2004mayjune

May/June 2004

Compassionate Caring of the Underserved

In This Issue • • • •

An Orthopedic Odyssey Tanzanian Health Care Advocating for Children Minnesota Health Access Survey

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$OCTORS -ETRO$OCTORS 4(% */52.!, /& 4(% (%..%0). !.$ 2!-3%9 -%$)#!, 3/#)%4)%3

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0ERIODICAL POSTAGE PAID AT -INNEAPOLIS

-INNESOTA 0OSTMASTER 3END ADDRESS CHANGES TO -ETRO$OCTORS (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES 'ODWARD 3TREET .% "ROADWAY 0LACE 7EST 3UITE -INNEAPOLIS -.

4O PROMOTE THEIR OBJECTIVES AND SERVICES THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES PRINT INFORMATION IN -ETRO$OCTORS REGARDING ACTIVITIES AND INTERESTS OF THE SOCIETIES 2ESPONSIBILITY IS NOT ASSUMED FOR OPINIONS EXPRESSED OR IMPLIED IN SIGNED ARTICLES AND BECAUSE OF THE FREEDOM GIVEN TO CONTRIBUTORS OPINIONS MAY NOT NECESSARILY REmECT THE OFlCIAL POSITION OF (-3 OR 2-3 3END LETTERS AND OTHER MATERIALS FOR CONSIDERATION TO -ETRO$OCTORS (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES 'ODWARD 3TREET .% "ROADWAY 0LACE 7EST 3UITE -INNEAPOLIS -. % MAIL BAUERFAMILY EARTHLINK NET &OR ADVERTISING RATES AND SPACE RESERVATIONS

CONTACT "ETSY 0IERRE %ASTWOOD #IRCLE -ONTICELLO -.

PHONE FAX E MAIL BETSY PIERREPRODUCTIONS COM -ETRO$OCTORS RESERVES THE RIGHT TO REJECT ANY ARTICLE OR ADVERTISING COPY NOT IN ACCORDANCE WITH EDITORIAL POLICY .ON MEMBERS MAY SUBSCRIBE TO -ETRO$OCTORS AT A COST OF PER YEAR OR PER ISSUE IF EXTRA COPIES ARE AVAILABLE &OR SUBSCRIPTION INFORMA TION CONTACT $OREEN (INES AT

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2ESULTS FROM THE -INNESOTA (EALTH !CCESS 3URVEY

!NGELA S 3TORY !N /RTHOPEDIC /DYSSEY ˆ 2OCKY -OUNTAIN (IGH ˆ 4ANZANIA 0ORTICO (EALTHNET !N !NSWER FOR THE 5NINSURED #OMMUNITY %DUCATION !DVOCATING FOR #HILDREN 0AY FOR 0ERFORMANCE 7ON T )MPROVE 1UALITY OR 2EDUCE #OSTS FOR -OST 3ERVICES )NDEX TO !DVERTISERS 'OVERNMENT 0RESCRIBED h"EST 0RACTICESv ˆ .OT 7HAT THE $OCTOR /RDERED

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#ARING (EARTS FOR (OMELESS 0EOPLE #ALL FOR 2ESOLUTIONS .EW -EMBERS )N -EMORIAM 2-3 *OINS 2AMSEY 4OBACCO #OALITION 2ESULTS OF 2-3 0HYSICIAN 6OLUNTEER 7ORK 1UESTIONNAIRE (%..%0). -%$)#!, 3/#)%49

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-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

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)T S THE h3YSTEMv NOT h0OOR 1UALITYv 4HAT !ILS -EDICINE

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,!34 -/.4( ! ,%')3,!4/2 30%!+).' TO A GROUP OF DOCTORS ALLEGED THAT hPOOR QUALITY CAREv IS A CAUSE OF MEDICAL INmATION &INDING hBEST PRACTICESv AND hPAYING FOR QUALITY PERFORMANCEv WOULD BE THE REMEDY )F ONLY THINGS WERE SO SIMPLE OR THAT THE REMEDY WOULD HAVE ANY EFFECT ON INmATION

4HERE ARE MANY CAUSES OF MEDICAL INmATION BUT POOR QUALITY OF CLINIC CARE IS NOT ONE OF THEM )T IS OFTEN SAID THAT OUR CURRENT SYSTEM OF MANAGED CARE IS hBROKEN v )T S HARD TO DISAGREE AND THAT IS WHERE WE SHOULD LOOK

4HE ROAD TO MEDICAL INmATION IN THE 5 3 BEGAN WITH SUBSIDIZED HEALTH INSURANCE FOR WORKERS IN 7ORLD 7AR )) FOLLOWED IN WITH INSURANCE FOR THE OLD AND OFlCIAL POOR 4HIS PIECEMEAL VERSION OF A .ATIONAL (EALTH )NSURANCE PROGRAM RESULTED IN DEMAND INmATION AS SER VICES APPEARED TO BE NEARLY hFREEv AND hTHE BOSS PAID FOR IT v 4O AVERT THE POLITICAL RISK OF REPEALING POPULAR SUBSIDIES DRIVING DEMAND REGULATORY RATIONING MEASURES WERE DEVISED TO CONTROL USE OF MEDICAL CARE SUPPLIES

&EDERAL REGULATION OF SUPPLIES BEGAN WITH lXING PRICES IN

CERTIlCATES OF NEED DEFUNCT SINCE HOSPITAL $2'S IN AND PASSAGE OF THE (-/ !CT IN 4HIS !CT ALLOWED COMMERCIAL INSUR ANCE CORPORATIONS GENERICALLY -ANAGED #ARE /RGANIZATIONS OR -#/S THE UNPRECEDENTED AND PERVERSE POWER TO CONTROL USE AND DELIVERY OF THE BENElTS THEY INSURED "Y -#/S CONTROLLED PERCENT OF THE COMMERCIAL HEALTH INSURANCE MARKET )T WAS ALLEGED THAT COST OF CARE WOULD DECREASE WHEN PROlT MOTIVES DROVE THE -#/ CORPORATIONS TO hMAINTAIN HEALTHv BY PRACTICING hWELL CAREv INSTEAD OF hSICK CARE v

"UT MARKETING SLOGANS CONTAINED NO SECRET REMEDY TO MAINTAIN HEALTH OR CONTAIN COSTS ˆ INmATION IS RAMPANT 4HE UNRECOGNIZED mAW CAUSING REGULATORY FAILURE IS THE FATAL COMBINATION OF PATERNALISTIC HEALTH SERVICE REGULATION AND hFREE CARE v -ANAGERS FAIL BECAUSE THEY ARE ECONOMICALLY BLIND WHEN ATTEMPTING TO ALLOCATE RESOURCES FROM A lXED BUDGET IN THE ABSENCE OF ORDINARY MARKET INFORMATION FURNISHED BY THE PURCHASES OF MILLIONS OF PRUDENT PRICE SENSITIVE CUSTOMERS 3UDDENLY WE AGAIN HEAR ECHOES OF S MARKETING SLOGANS h(EALTH MAINTENANCEv IS ECHOED BY hBEST PRACTICESv AND PROlTS FOR hWELL CAREv IS ECHOED BY INCENTIVE hPAY FOR QUALITY PERFORMANCE v 0OPULATION CENTERED STATISTICS AND SLOGANS EMPTY OF REAL EFlCACY MAY MEET THE NEEDS OF THOSE WANTING AN INmATION SCAPEGOAT OR OF THOSE BAFmED BY INmATION BUT WILL NOT FUR NISH THE MEANS NEEDED TO CONTROL INmATION OR IMPROVE QUALITY PATIENT CENTERED CARE ITS TIMELINESS PERSONALIZATION CONTINUITY AND ACCESS TO EXPERTISE

,AWRENCE #ASALINO OF THE 5NIVERSITY OF #HICAGO HAS VOICED CONCERN WHEN QUALITY IS DElNED AND REWARDED IN TERMS OF WHAT CAN BE COUNTED OR MEASURED BY SELF INTERESTED INSURANCE EXECUTIVES AND ACCREDITING AGENCIES ! FEW HIGH PROlLE DISEASES MEASURED BY hREPORT CARDSv CAN INAPPROPRIATELY SKEW RESOURCES TO hCOMPLIANCE v AND THEN ARE ALLEGED TO REmECT THE QUALITY OF ALL CLINIC CARE -OST OF WHAT DOCTORS DO IS NOT MEASURABLE $OCTORS EACH DAY LISTEN CAREFULLY TO A GREAT VARIETY OF PATIENTS FOR SUBTLE CLUES IN THEIR SYMPTOMS AND IN COMFORTING THOSE WHO HURT IN BODY AND MIND #ORPORATE STATISTICIANS AND ACCOUNTANTS RARELY lND SUCH TIME CONSUMING QUALITY ACTIVITIES INTERESTING

5NLIKE WIDGET PRODUCTION MEDICAL QUALITY ASSESSMENT LOOKS AT A COMPLEX MOVING TARGET #LINICS HAVE LITTLE CONTROL OVER CHANGE IN DISEASES AS PATIENTS AGE OR PATIENT COMPLIANCE AND LIFE STYLES 9ET THESE FACTORS CAN IN PART INmUENCE hREPORT CARDSv FOR CLINIC REWARDS AND PUN ISHMENTS

4HERE CAN BE REAL VALUE IN STATISTICAL STUDIES OF POPULATIONS WHEN DONE WITH INDEPENDENT REVIEW BOARD EVALUATIONS CAREFUL PROTECTION OF PATIENT PRIVACY AND THE USE OF DATA FOR DIRECTING INVESTMENT TO WHERE PATIENTS ARE TREATED I E CLINIC SYSTEMS TECHNOLOGY AND CONTINUOUS EDUCATION IN RAPIDLY CHANGING MEDICAL INNOVATIONS "EFORE THE hQUALITY FOR COST CONTROLv FAD BECAME A POPULAR SLOGAN EVIDENCE BASED STUDIES OF SENIORS IN TRADITIONAL -EDICARE AS WELL AS OF THE GENERAL PUBLIC AT ALL AGES HAVE SHOWN EXCELLENT QUALITY OF CARE IMPROVEMENTS OVER SHORT PERIODS OF TIME %CONOMISTS RECKONED THIS WAS STRIKING EVIDENCE OF THE CONSEQUENCES OF IMPROVED MEDICAL CARE TECHNOLOGY

-ANY HAVE POINTED OUT THAT THE PROBLEMS OF QUALITY MEDICAL CARE AND OF ERRORS ARE MORE THE RESULT OF BAD SYSTEMS THAN OF BAD APPLES 4HE INSPECTION MODEL OF QUALITY hNAME BLAME SHAME v DOES NOT PREVENT OR lX SYSTEM FAILURES 1UALITY MEANS PROPER INVESTMENT NOT CORPORATE OR STATE COMPLIANCE THREATS OF lNANCIAL LOSS ADVERSE hREPORT CARDv PUBLICA TION AND OTHER PUNISHMENTS YET TO BE ANNOUNCED

