. ✦

Charles Bolles Bolles-Rogers Award A SPECIAL RECEPTION was held on November 3 to honor Ernie Ruiz, M.D. as the 2003 Charles Bolles Bolles-Rogers Award recipient. Dr. Ruiz was nominated by his colleagues at the Hennepin County Medical Center and Hennepin Faculty Associates. In the nomination letter, Donald M. Jacobs, M.D. stated that “During his career, Dr. Ruiz was a full-time surgeon at HCMC and started one of the first residencies and departments in emergency medicine in the country. He started the first advanced life support pre-hospital care systems. Dr. Ruiz served for 20 years as chief of emergency medicine at HCMC and for many years as medical director of the West-Metro EMS system. …Ernie has worked tirelessly his entire career for the betterment of emergency care in this community and for the improvement of the educational system in emergency care throughout the state of Minnesota.”

MetroDoctors

Dr. Joseph Clinton (left) and Dr. Mick Belzer (right) were present at the reception where Dr. Ernie Ruiz, (center) was honored as the 2003 Charles Bolles Bolles-Rogers Award recipient.

The Charles Bolles Bolles-Rogers Award was established in 1951 by Mr. Bolles-Rogers in recognition of a physician who, in the opinion of their colleagues, has made “an extraordinary contribution to medical research, medical achievement or leadership and has become the outstanding physician of this and other years.” ✦

The Journal of the Hennepin and Ramsey Medical Societies

HMS NEWS

New Members HMS welcomes these new members to the Society.

Rosalie Frances Siy, M.D. Internal Medicine Allina Medical Clinic-Edina

Resident Amy N. Harrison, M.D. Pediatric Pulmonology Crystal T. Schlosser, M.D. General Surgery

Cephas Mawuena Agbeh, M.D. Obstetrics & Gynecology Columbia Park Medical Group Fridley Plaza Clinic

Holly B. Yang, M.D. Internal Medicine University of Minnesota Physicians

Gail M. Amundson, M.D. Internal Medicine HeathPartners - Bloomington

Medical Student

Thomas J. Bloss, M.D. Rheumatology Hennepin County Medical Center Andrea J. Flom, M.D. Obstetrics & Gynecology John A. Haugen Assoc., P.A. Jorge A. Granja, M.D. General Surgery Associates in General & Vascular Surgery, Ltd. Jay H. Krachmer, M.D. Ophthalmology University of Minnesota Cyril Jay Kruse, M.D. Orthopaedic Surgery Orthopaedic Partners, P.A. Mary J. Lawler, M.D. Pediatrics Southdale Pediatric Associates, Ltd. Michael P. Leehy, M.D. Internal Medicine Thomas K. Pettus, M.D., C.M.D. Geriatric Internal Medicine Thomas K Pettus, M.D., P.A.

MetroDoctors

(University of Minnesota)

Adam Douglas Bloemke Emily R. Conover Aaron Scott Douglas Daniel T. Franc Gregory Lawrence Geers Louie G. Jain Andrew Jon Kopperud Jaimee D. McPadden Joylynn A. Miller Benjamin Lars Mitlyng Thomas Opheim Daniel William Soular Amy Stroschein David Thomas Tapper Julia L. Weinkauf Sara Johanna Wilcox Jordan Marie Wilson ✦

World Premiere — Hiding in the Open The world premiere of a play, based on the book Hiding in the Open, will be held at the Great American History Theatre March 27-April 25, 2004. The book was written by Sabrina S. Zimering, M.D., member of the HMS Senior Physicians Association.

For more information and performance schedule, visit online at www.historytheatre.com or call 651292-4323.

The Journal of the Hennepin and Ramsey Medical Societies

In Memoriam WAYNE ALFRED CHADBOURN, M.D., died on October 25 at the age of 85. He graduated from Hamline University and received his medical degree from the University of Minnesota Medical School. He served in the U.S. Navy and took part in the South Pacific campaign during World War II. Dr. Chadbourn practiced general medicine for several years in Litchfield, Minnesota. In the early 1950s, he completed his residency in pathology. He was a partner in Lufkin Medical Labs of Minneapolis. Dr. Chadbourn joined HMS in 1947.