)NmATION AND PATIENT DISSATISFACTION WITH QUEUES ARE NOT SYMP TOMS OF POOR QUALITY MEDICAL CARE BUT SYMPTOMS OF A DYSFUNCTIONAL REGULATORY SYSTEM 4HE EVIDENCE IS THAT GIVEN THE TOOLS AND FREED FROM HARASSMENT OUR HIGHLY TRAINED MEDICAL PROFESSIONALS AT ALL LEVELS DOC TORS 2.S TECHNICIANS AND SO FORTH CAN PERFORM COMPLEX PATIENT CARE WITH EXCELLENCE

4HE INmATION CULPRIT IGNORED BY SOME LEGISLATORS IS A PATERNALISTIC REGULATORY SYSTEM THAT IS INDEED BROKEN ˆ AND BEYOND REPAIR 4HERE IS A BETTER WAY U

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2OBERT 7 'EIST - $ IS A RETIRED UROLOGIST RESIDING IN .ORTH /AKS

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-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

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%DITOR S .OTE -ARC 7 -ANLEY - $ -0( IS THE EXECUTIVE DIRECTOR

#ENTER FOR 4OBACCO 2EDUCTION AND (EALTH )MPROVEMENT "LUE #ROSS AND "LUE 3HIELD OF -INNESOTA (E IS RESPONSIBLE FOR THE DEVELOPMENT

IMPLEMENTATION AND EVALUATION OF ALL CENTER PROGRAMS WHICH ARE DE SIGNED TO REDUCE TOBACCO USE PREVENT HEART DISEASE AND PREVENT CANCER $R -ANLEY RECEIVED HIS MEDICAL DEGREE FROM THE 5NIVERSITY OF 7ASH INGTON 3EATTLE AND A MASTERS IN PUBLIC HEALTH FROM 4HE *OHNS (OPKINS 5NIVERSITY 3CHOOL OF (YGIENE 0UBLIC (EALTH "ALTIMORE -ARYLAND (E IS BOARD CERTIlED IN 0UBLIC (EALTH AND 0REVENTIVE -EDICINE

1 !

9OU CAME TO "LUE #ROSS AND "LUE 3HIELD OF -INNESOTA FROM THE .ATIONAL #ANCER )NSTITUTE lVE YEARS AGO 7HAT ATTRACTED YOU TO "LUE #ROSS AND TO -INNESOTA )T WAS OBVIOUS TO ME THAT "LUE #ROSS HAD AN UNSHAKABLE COMMITMENT TO REDUCING TOBACCO USE AND IMPROVING HEALTH 4HAT COMMITMENT FROM THE COMPANY S LEADERS WAS MY TOP REASON FOR COMING HERE ) HAD WORKED IN THE FEDERAL GOVERNMENT FOR YEARS AND ) WAS EXCITED ABOUT THE CHANCE TO DEVELOP HEALTH IMPROVEMENT PROGRAMS IN A CORPORATE SETTING )T ALLOWED ME TO TACKLE DIFlCULT PUBLIC HEALTH PROBLEMS WITH THE HELP OF BUSINESS PEOPLE COMMUNICATIONS PROFESSIONALS AND OTHERS WITHIN "LUE #ROSS !LSO ) ALREADY KNEW MANY PEOPLE IN THE -INNESOTA PUBLIC HEALTH COMMUNITY AND ) WAS HONORED TO JOIN THEM /N A PERSONAL LEVEL MY WIFE AND ) WERE GLAD TO COME TO -INNESOTA BECAUSE WE KNEW IT WOULD BE A GREAT PLACE TO RAISE OUR SONS

(OW DOES THE #ENTER FOR 4OBACCO 2EDUCTION AND (EALTH )MPROVEMENT AND ITS PREVENTION FOCUS lT IN WITH THE REST OF "LUE #ROSS "LUE #ROSS HAS ALWAYS BEEN A MISSION DRIVEN ORGANIZATION )T HAS A UNIQUE STATE MANDATE TO hPROMOTE A WIDER MORE ECONOMICAL AND TIMELY AVAIL ABILITY OF HEALTH SERVICESxAND THEREBY ADVANCE PUBLIC HEALTH AND THE ART AND SCIENCE OF MEDICAL AND HEALTH CARE v 4HE WORK OF THE #ENTER FOR 4OBACCO 2EDUCTION AND (EALTH )MPROVEMENT ย WHERE ) M THE EXECU TIVE DIRECTOR ย IS ONE OF SEVERAL WAYS "LUE #ROSS IS MAKING A HEALTHY DIFFERENCE IN OUR STATE 4HE #ENTER FOCUSES ON PREVENTING THE LEADING CAUSES OF DEATH AND DISABILITY IN THE STATE BY ADDRESSING THEIR UNDERLYING CAUSES ย INCLUDING TOBACCO USE PHYSICAL INACTIVITY AND POOR NUTRITION -ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

/UR #HIEF %XECUTIVE /FlCER -ARK "ANKS IS A FELLOW PHYSICIAN AND DEEPLY SUPPORTS THE WORK WE DO IN THE #ENTER ) AM LUCKY TO WORK IN AN ORGANIZATION THAT REALLY VALUES PREVENTION

4ELL US A BIT ABOUT THE #ENTER /UR WORK IN THE #ENTER IS A DIRECT RESULT OF "LUE #ROSS LAWSUIT AGAINST THE TOBACCO COMPANIES 7HEN THAT LAWSUIT WAS SETTLED IN

WE WON IMPORTANT PUBLIC HEALTH CONCESSIONS INCLUDING THE RELEASE OF PREVIOUSLY SECRET TOBACCO COMPANY DOCUMENTS "LUE #ROSS AND OUR CO PLAINTIFF THE STATE OF -INNESOTA WERE AWARDED SEPARATE lNANCIAL SETTLEMENTS 4HE "LUE #ROSS FUNDS ARE STILL HELD UP IN COURT BUT OUR HEALTH IMPROVEMENT WORK IS ALREADY UNDER WAY 7E FOCUS ON REDUCING TOBACCO USE AND OTHER HEART DISEASE AND CANCER RISK FACTORS FOR OUR MEMBERS AND ALL -INNESOTANS 7E TAKE A COMPREHENSIVE SCIENCE BASED APPROACH THAT INCLUDES CLINICAL INTERVEN TIONS PUBLIC AWARENESS CAMPAIGNS COMMUNITY POLICY INITIATIVES AND OUTREACH TO HIGH RISK GROUPS /NE OF OUR MOST VISIBLE PROGRAMS IS THE "LUE0RINT FOR (EALTHยง STOP SMOKING PROGRAM FOR "LUE #ROSS MEMBERS 4HROUGH IT WE VE COUNSELED THOUSANDS OF SMOKERS OVER THE PAST FEW YEARS AND HELPED MORE THAN SUCCESSFULLY QUIT 7E ALSO HAVE BEEN WORKING TO INCREASE THE STATE S EXCISE TAX ON TOBACCO AND TO HELP COMMUNITIES PROTECT PEOPLE FROM SECONDHAND SMOKE ย BOTH OF THESE STRATEGIES HELP SMOKERS QUIT AND IMPROVE HEALTH 4WO YEARS AGO WE RAN A SUCCESSFUL PUBLIC AWARENESS CAMPAIGN ABOUT THE DANGERS OF HIGH BLOOD PRESSURE IN WHICH WE ENCOURAGED -INNESOTANS TO KNOW THEIR BLOOD PRESSURE NUMBERS AND GET HELP IF THEY WERE OR HIGHER *UST NOW WE VE LAUNCHED A TERRIlC NEW CAMPAIGN TO PROMOTE PHYSICAL ACTIVITY 7E RE PILOTING THE hDOv CAMPAIGN IN PARTNERSHIP WITH THE !MERICAN (EART !SSOCIATION IN $ULUTH AND "ROOKLYN #ENTER USING INNOVATIVE MESSAGES AND STREET MARKETING TO HELP PEOPLE lND EVERYDAY OPPORTUNITIES FOR ADDING PHYSICAL ACTIVITY TO THEIR LIVES #ONTINUED ON PAGE

-AY *UNE

#OLLEAGUE )NTERVIEW #ONTINUED FROM PAGE

(OW DOES THE #ENTER EVALUATE ITS PROGRAMS %VALUATION IS A KEY PART OF OUR WORK 7E MONITOR TOBACCO PREVALENCE RATES THROUGH A BROAD AND RIGOROUS POPULATION BASED SURVEY AND CONDUCT EVALUATIONS OF OUR MAJOR PROGRAM COMPONENTS 7E SHARE OUR RESULTS THROUGH LOTS OF PRESENTATIONS AND PUBLICATIONS 7E HAVE WORKED CLOSELY WITH THE -INNESOTA $EPARTMENT OF (EALTH 5NIVERSITY OF -INNESOTA

AND -INNESOTA 0ARTNERSHIP FOR !CTION !GAINST 4OBACCO TO PROVIDE SCI ENTIlCALLY VALID DATA ON -INNESOTA S KNOWLEDGE ATTITUDES AND BEHAVIORS CONCERNING ADULT TOBACCO USE AND EXPOSURE TO SECONDHAND SMOKE IN ORDER TO SUPPORT POLICY DEVELOPMENT ADVOCACY AND PROGRAM PLANNING

7HAT DOES SUCCESS LOOK LIKE FOR YOU AND THE #ENTER &OR STARTERS WE ARE COMMITTED TO ACHIEVING LOWER SMOKING RATES AND INCREASED LEVELS OF PHYSICAL ACTIVITY "Y REDUCING THESE KEY RISK FACTORS

-INNESOTA WILL END UP WITH LESS CANCER LESS HEART DISEASE AND LOWER HEALTH CARE COSTS 4HOSE BIG GOALS WON T BE ACHIEVED OVERNIGHT SO WE HAVE INTERIM MEASURES TO GAUGE OUR PROGRESS "UT ULTIMATELY THOSE ARE THE GOALS WE ARE AFTER

(OW IS "LUE #ROSS HELPING MEMBERS QUIT SMOKING 7E ATTACK THE PROBLEM FROM A NUMBER OF DIFFERENT ANGLES 7E REWARD PHYSICIANS WHO TREAT SMOKERS EFFECTIVELY 7E OFFER ˆ AND ADVERTISE ˆ A PHONE COUNSELING PROGRAM THAT HAS PROVEN EFFECTIVE FOR THOUSANDS OF "LUE #ROSS MEMBERS 4HAT S FOR ANY READER WHO WILL DO US THE GREAT FAVOR OF REFERRING PATIENTS 7E OFFER THE FULL RANGE OF CESSATION MEDICATIONS TO OUR FULLY INSURED MEMBERS AND MANY OF OUR SELF INSURED GROUPS ALSO CHOOSE THAT COVERAGE 7E DEVELOPED AN INNOVATIVE PUBLIC EDUCATION CAMPAIGN SPECIlCALLY AIMED AT COLLEGE STUDENTS WHO SMOKE 4HE LIST GOES ON BUT THOSE ARE A FEW OF OUR MAJOR INITIATIVES

7HY IS TOBACCO CONTROL STILL IMPORTANT 7HY HAVEN T WE SOLVED THE PROBLEM 4OBACCO CONTROL IS IMPORTANT BECAUSE TOBACCO IS THE LEADING CAUSE OF PREVENTABLE DEATH AND DISABILITY IN THE NATION 7HY HAVEN T WE SOLVED THE PROBLEM #ANDIDLY WE AREN T SOLVING THE PROBLEM BECAUSE THE TOBACCO INDUSTRY HAS MORE WILL AND RESOURCES TO PROMOTE TOBACCO THAN THE REST OF SOCIETY HAS TO DISCOURAGE IT ! MOUNTAIN OF RESEARCH HAS SHOWN US HOW TO REDUCE TOBACCO USE ˆ SIGNIlCANTLY INCREASE THE CIGARETTE TAX

CREATE MORE SMOKE FREE AREAS TREAT TOBACCO ADDICTION AND INVEST IN PREVENTION 7E AS A SOCIETY JUST HAVEN T HAD THE COLLECTIVE WILL TO TACKLE THE PROBLEM AGGRESSIVELY !S A RESULT MILLIONS CONTINUE TO DIE WHOLLY PREVENTABLE DEATHS AND THE HEALTH CARE COSTS CONTINUE TO MOUNT

7HAT ARE THE BIGGEST OPPORTUNI TIES FOR -INNESOTA TOBACCO REDUC TION IN THE NEXT FEW YEARS

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%VERYONE IS TRYING TO lGURE OUT HOW TO CONTROL HEALTH CARE COSTS )N OUR STATEWIDE -INNESOTA $ECIDES TOWN HALL MEETINGS A FEW YEARS AGO

-INNESOTANS TOLD "LUE #ROSS THAT THEY VALUE AND WANT MORE EMPHASIS ON PREVENTION 3O ANY SERIOUS THOUGHTFUL DISCUSSION OF HEALTH CARE COSTS SHOULD LEAD TO A REINVIGORATED EM PHASIS ON TOBACCO REDUCTION 7E WILL MAKE A LOT OF PROGRESS CONTROLLING HEALTH CARE COSTS IF WE TAKE AT LEAST THREE STEPS &IRST INCREASE THE CIGARETTE EXCISE TAX BY A DOLLAR PER PACK OR MORE WHICH WILL REDUCE THE SMOKING RATE 3ECOND CREATE MORE SMOKE FREE ENVIRONMENTS

INCLUDING RESTAURANTS AND BARS 4HIRD FUND STATEWIDE TOBACCO PREVENTION PROGRAMS AT THE LEVEL RECOMMENDED BY THE #ENTERS FOR $ISEASE #ONTROL 4HE RESEARCH TELLS US WHAT WORKS SO WE JUST HAVE TO DO IT 4HAT S AN EXCITING OP PORTUNITY AND THESE ARE EXCITING TIMES U

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

6ARIATIONS IN THE 5SE OF (EALTH 3ERVICES IN -INNESOTA BY )NSURANCE 3TATUS 2ESULTS FROM THE -INNESOTA (EALTH !CCESS 3URVEY

4

4(%2% !2% -!.9 490%3 /& "!22)%23 THAT CAN PREVENT PEOPLE

FROM HAVING ACCESS TO APPROPRIATE AND TIMELY HEALTH CARE /F THESE BAR RIERS A LACK OF HEALTH INSURANCE COVERAGE IS ONE OF THE MOST SIGNIlCANT 4HE PURPOSE OF THIS ISSUE BRIEF IS TO PRESENT lNDINGS ON ACCESS AND THE USE OF HEALTH CARE SERVICES AMONG UNINSURED -INNESOTANS COMPARED TO PEOPLE WITH PRIVATE HEALTH INSURANCE COVERAGE 4HE ANALYSIS IN THIS ISSUE BRIEF IS BASED ON DATA FROM THE -INNESOTA (EALTH !CCESS 3URVEY THAT WAS CONDUCTED BY THE -INNESOTA $EPARTMENT OF (EALTH IN COLLABORATION WITH THE 5NIVERSITY OF -INNE SOTA 3CHOOL OF 0UBLIC (EALTH $IVISION OF (EALTH 3ERVICES 2ESEARCH AND 0OLICY 4HE -INNESOTA (EALTH !CCESS 3URVEY IS THE LARGEST AND MOST COMPREHENSIVE HEALTH INSURANCE SURVEY CONDUCTED IN -INNESOTA TO DATE 4HIS SURVEY WAS FUNDED BY A GRANT FROM THE 5 3 $EPARTMENT OF (EALTH AND (UMAN 3ERVICES (EALTH 2ESOURCES AND 3ERVICES !DMINISTRATION (23!

5SUAL 3OURCE OF #ARE (AVING A USUAL SOURCE OF CARE Â&#x2C6; A PLACE THAT A PERSON GOES TO WITH NEW HEALTH PROBLEMS REQUIRING A DOCTOR S ATTENTION Â&#x2C6; IS A KEY INDICATOR OF ACCESS TO PRIMARY CARE AND WHETHER A PERSON IS LIKELY TO HAVE CONTINUITY OF CARE !S 4ABLE SHOWS THE LIKELIHOOD OF HAVING A USUAL SOURCE OF CARE VARIES SIGNIlCANTLY BY HEALTH INSURANCE STATUS 5NINSURED -INNESOTANS ARE BETWEEN THREE AND lVE TIMES MORE LIKELY TO LACK A USUAL SOURCE OF CARE THAN PEOPLE WITH PRIVATE INSURANCE .EARLY HALF PERCENT OF PEOPLE UNINSURED FOR A YEAR OR MORE I E THE LONG TERM UNINSURED DID NOT HAVE A USUAL SOURCE OF CARE COMPARED TO ABOUT ONE QUARTER PERCENT OF PEOPLE UNINSURED FOR LESS THAN A YEAR )N CONTRAST FEWER THAN PERCENT OF THE PRIVATELY INSURED LACKED A USUAL SOURCE OF CARE

4ABLE 0ERCENTAGE OF -INNESOTANS 7ITH A 5SUAL 3OURCE OF #ARE BY (EALTH )NSURANCE 3TATUS (AVE A 5SUAL 3OURCE OF #ARE 9ES

.O

'ROUP #OVERAGE

)NDIVIDUAL #OVERAGE

5NINSURED 9EAR OR -ORE

5NINSURED ,ESS THAN 9EAR

0RIVATE #OVERAGE /VERALL

5NINSURED AT THE 4IME OF 3URVEY

.UMBERS IN BOLD INDICATE A STATISTICALLY SIGNIlCANT DIFFERENCE LEVEL FROM THE RATE OF THE PRIVATELY INSURED OVERALL 'ROUP COVERAGE IS COVERAGE THROUGH AN EMPLOYER )NDIVIDUAL COVERAGE IS PURCHASED IN THE INDIVIDUAL MARKET

3INCE HAVING HEALTH INSURANCE COVERAGE IS A STRONG DETERMINANT OF HAVING A USUAL SOURCE OF CARE WE EXPECT THE MAIN REASONS FOR LACKING A USUAL SOURCE OF CARE TO BE RELATED TO WHETHER OR NOT A PERSON HAS HEALTH INSURANCE COVERAGE 4ABLE SHOWS THAT THIS IS IN FACT THE CASE /F THOSE UNINSURED AND LACKING A USUAL SOURCE OF CARE NEARLY PERCENT REPORTED BEING UNINSURED AS ONE OF THE MAIN REASONS FOR NOT HAVING A USUAL SOURCE OF CARE !N ADDITIONAL PERCENT OF THE UNINSURED REPORTED OTHER lNANCIAL REASONS FOR LACKING A USUAL SOURCE OF CARE IT IS LIKELY THAT FOR SOME PEOPLE THIS ANSWER REFERRED TO THE COST OF HEALTH INSURANCE &OR BOTH THE INSURED AND THE UNINSURED THE MOST COMMON REASON GIVEN FOR NOT HAVING A USUAL SOURCE OF CARE WAS THAT THEY FELT THEY DID NOT HAVE A NEED FOR ONE BECAUSE THEY WERE RARELY SICK PERCENT OF PEOPLE WITH PRIVATE INSURANCE AND PERCENT OF THE UNINSURED )N SUMMARY WHILE IT IS COMMON FOR #ONTINUED ON PAGE

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

-AY *UNE

-INNESOTA (EALTH !CCESS 3URVEY #ONTINUED FROM PAGE

4ABLE

PEOPLE WHO DO NOT HAVE A USUAL SOURCE OF CARE TO REPORT THAT THEY HAVE NO NEED FOR ONE IT IS MORE LIKELY AMONG THE UNINSURED THAT THE REASON FOR LACKING A USUAL SOURCE OF CARE IS NOT VOLUNTARY 4ABLE ALSO SHOWS AN INTERESTING VARIATION BETWEEN THE RESPONSES OF THOSE WITH GROUP INSURANCE AND THOSE WITH INSURANCE COVERAGE PUR CHASED IN THE INDIVIDUAL MARKET ! SIGNIlCANTLY HIGHER PROPORTION OF THE INDIVIDUALLY INSURED PERCENT THAN THOSE WITH GROUP INSURANCE PERCENT REPORT LACKING A USUAL SOURCE OF CARE BECAUSE THEY CANNOT AFFORD ONE /NE REASON FOR THIS DIFFERENCE IS LIKELY THE FACT THAT PEOPLE WITH INDIVIDUAL COVERAGE HAVE LESS COMPREHENSIVE INSURANCE BENElTS THAN PEOPLE WITH GROUP COVERAGE Â&#x2C6; FOR EXAMPLE THEY USUALLY HAVE POLI CIES WITH HIGHER DEDUCTIBLES #ONSEQUENTLY THE UP FRONT COST THAT THE INDIVIDUALLY INSURED HAVE TO PAY OUT OF POCKET MAY POTENTIALLY ACT AS A DETERRENT TO MAINTAINING A USUAL SOURCE OF CARE