PAUL T. LOWRY, M.D., died on November 7. He was 87. He graduated from Harvard College and Harvard Medical School. Early in his career he practiced academic medicine at the University of Minnesota. Dr. Lowry practiced internal medicine with Lowry Medical Associates for nearly 35 years in Minneapolis and Edina. He earned his Ph.D. in history at the University of Minnesota at the age of 77, following his retirement from medical practice.

Dr. Lowry joined HMS in 1952.

ANTON “TONY” GERALD LYZENGA, M.D., died November 7 at the age of 79. He went to Midshipmans School at Columbia University in New York, and following graduation served on a minesweeper from 1943-1946.

Upon discharge from the Navy, he received his medical degree from the University of Michigan School of Medicine. Dr. Lyzenga practiced medicine for 52 years, primarily with the Penn Avenue Medical Group on 81st and Penn in Bloomington. When the clinic closed in 1993, he briefly went to Bloomington Lake Clinic.

He then joined Now Care in Minnetonka where he retired from in March of 2003. Dr. Lyzenga joined HMS in 1954.

EDWARD L. “EDDIE” SEGAL, M.D., died in November at the age of 76. He received his medical degree from the University of Minnesota. He completed his residency at the University of Minnesota in clinical pathology and followed with a fellowship in anatomic pathology at the Mayo Clinic. Dr. Segal was a pathologist at Methodist Hospital in St. Louis Park and practiced for 30 years with his brother, Marty. He was a clinical associate professor at the University of Minnesota in the Department of Laboratory Medicine and Pathology. Dr. Segal served as president of the HMS Senior Physicians Association in 200203. He joined HMS in 1960. ✦ January/February 2004

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Hennepin Medical Society

Active Richard Adair, M.D. Internal Medicine Abbott Northwestern Hospital

Kamal K. Sahgal, M.D. Internal Medicine Park Nicollet Clinic-Wayzata

HMS ALLIANCE NEWS CHERYL JACOBS, LICSW

Sharing the Gifts We Were Given

I

I WAS PERFORMING my standard interview with potential donor Lisa (not her real name) when I asked how she knew the intended recipient of her kidney. “Oh, I’ve never met him, but I learned that he needed a transplant through our church bulletin.” “Why do you want to go through such a major surgery for someone you don’t know?” She responded, as many volunteers do, “because I know there’s a severe shortage of organ donors and he might not survive the length of time it takes before getting called with a kidney.” She was right.

Right now, more than 83,000 people in the U.S. are waiting for a life-saving organ transplant. Of those people, 2,127 are Minnesotans — hoping for a needed kidney, liver, pancreas, heart, lung, or intestine. Recipients wait an average of three to five years before an appropriate organ becomes available.

Seventeen people die each day while on that waiting list.

Living Donation As medical science improves, opportunities for successful transplants continue to increase, but the number of organs available from people who have died does not. The alternative is living donation. In 2001, for the first time, the number of living donors in the U.S. surpassed the number of those who donated at the time of death.

Living donation means that an organ, or part of an organ is taken from a healthy person to replace a non-functioning organ in another. Thus far, living donations can involve the kidney, liver, lung, pancreas and intestine.

We’re fortunate in Minnesota to have four transplant programs: Abbott Northwestern, Hennepin County Medical Center, the Mayo Clinic, and the University of Minnesota-Fairview Transplant Services.

Traditionally, living donors had to be siblings, parents, or other biological next-ofkin to their recipients. Effective medications have now been developed that help prevent rejection of organs from non-biologically 32

January/February 2004

related donors. Spouses, friends, co-workers, acquaintances, and complete strangers, like Lisa, are now able to donate to those in need of a transplant.

The decision is a serious one; each volunteer must cautiously weigh the personal risks and benefits of living donation. Careful medical and psychological screening is performed to assure that donors fully comprehend the procedure, are comfortable with their decision, and are able to plan appropriately for their recovery. (There are no medical costs to the donor to donate.) Living donors have told us that they were glad they made the decision to donate and were pleased to have had the opportunity to help someone in need.