0ERCENTAGE OF -INNESOTANS 7ITHOUT A 5SUAL 3OURCE OF #ARE BY )NSURANCE 4YPE AND $EMOGRAPHIC 'ROUP

/VERALL 2ATE

5NINSURED

0RIVATE #OVERAGE

!GE

-ALE

&EMALE

,OW INCOME

(IGHER INCOME

7HITE

.ON 7HITE

5 3

.OT 5 3

'REATER -INNESOTA

4WIN #ITIES

'ENDER

4ABLE -AIN 2EASON FOR .OT (AVING A 5SUAL 3OURCE OF #ARE 0RIVATE #OVERAGE 5NINSURED

!LL 0RIVATE #OVERAGE

&INANCIAL REASONS NOT AFFORDABLE

.O INSURANCE COVERAGE

)NCOME

'ROUP #OVERAGE

)NDIVIDUAL #OVERAGE

.O NEED BECAUSE RARELY GET SICK

4IME AND TRANSPORTATION BARRIERS

,ANGUAGE AND TRUST BARRIERS

2ACE

2ECENT CHANGES WITH DOCTORS OR HEALTH PLAN /THER REASONS

.UMBERS IN BOLD INDICATE A STATISTICALLY SIGNIlCANT DIFFERENCE LEVEL FROM THE DISTRIBUTION OF THE PRIVATELY INSURED OVERALL *UST AS THE RATES OF INSURANCE COVERAGE VARY BY DEMOGRAPHIC CATEGORY SO DOES THE LIKELIHOOD OF LACKING A USUAL SOURCE OF CARE 4ABLE SHOWS THOSE VARIATIONS BY AGE GENDER RACE AND INCOME AND COMPARES THE RATES FOR DIFFERENT DEMOGRAPHIC GROUPS TO THE OVERALL POPULATION OF THE UNINSURED AND THE PRIVATELY INSURED 7HILE THE PERCENT OF -INNESOTANS WHO LACK A USUAL SOURCE OF CARE VARIES SIGNIlCANTLY BY INSURANCE TYPE SOME CONSISTENT PATTERNS ACROSS DEMOGRAPHIC GROUPS ARE EVIDENT AS SHOWN IN 4ABLE !MONG THE UN INSURED CHILDREN YOUNGER THAN ARE THE LEAST LIKELY AND MALES THE MOST LIKELY TO LACK A USUAL SOURCE OF CARE !MONG THE PRIVATELY INSURED

FEMALES ARE LEAST LIKELY AND ADULTS BETWEEN AND ARE MOST LIKELY TO LACK A USUAL SOURCE OF CARE

-AY *UNE

#OUNTRY OF /RIGIN

2EGION

.UMBERS IN BOLD INDICATE A STATISTICALLY SIGNIlCANT DIFFERENCE LEVEL FROM THE OVERALL RATES OF THE UNINSURED OR THE PRIVATELY INSURED h,OW INCOMEv IS DElNED AS OF POVERTY OR BELOW 4HIS IS FOR A FAMILY OF FOUR ACCORDING TO THE &EDERAL 0OVERTY 'UIDELINE h(IGHER INCOMEv IS ABOVE OF POVERTY

3OURCES OF #ARE )N ADDITION TO BEING LESS LIKELY TO HAVE A USUAL SOURCE OF CARE THE UNINSURED ALSO REPORT BEING LESS HEALTHY THAN THE POPULATION AS A WHOLE !BOUT PERCENT OF THE UNINSURED REPORT BEING IN FAIR OR POOR HEALTH COMPARED WITH ONLY PERCENT OF THE PRIVATELY INSURED A DIFFERENCE THAT IS STATISTI CALLY SIGNIlCANT $ESPITE BEING LESS HEALTHY ON AVERAGE THE UNINSURED USE FEWER HEALTH SERVICES 4HERE ARE SOME SIGNIlCANT DIFFERENCES IN THE WAYS THAT THE UNINSURED ACCESS HEALTH CARE SERVICES COMPARED TO PEOPLE WITH PRIVATE COVERAGE -ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

4HOSE DIFFERENCES FOR PEOPLE WHO HAVE A USUAL SOURCE OF CARE ARE SHOWN IN 4ABLE 7HILE BOTH POPULATION GROUPS RELY MOSTLY ON CLINICS AND DOC TORS OFlCES TO OBTAIN CARE PERCENT OF THE UNINSURED AND PERCENT OF THOSE WITH PRIVATE COVERAGE THE UNINSURED ARE MORE LIKELY TO USE PUBLIC HEALTH OR COMMUNITY CLINICS PERCENT COMPARED WITH PERCENT AND LESS LIKELY TO USE PRIVATE CLINICS THAN THOSE WITH PRIVATE HEALTH INSURANCE COVERAGE PERCENT COMPARED WITH PERCENT &URTHER THE UNINSURED ARE ALSO MORE LIKELY THAN THE PRIVATELY INSURED TO RELY ON EMERGENCY ROOM AND URGENT CARE SETTINGS PERCENT COMPARED WITH PERCENT 4HERE ARE TWO PRIMARY IMPLICATIONS OF THE GREATER RELIANCE OF THE UNINSURED ON EMERGENCY ROOMS AND URGENT CARE &IRST SERVICES DELIVERED IN THESE SETTINGS ARE MORE EXPENSIVE THAN COMPARABLE SERVICES PROVIDED AT PHYSICIAN CLINICS 4HIS HIGHER COST IS EITHER BORNE BY THE UNINSURED THEMSELVES OR SHOWS UP AS UNCOMPENSATED CARE FOR HEALTH CARE PROVID ERS 3OME OF THIS UNCOMPENSATED CARE IS PAID FOR THROUGH HIGHER PRICES CHARGED FOR OTHER PATIENTS SOME IS ABSORBED BY THE PROVIDER AS FORGONE INCOME AND SOME IS PAID FOR BY TAXPAYERS THROUGH PUBLIC SUBSIDIES 3ECOND PATIENTS WHO RELY ON THE EMERGENCY ROOM FOR THEIR PRIMARY CARE NEEDS ARE LESS LIKELY TO RECEIVE PREVENTIVE CARE SERVICES AND MORE LIKELY TO LACK CONTINUITY OF CARE !S A RESULT THEY MAY DELAY SEEKING NEEDED CARE AND PRESENT WITH GREATER COMPLICATIONS OR AT AN ADVANCED POINT IN THEIR ILLNESS

4ABLE ,OCATION 7HERE -INNESOTANS 7ITH A 5SUAL 3OURCE OF #ARE /BTAIN (EALTH #ARE 3ERVICES 5NINSURED %2 5RGENT #ARE

0RIVATE #OVERAGE

0UBLIC HEALTH COMMUNITY CLINIC

(OSPITAL OUTPATIENT CLINC

0RIVATE CLINIC DOCTOR S OFlCE

/THER

(OSPITAL

3OME OTHER PLACE

#LINIC $OCTOR S OFlCE

4OTAL

.UMBERS IN BOLD INDICATE A STATISTICALLY SIGNIlCANT DIFFERENCE LEVEL FROM THE DISTRIBUTION FOR THE PRIVATELY INSURED RESPONDENTS #ONlDENCE IN !BILITY TO 'ET #ARE 4ABLE DEPICTS THE RELATIVE CONlDENCE OF SURVEY RESPONDENTS IN BEING ABLE TO OBTAIN CARE WHEN NEEDED !S EXPECTED PEOPLE WITH PRIVATE HEALTH INSURANCE COVERAGE ARE MORE CONlDENT IN THEIR ABILITY TO OBTAIN NEEDED CARE THAN THE UNINSURED !BOUT PERCENT OF PEOPLE WITH PRIVATE COVER AGE ARE EITHER STRONGLY OR SOMEWHAT CONlDENT THAT THEY CAN OBTAIN CARE WHEN NEEDED )N CONTRAST ONLY ABOUT TWO THIRDS OF THE UNINSURED PERCENT ARE SIMILARLY CONlDENT IN THEIR ABILITY TO GET NEEDED CARE 4ABLE ALSO SHOWS ANOTHER DISTINCTION BETWEEN THE RESPONSES OF THE UNINSURED -ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

AND THE PRIVATELY INSURED 4HE PRIVATELY INSURED ARE MUCH MORE LIKELY TO BE STRONGLY CONlDENT OF THEIR ABILITY TO OBTAIN CARE THAN THE UNINSURED !BOUT PERCENT OF THE PRIVATELY INSURED RESPONDENTS ARE STRONGLY CON lDENT COMPARED WITH ONLY ONE THIRD OF THE UNINSURED

4ABLE #ONlDENCE IN !BILITY TO /BTAIN #ARE h) AM CONlDENT THAT ) CAN GET THE CARE ) NEED WHEN ) NEED ITv 0RIVATE #OVERAGE 5NINSURED

!LL 0RIVATE 'ROUP #OVERAGE #OVERAGE

)NDIVIDUAL #OVERAGE

!GREE STRONGLY AGREE

SOMEWHAT AGREE

SOMEWHAT DISAGREE

STRONGLY DISAGREE

$ISAGREE

.UMBERS IN BOLD INDICATE A STATISTICALLY SIGNIlCANT DIFFERENCE LEVEL FROM THE DISTRIBUTION FOR THE PRIVATELY INSURED OVERALL 7HEN STUDYING REPORTED CONlDENCE IN BEING ABLE TO OBTAIN CARE BY AGE GROUP ONE CATEGORY STANDS OUT Â&#x2C6; RESPONDENTS ON BEHALF OF UNINSURED CHILDREN ARE WHEN COMPARED WITH UNINSURED OVERALL MORE CONlDENT IN THEIR ABILITY TO OBTAIN CARE WHEN THE CHILDREN NEED IT $ESPITE SIG NIlCANT BARRIERS TO OBTAINING HEALTH SERVICES PERCENT OF CARETAKERS OF UNINSURED CHILDREN ARE CONlDENT ABOUT BEING ABLE TO GET NEEDED CARE FOR THEIR CHILDREN COMPARED TO PERCENT FOR THE UNINSURED OVERALL 3TILL THIS LEVEL OF CONlDENCE IS LOWER THAN FOR PRIVATELY INSURED CHILDREN PERCENT 5SE OF 3ERVICES 4HIS SECTION PROVIDES AN OVERVIEW OF THE USE OF HEALTH SERVICES AMONG THE PRIVATELY INSURED AND THE UNINSURED BY REPORTING THE NUMBER OF DOC TOR VISITS THE NUMBER OF INPATIENT VISITS AND THE VOLUME OF EMERGENCY ROOM USE &IGURE DEPICTS THE VARIATION IN THE NUMBER OF PHYSICIAN VISITS IN THE THREE MONTHS PRIOR TO THE SURVEY BY TYPE OF INSURANCE COVERAGE $ESPITE THE FACT THAT THE UNINSURED REPORT POORER HEALTH STATUS THEY ARE SIGNIlCANTLY LESS LIKELY TO INDICATE THAT THEY HAVE SEEN A PHYSICIAN THAN PEOPLE WITH PRIVATE INSURANCE ! SIGNIlCANTLY GREATER PROPORTION OF THE UNINSURED DID NOT HAVE ANY PHYSICIAN VISIT IN THE THREE MONTHS PRIOR TO THE SURVEY COMPARED TO THE PRIVATELY INSURED PERCENT AND PERCENT

RESPECTIVELY 4HIS RESULT IS CONSISTENT WITH OTHER RESEARCH THAT SHOWS THAT THE UNINSURED USE FEWER HEALTH SERVICES DESPITE THEIR LESS FAVORABLE HEALTH STATUS )T IS UNCLEAR TO WHAT EXTENT THIS DIFFERENCE IS THE RESULT OF lNANCIAL BARRIERS THE UNINSURED FACE OR OF HIGHER UTILIZATION OF SERVICES

BY PEOPLE WITH INSURANCE COVERAGE #ONTINUED ON PAGE

-AY *UNE

-INNESOTA (EALTH !CCESS 3URVEY #ONTINUED FROM PAGE

&IGURE .UMBER OF 0HYSICIAN 6ISITS )N THE ,AST 4HREE -ONTHS BY )NSURANCE 4YPE

MORE THAN 6ISITS

TO 6ISITS TO 6ISITS

TO 6ISITS

6ISIT

.O 6ISITS

5NINSURED

&OOTNOTES

0RIVATE )NSURANCE

)NDICATES A STATISTICALLY SIGNIlCANT DIFFERENCE LEVEL FROM THE DISTRIBU TION FOR THE PRIVATELY INSURED !S SHOWN IN 4ABLE THERE IS NO STATISTICALLY SIGNIlCANT DIFFERENCE BETWEEN THE USE OF INPATIENT CARE AND EMERGENCY ROOM SERVICES OF THE UNINSURED AND THE PRIVATELY INSURED 4HIS MAY BE BECAUSE THE USE OF EMERGENCY ROOMS AND INPATIENT HOSPITALIZATIONS ARE USUALLY NOT DISCRETIONARY SER VICES AND THEREFORE WE EXPECT TO SEE SMALLER DIFFERENCES )N ADDITION A HOSPITALIZATION OR SERIOUS ILLNESS WOULD LIKELY BE AN EVENT THAT WOULD CAUSE UNINSURED PEOPLE TO SEEK COVERAGE OPTIONS 'IVEN THAT A LARGE SHARE OF THE UNINSURED ABOUT TWO THIRDS ARE POTENTIALLY ELIGIBLE FOR INSURANCE COVERAGE IT IS AT LEAST SOMEWHAT LIKELY THAT PEOPLE WHO ARE UNINSURED AND EXPERIENCE AN ILLNESS REQUIRING HOSPITALIZATION WILL BE ABLE TO OBTAIN INSURANCE COVERAGE

4ABLE 0ROPORTION OF 0OPULATION 5SING (OSPITAL 3ERVICES BY )NSURANCE 4YPE 5NINSURED

0RIVATE #OVERAGE

)NPATIENT #ARE /NE OR MORE VISITS

.O INPATIENT VISITS

/NE OR MORE VISITS

.O EMERGENCY ROOM USE

$IFFERENCES BETWEEN THE PRIVATELY INSURED AND THE UNINSURED ARE NOT STATISTI CALLY SIGNIlCANT

! SUBSET OF RESPONDENTS TO THIS HOUSEHOLD SURVEY CONDUCTED BY TELEPHONE WERE ASKED ABOUT THE AVAILABILITY OF A USUAL SOURCE OF CARE THE LOCATION OF THAT CARE AND THE VOLUME OF INPATIENT AND OUTPATIENT VISITS 3PECIlCALLY POPULATIONS WHO RECEIVED THESE USE QUESTIONS INCLUDED ALL OF THE UNINSURED PARTICIPATED IN THE SURVEY

ALL THOSE WITH INDIVIDUAL COVERAGE

AND A SUBSET OF -INNESOTANS WITH GROUP COVERAGE &OR MORE DETAIL ON THE SURVEY METHODOLOGY SEE -$( (EALTH %CONOMICS 0ROGRAM h-INNESOTA S 5NINSURED &INDINGS FROM THE (EALTH !CCESS 3URVEY v !PPENDIX !

3TARlELD " 0RIMARY #ARE "ALANCING (EALTH .EEDS 3ERVICES AND 4ECHNOLOGY

/XFORD 5NIVERSITY 0RESS .EW 9ORK 2ESULTS PERTAINING TO RESPONSES FROM PEOPLE WITH INDIVIDUAL OR GROUP COVERAGE ARE

UNLESS NOTED OTHERWISE REPORTED IN A hPRIVATE COVERAGEv CATEGORY 4HIS IS DONE BE CAUSE RESULTS FOR PEOPLE WITH INDIVIDUAL COVERAGE IN MOST CASES TRACK CLOSELY THOSE FOR PEOPLE WITH GROUP COVERAGE ! FORTHCOMING STUDY BY THE (EALTH %CONOMICS 0ROGRAM REPORTS THAT THE MEDIAN DEDUCTIBLES FOR -INNESOTANS WITH INDIVIDUAL COVERAGE WAS PER PERSON 4HIS COMPARES TO RECENTLY PUBLISHED NATIONAL DATA SHOWING THE AVERAGE ANNUAL DEDUCTIBLE FOR EMPLOYER BASED SINGLE COVERAGE TO BE 4HE +AISER &AMILY &OUNDATION AND (EALTH 2ESEARCH AND %DUCATIONAL 4RUST %MPLOYER (EALTH "ENElT !NNUAL 3URVEY

P 3EE FOR MORE DETAIL -INNESOTA $EPARTMENT OF (EALTH (EALTH %CONOMICS 0ROGRAM

4HE +AISER #OMMISSION ON -EDICAID AND THE 5NINSURED h3ICKER AND 0OORER 4HE #ONSEQUENCES OF "EING 5NINSURED v P )NSTITUTE OF -EDICINE #OMMITTEE ON THE #ONSEQUENCES OF 5NINSURANCE #ARE 7ITHOUT #OVERAGE 4OO ,ITTLE 4OO ,ATE .ATIONAL !CADEMY 0RESS 7ASHINGTON $ #

P 7HERE THE TARGETED RESPONDENT WAS A CHILD A PARENT WAS ASKED ABOUT HIS OR HER CONlDENCE WITH BEING ABLE TO GET NEEDED CARE FOR THE CHILD )NSTITUTE OF -EDICINE #OMMITTEE ON THE #ONSEQUENCES OF 5NINSURANCE 3TUDIES ALSO REPORT THAT THE UNINSURED ARE MORE LIKELY TO DELAY NEEDED CARE (OWEVER WE CANNOT TEST THIS FOR -INNESOTA AS WE DID NOT ASK THAT QUESTION IN OUR SURVEY .OTE THE GREATER RELIANCE ON EMERGENCY ROOM AND URGENT CARE SETTING REPORTED IN 4ABLE REFERS ONLY TO UNINSURED WHO HAVE A USUAL SOURCE OF CARE )N CONTRAST THIS ANALYSIS INCLUDES EVERY UNINSURED PERSON

%MERGENCY 2OOM 5SE

-AY *UNE

3UMMARY 4HIS ISSUE BRIEF SHOWS THAT THE UNINSURED ARE LESS LIKELY TO HAVE A USUAL SOURCE OF CARE LESS LIKELY TO USE HEALTH CARE SERVICES MORE LIKELY TO RECEIVE CARE IN AN URGENT CARE SETTING AND LESS CONlDENT IN THEIR ABILITY TO GET CARE WHEN THEY NEED IT !LL OF THESE ISSUES HAVE POTENTIAL CONSEQUENCES FOR THE HEALTH STATUS OF THE UNINSURED AND HEALTH OUTCOMES WHEN THEY DO RECEIVE CARE )N A RECENT SUMMARY OF RESEARCH ON THIS TOPIC THE )NSTITUTE OF -EDICINE NOTED THAT WORKING AGE !MERICANS WITHOUT HEALTH INSURANCE ARE MORE LIKELY TO v RECEIVE TOO LITTLE MEDICAL CARE AND RECEIVE IT TOO LATE v BE SICKER AND DIE SOONER AND v RECEIVE POORER CARE WHEN THEY ARE IN THE HOSPITAL EVEN FOR ACUTE SITU ATIONS LIKE A MOTOR VEHICLE CRASH 'IVEN THAT HEALTH INSURANCE AND HAVING A USUAL SOURCE OF CARE ARE ASSOCIATED WITH BETTER HEALTH AND IMPROVED HEALTH OUTCOMES POLICY MAKERS SHOULD CONTINUE TO EXPLORE WAYS TO ENSURE THAT ALL -INNESOTANS HAVE ACCESS TO AFFORDABLE HIGH QUALITY HEALTH INSURANCE COVERAGE U

-INNESOTA $EPARTMENT OF (EALTH (EALTH %CONOMICS 0ROGRAM P )NSTITUTE OF -EDICINE #OMMITTEE ON THE #ONSEQUENCES OF 5NINSURANCE 2EPORT 3UMMARY P

2EPRINTED WITH PERMISSION FROM (EALTH %CONOMICS 0ROGRAM )SSUE "RIEF

&EBRUARY -ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

$QJHOD·V 6WRU\

$Q 2UWKRSHGLF 2G\VVH\

)

). *5.% ) 42!6%,%$ WITH MY WIFE

,U,U AND MY FOUR CHILDREN 4ALIA 4RICIA -I CHAEL AND 0ATRICK TO (ONDURAS TO VOLUNTEER AT AN ORPHANAGE !T THE hRANCHv CHILDREN RECEIVE THE LOVE CARE AND EDUCATION THEY NEED TO DEVELOP INTO SELF SUSTAINING ADULTS !S IS COMMON IN THE VOLUNTEER S EXPERIENCE WE WERE ALL MORE PROFOUNDLY CHANGED THAN WERE THOSE WITH WHOM WE MADE CONTACT

) HAD VOLUNTEERED PREVIOUSLY THROUGH AN EXCELLENT ORGANIZATION /RTHOPEDICS /VERSEAS

BUT VOLUNTEER ACTIVITIES FOR MY CHILDREN WERE NOT AVAILABLE AND THERE WAS NOT A SECURE AREA WHERE WORRYING OF THEIR WHEREABOUTS WOULD NOT BE AN ISSUE ) WAS LOOKING FOR AN EXPERIENCE FOR MY ENTIRE FAMILY !T .UESTROS 0EQUENOS (ERMANOS .0( Â&#x2C6; hOUR LITTLE BROTHERS AND SISTERSv THE OPPORTUNITY FOR WHICH ) D BEEN SEARCHING WAS FOUND )T IS NESTLED IN THE CENTER OF ITS

ACRE WOODED PROPERTY

FEET ABOVE SEA LEVEL AMONG ROLLING HILLS

%ACH MORNING ) SET OUT ON A lVE MILE RUN WITH TWO YEAR OLD VOLUNTEERS FROM 'ERMANY ) SPENT MOST OF THE DAY AT THE hCLINICA EXTERNAv Â&#x2C6;A CLINIC RUN BY A VOLUNTEER PRIMARY CARE PHYSICIAN OR NURSE PRACTITIONER ON THE .0( PROPERTY

WHICH SERVED INDIGENT ADULTS AND CHILDREN FROM THE SURROUNDING COUNTRYSIDE )T INVOLVED MOSTLY PRIMARY CARE DIABETES (4.