Designated Donation LifeSource is Minnesota’s non-profit organ procurement organization (OPO) responsible for managing and allocating organs that are donated at the time of death. Organs are matched with a recipient based on best medical match, severity of illness, waiting time on list and other considerations. The OPO’s trained coordinators talk with the family about donation and provide support through their donor family services program.

There are a variety of ways in which one can designate the desire to donate organs and tissue upon death: a driver’s license, an advanced health care directive, a special donor card, or simply telling loved ones about the desire to become an organ donor. (Over half of Minnesotans have marked themselves as potential organ donors on their driver’s license.) Providing direction in advance helps those faced with difficult decisions during such an emotional time. Family members may take great comfort knowing they are honoring their loved one’s wishes. Sadly, many do not make their intentions for organ donation known and an opportunity to save another life is lost.

in the Twin Cities from across the country for the U.S. Transplant Games, sponsored by the National Kidney Foundation and hosted by the University of Minnesota. The Games will showcase how effective transplantation is in helping recipients return to a normal, active life. They will also celebrate those whose generous gifts made those lives possible.

Anatomy Bequest The thorough understanding of human anatomy is critical to the development of competent physicians. This educational process, like organ transplantation, is dependent on individuals’ donations. The University of Minnesota’s Anatomy Bequest Program supports the generous intention to donate one’s body for medical study. As with the other donation processes, a careful screening is done, stringent guidelines are followed, and the wishes of the family are respected. Each year the medical students lead a memorial service to honor those who have contributed so much to their learning; family members of the donors are invited to attend.

If you’d like additional information on living donation see www.livingdonors.org or www.fairviewtransplant.org; for designated donation contact LifeSource at 1-888/5366283 or www.organdonation.org; and for information on gifting your body for medical study, see www.bequest.umn.edu. ✦ Cheryl Jacobs, an HMSA member, serves as a licensed independent clinical social worker with the Living Donor Program of the Fairview-University Medical Center. She is a nationally-respected authority on the psycho-social issues surrounding living organ donations.

U.S. Transplant Games In July 2004, nearly 12,000 people will arrive MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Continuing Medical Education 2004 CONFERENCES

Providing quality physician education for over 65 years P R I M A RY C A R E F O C U S

S U R G E RY F O C U S

Multiple Sclerosis: The Disease and Its Management March 6, 2004

Minimally Invasive Approaches in Surgical Oncology April 22-23, 2004

Thoracic Oncology and Primary Care March 19, 2004

Midwest Arthroplasty Course: The Knee – Ligament and Arthritis Surgery May 14-16, 2004

Allergy and Clinical Immunology April 23, 2004 Family Practice Review: Update 2004 May 3-7, 2004 Topics and Advances in Pediatrics June 10-11, 2004 Twin Cities Marathon Sports Medicine Conference October 1-2, 2004 Internal Medicine Review October 13-15, 2004

CARDIOLOGY FOCUS Cardiac Arrhythmias: An Interactive Update April 9, 2004 Lillehei Symposium: Cardiovascular Care for Primary Practitioners Spring 2004 Preventing Cardiovascular Events: Early Detection and Treatment October 1, 2004 * unless otherwise noted, courses take place in the Twin Cities Metro Area.

For more information contact: Continuing Medical Education 612.626.7600 or 1.800.776.8636 cmereg@umn.edu / www.med.umn.edu/cme fax: 612.626.7766

Advances in Trauma & Critical Care Surgery June 16-19, 2004 Lymphatic Mapping & Sentinel Lymph Node Biopsy Spring 2004 Pelvic Floor Workshop September 7, 2004 Endorectal Ultrasonography September 8, 2004 Principles of Colon & Rectal Surgery September 9-11, 2004

ALSO OFFERED Reducing Tobacco Use in Minnesota 2004 February 27, 2004 International Congress on Schizophrenia Research * Chicago, IL April 2-4, 2004 Aging Skin 2004 May 7, 2004 WORLD Lysosomal Disease Clinical Research Network May 13-15, 2004 Workshops in Clinical Hypnosis June 3-5, 2004 North Central Neonatology Issues Conference * Wisconsin Dells June 11-13, 2004