ETC AND HAD A REASONABLY WELL STOCKED PHARMACY ROOM )TS MISSION WAS TO SERVE THE INDIGENT AND THEY SAW APPROXIMATELY PATIENTS A DAY

!S AN ORTHOPEDIC SURGEON ) DIDN T HAVE AN IDEAL OPPORTUNITY TO USE MY SKILLS BUT THERE WAS ANOTHER COMPONENT ! GROUP OF (ONDURAN PHYSICIANS HAD ASSISTED .0( IN CONVERTING A SEMI TRUCK TRAILER INTO A SMALL OPERATING ROOM )T WAS EQUIPPED WITH AN ANESTHESIA MACHINE

AND THE REST OF THE BARE NECESSITIES ) WAS ABLE TO

"9 0%4%2 * $!,9 - $

PERFORM SEVERAL OUTPATIENT PROCEDURES WITH THE HELP OF A LOCAL ANESTHESIOLOGIST .0( IS IN THE PROCESS OF BUILDING A PERMANENT OUTPATIENT SUR GERY CENTER NEXT TO THE CLINIC AND PLANS TO SERVE THE SURROUNDING HILLSIDE COMMUNITIES /NCE THAT IS IN PLACE SURGEONS COULD MORE SPECIlCALLY OFFER THEIR SERVICES )T IS CURRENTLY AND WILL CONTINUE TO BE AN EXCELLENT VOLUNTEER OPPORTUNITY FOR THE PRIMARY CARE PHYSICIAN

-EANWHILE MY CHILDREN WERE KEEPING BUSY DIGGING DITCHES READING AND PLAYING WITH THE TODDLERS IN THE hBABY HOUSE v AND HELPING SKIN CHICKENS IN THE KITCHEN 4HEY ALSO HELPED MY WIFE ,U,U A PEDIATRIC NURSE PERFORM WELL CHILD CHECKUPS ON MOST OF THE SMALLER CHILDREN /NE OF MY FAMILY S HIGHLIGHTS WAS CLEANING THE CHILDREN S EARS 3EVERAL SMALL INTERESTING OBJECTS WERE RETRIEVED FROM THEIR EXTERNAL EAR CANALS 4HE (ONDURAN CHILDREN ENJOYED THE ATTENTION SO MUCH THAT THEY KEPT GETTING BACK IN LINE TO BE EXAMINED 4HEIR Â FOOT FRAMES LARGE BROWN EYES AND INFECTIOUS SMILES ALL STARTED LOOKING THE SAME &INALLY ,U,U HAD TO MARK EACH HAND TO KNOW IF THEY HAD BEEN SEEN BEFORE

! SPECIAL TWIST OF FATE OCCURRED WHEN ) EVALUATED A YEAR OLD GIRL ON THE RANCH NAMED !NGELA 4HREE YEARS EARLIER .0( HAD TAKEN HER IN ALONG WITH AN OLDER SISTER AND YOUNGER BROTHER

WHEN THEIR MOTHER DIED OF !)$3 4HEIR FATHER HAD SUCCUMBED TO !)$3 A FEW YEARS BEFORE &ORTUNATELY NONE OF THEIR CHILDREN CONTRACTED THE DISEASE

!NGELA WAS BORN WITH AN UNCOMMON CONDI TION CALLED CHONDROECTODERMAL DYSPLASIA )T IS A TYPE OF DWARlSM THAT INVOLVES SHORT LIMBS AND NORMAL TRUNK LENGTH )T INCLUDES HYPOPLASTIC NAILS ON THE HANDS AND FEET POLYDACTYLY !NGELA HAD AN EXTRA DIGIT ON EACH HAND AND FOOT AND LATERAL PROXIMAL TIBIAL GROWTH PLATE DYSPLASIA RESULTING IN ASYMMETRIC OVERGROWTH OF THE NORMAL MEDIAL ASPECT OF THE KNEE 4HIS GROWTH PATTERN CAUSES A VALGUS KNOCK KNEE DEFORMITY AT THE KNEES

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

!NGELA BEFORE HER SURGERY

7ITH APPROPRIATE WELL CHILD CHECKUPS THIS CONDITION WOULD HAVE BEEN RECOGNIZED EARLY AND ALLOWED BALANCING HER KNEE ALIGNMENT AS AN INFANT WITH AN EPIPHYSIODESIS GROWTH PLATE ARREST ON THE OVER GROWING MEDIAL SIDE TO PREVENT DEFORMITY 3INCE SHE LACKED ROUTINE MEDICAL CARE !NGELA S KNOCK KNEE ALIGNMENT MEASURED DEGREES ON EACH SIDE NORMAL DEGREES 3HE HAD TO SCISSOR ONE LEG IN FRONT OF THE OTHER TO STAND OR WALK 'IVEN THE DISTORTED BIOMECHANICS OF HER GAIT SHE WAS DESTINED TO DEVELOP PREMATURE ARTHRITIS AS A YOUNG ADULT AND WAS UNABLE TO KEEP UP WITH THE ACTIVITIES OF HER PEERS

) RECOGNIZED THAT A SINGLE REALIGNMENT OSTEOTOMY A CONTROLLED FRACTURE TO STRAIGHTEN THE LIMB WITH PLATES AND SCREWS TO MAINTAIN THE CORRECTION COULD NOT BE PERFORMED SINCE ABRUPT STRAIGHTENING WOULD DAMAGE THE SHORT ENED NERVES IN THE LIMB 3HE NEEDED A COMPLEX

GRADUAL RECONSTRUCTION WITH AN EXTERNAL lXATION SYSTEM OF PINS AND WIRES AND ADJUSTABLE TENSION COMPRESSION STRUTS 4HIS WOULD YIELD A GRADUAL CORRECTION OVER THREE MONTHS WHICH WOULD ALLOW THE NERVES VESSELS AND OTHER SOFT TISSUES TO ACCOMMODATE TO THE NEW SKELETAL ANATOMY 4HE PROCESS WOULD INCLUDE THE INITIAL SURGERY TO APPLY THE APPARATUS 4HEN WE WOULD NEED SOMEONE TO TURN ADJUSTABLE STRUTS ONE TO TWO MILLIMETERS EVERY SIX HOURS AROUND THE CLOCK FOR THE lRST THREE MONTHS 7EEKLY X RAYS AND DAILY PIN SITE CARE WOULD ALSO BE NEEDED /NCE THE LIMBS WERE STRAIGHT THE FRAMES WOULD BE LEFT ON #ONTINUED ON PAGE

-AY *UNE

!NGELA S 3TORY #ONTINUED FROM PAGE

FOR AN ADDITIONAL TWO MONTHS TO ALLOW THE BONES TO CONSOLIDATE MATURE HEALING OF THE OSTEOTOMIES IN THEIR NEW POSITION 4HEN THE FRAMES WOULD BE REMOVED AND THE TASK OF PHYSICAL THERAPY AND ACHIEVING KNEE MOTION WOULD BEGIN

) KNEW THAT THIS SURGICAL PROJECT WITH ITS TEDIOUS FOLLOW UP WAS NOT AVAILABLE IN (ONDU RAS 4HE DIRECTOR OF THE ORPHANAGE ASKED ME THE OBVIOUS QUESTION OF HAVING IT DONE IN THE 5NITED 3TATES 4HROUGH A SERIES OF MANY WONDER FUL PEOPLE WHO ANSWERED hYESv MANY TIMES OVER

!NGELA NOW HAS STRAIGHT LEGS $R -ARK $AHL AND ) PERFORMED THE SURGERY AT 'ILLETTE #HILDREN S (OS PITAL IN 3T 0AUL ON 3EPTEMBER 'IVEN THE ANTICIPATED POST OP CARE HOWEVER THE SURGERY WAS ONLY THE START

-Y WIFE ,U,U WAS KIND ENOUGH TO AGREE TO BE THE PRIMARY CAREGIVER FOR THIS YOUNG CHILD THROUGH THE ARDUOUS PROCESS OF HER ORTHOPEDIC ODYSSEY 3HE OPENED HER HEART AND OUR HOME TO !NGELA 3HE DID THE JOB OF TURNING THOSE STRUTS AROUND THE CLOCK KEEPING HER PIN SITES CLEAN AND TRANSPORTING HER TO WEEKLY APPOINTMENTS FOR X RAYS 3HE ALSO FED AND BATHED HER "UT MOST OF ALL SHE GAVE !NGELA A STEADY DIET OF LOVE AND CARE THAT ONLY A MOTHER CAN GIVE ) CANNOT THANK HER ENOUGH FOR ALL THE SACRIlCES SHE HAS MADE FOR !NGELA ,U,U HAS BEEN THE BEST EXAMPLE OF A HUMANITARIAN THAT ) HAVE EVER ENCOUNTERED 3HE HAS BEEN A MENTOR FOR ME AND FOR OUR FOUR TEENAGE CHILDREN

$R $ALY AND HIS WIFE ,ULU PROVIDE !NGELA WITH SOME WALKING ASSISTANCE

-AY *UNE

!NGELA PROUDLY SHOWS OFF HER STRAIGHT LEGS

!NOTHER PLAYER IN THIS DRAMA HAS BEEN -AR TA A SECOND YEAR MEDICAL STUDENT FROM (ONDURAS WHO VOLUNTEERED TO ACCOMPANY !NGELA -ARTA GREW UP IN THE ORPHANAGE IN (ONDURAS AND IS A BEAUTIFUL EXAMPLE OF THE SUCCESSFUL FORMULA FOR RAISING THE CHILDREN THERE 4HE CHILDREN ON THE RANCH CANNOT BE ADOPTED AS WE IN THE 5 3 WOULD CONSIDER OF AN ORPHANAGE 2ATHER THEY ARE PROVIDED AN EDUCATION + THROUGH FED AND CLOTHED AND TAUGHT AT LEAST ONE TRADE THAT WILL ENSURE THEIR EMPLOYABILITY !S IN ANY FAMILY

THEY ARE ALSO TAUGHT HOW TO BE hFAMILYv TO EACH OF THEIR MEMBERS 4HIS INCLUDES GIVING A YEAR OF SERVICE ONCE THEY REACH TO YEARS OLD BEFORE THEY hLEAVE HOMEv TO MAKE THEIR WAY IN THE WORLD 3UCH SERVICE MAY INCLUDE ASSISTANT TEACHING IN THE CLASSROOMS LABORING AND CARING FOR THE LIVESTOCK

OR ASSISTING WITH THE FARMING )F THE CHILD WANTS TO GO ON TO FURTHER EDUCATION AND CAN PASS THE APPROPRIATE EXAMS THE ORPHANAGE LIKE ANY OTHER FAMILY WILL HELP PAY FOR THEIR EDUCATION (ENCE

-ARTA IS IN MEDICAL SCHOOL

4HE INSPIRING PART OF -ARTA WAS HER WILLING NESS TO GIVE UP A SEMESTER OF HER MEDICAL SCHOOL CURRICULUM TO HELP !NGELA AND ACCOMPANY HER TO -INNESOTA (OW MANY OF US WOULD HAVE MADE THE SAME SACRIlCE -ARTA ALSO LIVED WITH OUR FAM ILY UNTIL HER RETURN TO (ONDURAS THIS PAST *ANUARY ) WAS HAPPY TO LEARN THAT HER TIME HERE STRENGTH ENED HER RESOLVE TO BECOME A PHYSICIAN 3HE WAS A GREAT HELP TO ALL OF US INCLUDING MY CHILDREN AND THEIR 3PANISH CLASS HOMEWORK 4HINK OF THE EFFECTS ON OUR SOCIETY IF WE WERE TO REQUIRE A YEAR OF SERVICE FROM ALL OUR YEAR OLDS BEFORE THEY MOVED ON ) WOULD LIKE TO AT LEAST APPLY IT TO MY OWN FAMILY Â&#x2C6;BUT PLEASE DON T TELL MY CHILDREN YET ) NEED TO PLAN MY NEGOTIATIONS

/UR CURRENT EXPERIENCE WITH !NGELA IS DRAW ING TO A CLOSE 7E WILL TRAVEL BACK TO (ONDURAS WITH HER IN -AY AND GET HER SETTLED INTO LIFE ON THE RANCH WITH HER TWO BIOLOGIC SIBLINGS AND HER MANY OTHER hSIBLINGSv THAT MAKE UP THE LOVING AND CARING ENVIRONMENT AT THIS SPECIAL PLACE !S YOU CAN TELL OUR LITTLE TWO WEEK VOLUNTEER TRIP TO (ONDURAS HAS EVOLVED INTO QUITE AN ADVENTURE !LTHOUGH MY WIFE AND KIDS SUSPECT A CONSPIRACY

) HAD NO PLANS FOR ALL THIS

"UT ) THINK THAT IS THE MAGIC OF VOLUNTEER ISM 3TEPPING OUT OF YOUR WORLD INTO SOMEONE ELSE S WORLD WITHOUT THE EXPECTATION OF REMUNERA TION YIELDS MANY SURPRISES HOPEFULLY MOST OF THEM PLEASANT )T DELIVERS NEW PERSPECTIVES TO YOUR THINKING )T ALLOWS YOU TO FEEL AND TOUCH OTHER LIVES IN A WAY THAT CANNOT BE ACHIEVED BY SIMPLY DONATING TO A CHARITY 4HE lNANCIAL SUPPORT OF CHARITIES IS OBVIOUSLY NECESSARY AND GOOD BUT IT DOES LACK THE PARTICIPATORY ASPECT THAT PERSONAL VOLUNTEERISM PROVIDES

) KNOW THAT ) AM A DIFFERENT AND HOPEFULLY BETTER PERSON FROM THIS EXPERIENCE ) HAVE LEARNED THAT MY PATIENTS IN -INNESOTA SUFFER JUST AS MUCH AS THOSE IN A DEVELOPING COUNTRY (OPEFULLY ) AM ABLE TO KEEP SOME OF THAT ALTRUISTIC mAME BURNING AMIDST THE CHALLENGES OF 5 3 MEDICINE (ASSLES WITH PAPERWORK 265 S POOR REIMBURSEMENT

RISING OFlCE OVERHEAD COSTS ELECTRONIC MEDICAL RECORD UPGRADES ETC ARE ENOUGH TO ERODE ANYONE S FERVOR FOR MEDICINE 6OLUNTEERING CAN BE A HELPFUL SALVE TO THESE WOUNDS ) WOULD ENDORSE VOLUNTEER ING AT ANY LEVEL BUT MEDICAL VOLUNTEERISM CAN BE PARTICULARLY REWARDING )F YOU WOULD LIKE TO LEARN MORE ABOUT THE ORPHANAGE IN (ONDURAS

VISIT ITS 7EB SITE AT WWW NPHHONDURAS ORG 9OU COULD ALSO CALL -INNESOTA &RIENDS OF THE /RPHANS AT OR E MAIL ME AT PDALY SUMMITORTHO COM U

!NGELA AND $R $ALY ENJOYING THEIR TIME TOGETHER

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

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NIA WE WERE AT THE FOOTHILLS OF THE MOUNTAINS SOUTH OF +IBAKWE DEEP IN THE -PWAPWA VALLEY HEADED FOR ,UFU AT THE RIDGE OF THIS MOUNTAIN RANGE /UR 4OYOTA ,AND#RUISER HAD ALREADY BEEN CHALLENGED SNAKING ITS WAY THROUGH TRACKS ALONG MAIZE PATCHES AND THROUGH DRIED GUL LEYS /UR -ASAAI EVANGELIST WOULD POINT THE WAY ANYTIME THAT WE QUESTIONED THE ROUTE AHEAD 7E THEN STARTED ASCENDING THE CRUDE SWITCHBACKS UP THE MOUNTAINSIDE TO ,UFU &ROM THE HEIGHT OF THE GRASS OVER THE TRACKS OFTEN REACHING ABOVE THE HEIGHT OF THE HOOD ) lGURED WE WERE THE lRST MOTORIZED VEHICLE UP THIS TRAIL WITHIN THE YEAR 4WO HOURS LATER WE HAD LITERALLY AND lGURATIVELY SHOOK SO MUCH THAT WE WERE SLAP HAPPY ONLY TO COME UPON A SMALL BRIDGE OVER A GULLEY MADE OF ROUGH LOGS HAPHAZARDLY LAID ACROSS TWO WOODEN BEAMS /NE OF OUR PARTY WALKED AHEAD TO TAKE A VIDEO OF THIS CROSSING ) lGURE AS AN EXCUSE TO GUAR ANTEE HIS SURVIVAL #ROSSING SAFELY WE ENTERED THE SMALL HAMLET OF ,UFU HIGH ON THE RIDGE OF THIS MOUNTAIN RANGE MEASURING FEET ELEVATION BY OUR HAND HELD '03 WITH A CLEAR VIEW OF THE -PWAPWA VALLEY TO THE NORTH AND THE )RINGA VALLEY TO THE SOUTH 7HY WOULD "OBBY A RETIRED BIO TECH EXECUTIVE FROM -INNESOTA 7ALLY A DENTIST FROM /REGON AND ME AN %2 PHYSICIAN FROM THE -AYO (EALTH 3YSTEM lND THEMSELVES TO GETHER ON THIS DISTANT MOUNTAINTOP 4HE AN SWER MAY BE THREE FOLD &IRST ARE CROSS CULTURAL RELATIONSHIPS "OBBY HAD STRUCK A CLOSE FAMILY BOND TO THE ,UTHERAN BISHOP OF THE $ODOMA $IOCESE Â&#x2C6; $R 0ETER -WAMASIKA 4HIS BRINGS US TO THE SECOND $R 0ETER -WAMASIKA S VI SION FOR IMPROVED HEALTH CARE FOR HIS mOCK

HIS DIOCESE POPULATED BY THE POOREST AND LEAST

SERVED PEOPLE OF 4ANZANIA

ALREADY ONE OF THE POOREST COUNTRIES IN THE WORLD 4HE THIRD IS THE SHARED #HRISTIAN CALL AMONGST THE FOUR OF US TO SERVE THE POOR 4HE BISHOP HAD SPENT HIS EARLY YEARS AS BISHOP OF THIS DIOCESE DRIV ING TO THE REMOTEST ENDS OF THE TRAILS ON HIS MOTORBIKE

THUS DISCOVERING ,UFU 7ALLY AND ) HAD WORKED TOGETHER AS DENTAL AND MEDICAL MISSIONAR IES YEARS AGO IN -ADAGASCAR "OBBY HAD RUN INTO ME WHILE PRESENTING HIS VISION FOR A ,UTHERAN HEALTH CENTER IN $ODOMA TO THE EXECUTIVE COMMITTEE OF 'LOBAL (EALTH -INISTRIES A NON PROlT IN &RIDLEY -. THAT SUPPORTS ,UTHERAN HEALTH CARE OVERSEAS !S PRESIDENT OF '(- UPON HEARING THE PRO POSAL ) WAS CAUGHT WITH THE CALL TO MISSION AGAIN 3HORTLY THEREAFTER ) RESIGNED MY POST AS PRESIDENT OF '(- AND CALLED MY BUDDY

7ALLY TO JOIN ME IN THIS VENTURE "ACK TO ,UFU )T WAS CLEAR THAT NOTICE OF OUR ARRIVAL HAD NOT MADE IT UP THE MOUNTAIN 7E STARTLED AN OLD LADY DRYING HER RECENTLY HARVESTED MAIZE ON DRIED GOAT SKINS 4HE DISPENSARY NURSE QUICKLY APPEARED TO GREET US INTO THE DISPENSARY COMPLEX MADE UP OF A TWO ROOM MUD BRICK BUILDING WITH A TIN ROOF AND HER SMALL HOUSE ADJACENT OF SIMILAR STRUC TURE COMPLIMENTED BY A SMALL CHICKEN HOUSE 3OMEONE ARRIVED WITH SODA POP AND CRACKERS AS A GREETING hTEA v 7ALLY AND ) HAD FUN SHARING OUR CRACKERS WITH THE RAPIDLY GROWING AUDIENCE OF CHILDREN SURROUNDING THE BUILDING ) NO TICED THAT THE MAJORITY HAD GENERALIZED SCABIES

TESTIMONY THAT THERE WAS NO WELL OR ACCESS TO

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WATER IN CLOSE VICINITY 7ALLY AND ) ASKED PER MISSION TO HAVE A LOOK AT THE MOUTHS OF THOSE THAT HAD GATHERED 4HE TEETH UP TO ADULTHOOD APPEARED IN GOOD CONDITION SUGGESTING GOOD NATURAL mUORIDE &ROM THAT AGE UP SHOWED VARIOUS DE GREES OF DECAY AND NEGLECT 7E THEN WERE TAKEN ON A TOUR OF THE DISPENSARY 4HE PATIENT HOLDING ROOM HAD ONLY ONE PIECE OF FURNI TURE Â&#x2C6; A CRUDE BED MADE UP OF A FRAME OF ROUGH TIMBERS WITH CRISS CROSSED SISAL ROPE WITHOUT A MAT TRESS 4HE NEXT ROOM HAD A TABLE AND CHAIR A LOCKED CUPBOARD WITH SOME BASIC MEDICATIONS AND A HAND WRITTEN POSTER LISTING THE TOP DISEASES EXPERIENCED AT THIS CENTER !FTER VIEWING A NEARBY FAILED ATTEMPT AT A WELL WE THANKED OUR HOSTS FOR THEIR ASSISTANCE AND CLOSED WITH PRAYERS FOR 'OD TO BLESS OUR EFFORTS TO IMPROVE THE HEALTH OF THIS DISTANT COMMUNITY !S WE HEADED DOWN THE MOUNTAIN MY OVER RIDING THOUGHT WAS h7HERE DO WE START v 4HEY NEED MOST EVERYTHING AN IMPROVED ROAD FOR ACCESS A WELL FOR POTABLE WATER A COMMU NITY SURVEY TO ASSESS THE REAL AND PERCEIVED NEEDS OF THE COMMUNITY ADEQUATE TRAINING FOR DISPENSARY STAFF IMPROVED FACILITIES WITH BASIC LABORATORY CAPABILITIES A BUSINESS PLAN

SUBSIDIES TO ASSURE SUSTAINABILITYx 4HE lRST PRIORITY AFTER THE REQUISITE GOV ERNMENT PERMITS WILL BE A COMMUNITY SURVEY OF EACH VILLAGE SERVED BY THE SIX DISPENSARIES CLINICS IN THIS $ODOMA AREA 7E HOPE TO COMPLETE THIS OVER A SIX MONTH PERIOD WITH AN !MERICAN VOLUNTEER ASSISTING A 4ANZANIAN PUBLIC HEALTH NURSE VISITING THE SIX CLINICS 4HIS WILL ALLOW US TO ESTABLISH CRITICAL RELATIONSHIPS WITH THE LEADERSHIP OF THE AREAS SHARPEN OUR VISION OF THE IMPROVEMENTS NEEDED IN HEALTH CARE AND ALLOW US TO SHARE WITH THE DIOCESE EVANGELISTS 4HE SECOND PRIORITY WILL BE TO DEVELOP THE ARCHITECTURAL PLANS FOR THE $ODOMA #HRISTIAN -EDICAL #ENTER $#-# WITH HOPES OF BREAK ING GROUND THIS SPRING AND EVENTUAL COMPLETION

OF THE INITIAL BED COMPLEX THE FALL OF !S THE $ODOMA GOVERNMENT HOSPITAL AND THE NEARBY !NGLICAN -VUMI HOSPITAL CANNOT KEEP UP WITH THE NEEDS OF THIS LARGE PROVINCE

$#-# WILL COMPLEMENT THE HOSPITAL NEEDS OF THE PROVINCE PROVIDE A BASE OF SUPPORT FOR THE

"ISHOP -WAMASIKA AND HIS WIFE WITH RURAL WOMEN

SIX EXISTING ,UTHERAN DISPENSARIES AND PROVIDE HIGH END DENTAL CARE AND TRAINING ORTHOPE DICS AND PLASTICS MAXILLO FACIAL SURGERY Â&#x2C6; ALL OF WHICH ARE NOT AVAILABLE IN CENTRAL 4ANZANIA !NY REVENUE FROM THIS SPECIALTY CARE WILL ASSIST IN THE SUSTAINABILITY OF THE PRIMARY CARE SERVICES OF THE MEDICAL CENTER AND CLINICS 4HE THIRD AND POSSIBLY MOST IMPORTANT PRIORITY WILL BE TO ESTABLISH A PARTNERSHIP WITH A LARGER HEALTH CARE ORGANIZATION IN THE 5 3 THUS ALLOWING SHARING OF CROSS CULTURAL PROFESSIONAL EXPERIENCES AND CREATING A NEEDED AWARENESS TO THE 5 3 PARTNER OF THE DISPARITY IN HEALTH ACCESS IN SUB 3AHARAN !FRICA /NE GOOD EXAMPLE OF THIS NEW PARADIGM IN THIRD WORLD HEALTH CARE PARTNERING IS 3AINT -ARY S $ULUTH #LINIC S RELA TIONSHIP WITH .GAOUNDERE ,UTHERAN (OSPITAL IN #AMEROON 3UCH PARTNERING CAN ONLY RENEW OUR COMMON CALLING AS HEALTH CARE PROVIDERS TO SERVE THE POOR AND GO A LONG WAY IN COUNTERING THE THIRD WORLD OFTEN DEEP ROOTED SUSPICIONS OF THE TRUE INTENTIONS OF THE 5 3 IN THE WORLD TODAY U *OHN - 4OSO - $ IS A SON OF ,UTHERAN MIS SIONARIES TO -ADAGASCAR FAMILY PHYSICIAN TRAINED

AND NOW WORKING IN THE -AYO (EALTH 3YSTEM AS AN %2 PHYSICIAN AND INTERNATIONAL HEALTH CONSULTANT

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

0ORTICO (EALTHNET !N !NSWER FOR THE 5NINSURED

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/6%2 4(% 0!34 3%6%2!, MONTHS YOU

HAVE LIKELY READ ABOUT THE NEW RESTRICTIONS ON THE ELIGIBILITY GUIDELINES FOR -INNESOTA S HEALTH CARE PROGRAMS -ANY PEOPLE HAVE PREDICTED A RESULTANT SPIKE IN THE NUMBER OF UNINSURED PEOPLE IN OUR COMMUNITY 0ORTICO (EALTHNET 0ORTICO A 4WIN #ITIES BASED HEALTH CARE SAFETY NET PROGRAM IS ALREADY EXPERIENCING A DELUGE OF NEW INQUIRIES FROM PEOPLE AFFECTED

BY THESE CHANGES 4HE GOOD NEWS IS THAT DESPITE THE GROWING NUMBERS OF UNINSURED PEOPLE 0OR TICO AND OTHER COMMUNITY ORGANIZATIONS ARE WORKING HARD TO REDUCE THE NUMBER OF PEOPLE WITHOUT COVERAGE FOR HEALTH CARE SERVICES 3INCE 0ORTICO (EALTHNET FORMERLY -ETRO%AST 0ROGRAM FOR (EALTH HAS HELPED

UNINSURED PEOPLE EACH YEAR CONNECT TO HEALTH COVERAGE PROGRAMS &UNDED

BY A VARIETY OF SOURCES THAT INCLUDE lVE MAJOR HOSPITAL PARTNERS 0ORTICO ACCOMPLISHES THIS IN TWO WAYS 0ORTICO S OUTREACH WORKERS IDENTIFY UNINSURED COMMUNITY MEMBERS AND PROVIDE PERSONALIZED ASSISTANCE WITH APPLICA TIONS AND ENROLLMENT IN -INNESOTA S HEALTH CARE PROGRAMS AND FOR LOW INCOME INDIVIDUALS AND FAMILIES WHO DO NOT QUALIFY FOR PUBLIC PROGRAMS 0ORTICO OFFERS A UNIQUE PROGRAM THAT PROVIDES ACCESS TO PREVENTIVE PRIMARY AND SPECIALTY MEDICAL CARE )T SURPRISES MANY TO KNOW THAT NEARLY PERCENT OF ADULTS WHO TURN TO 0ORTICO (EALTH NET FOR HELP HAVE JOBS 4HEY ARE OFTEN IN TEM PORARY SITUATIONS THAT HAVE LEFT THEM WITHOUT HEALTH COVERAGE /THERS WHO SEEK ASSISTANCE FROM THE PROGRAM ARE NEWER IMMIGRANTS 4HE -INNESOTA $EPARTMENT OF (EALTH REPORTS THAT A DISPROPORTIONATE NUMBER OF PEOPLE WITHOUT HEALTH INSURANCE ARE FOUND IN THE ,ATINO !FRI CAN !MERICAN AND !SIAN !MERICAN COMMUNI TIES )N RESPONSE TO THIS GROWING NEED 0ORTICO "9 $%"2! (/,-'2%.

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HAS BEEN SEEKING OPPORTUNITIES TO INCREASE ITS OUTREACH EFFORTS IN THESE COMMUNITIES )N *ULY THE #HILDREN S $EFENSE &UND -INNESOTA RECOGNIZED 0ORTICO S SUCCESS IN ASSISTING PEOPLE WITH lNDING HEALTH COVER AGE AND INVITED THE ORGANIZATION TO INITIATE A PILOT PROJECT AS PART OF THEIR #OVER !LL +IDS AND &AMILIES #+& GRANT &UNDED IN LARGE PART

BY THE 2OBERT 7OOD *OHNSON &OUNDATION

#+& IS A NATIONAL HEALTH CARE ACCESS INITIATIVE WITH PROJECTS IN MOST EVERY STATE 4HE GOAL OF 0ORTICO S #+& PILOT WITH #HILDREN S $EFENSE &UND -INNESOTA IS TO REACH MORE UNINSURED FAMILIES WITH CHILDREN IN THE EAST METROPOLITAN ,ATINO COMMUNITY 4HE COLLABORATION HAS BEEN A PERFECT MATCH 4WO OF THE MAJOR GOALS FOR -INNESOTA S #+& PROJECT ARE TO SIMPLIFY AND COORDINATE THE APPLICATION PROCESS FOR FAMILIES SEEKING HEALTH COVERAGE !S A GRANTEE OF THE -INNE SOTA $EPARTMENT OF (UMAN 3ERVICES (EALTH #ARE 0ROGRAM /UTREACH 0ROJECT 0ORTICO HAS NEARLY SEVEN YEARS OF EXPERIENCE HELPING FAMI LIES NAVIGATE THROUGH THE APPLICATION PROCESS FOR -INNESOTA S HEALTH CARE PROGRAMS /VER THE YEARS #HILDREN S $EFENSE &UND -INNESOTA THROUGH ITS WORK ON THE #+& PROJ ECT HAS MADE GREAT STRIDES IN WORKING WITH THE STATE LEGISLATURE TO SHORTEN AND SIMPLIFY AP

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

PLICATIONS FOR HEALTH COVERAGE PROGRAMS %VEN SHORTER AND LESS COMPLICATED FORMS HOWEVER

CAN STILL BE IMPOSING TO FAMILIES WHO ARE JUG GLING MULTIPLE STRESSES AND RESPONSIBILITIES !DD THE FACT THAT MANY POTENTIAL APPLICANTS DO NOT SPEAK %NGLISH AS THEIR lRST LANGUAGE AND THE COMPLICATIONS SEEM INSURMOUNTABLE 0ORTICO S DIVERSE AND MULTILINGUAL STAFF HAS THE EXPERI ENCE AND TRAINING TO HELP FAMILIES THROUGH THE ENTIRE APPLICATION PROCESS UNTIL THEY ARE SUCCESSFULLY ENROLLED IN AN APPROPRIATE HEALTH CARE PROGRAM 4HOSE INELIGIBLE FOR -INNESOTA S HEALTH CARE PROGRAMS APPLY TO 0ORTICO S COVER AGE PROGRAM 7ITH A VARIETY OF TARGETED OUTREACH EFFORTS THE #+& PILOT PROJECT HAS BEEN EX TREMELY SUCCESSFUL IN REACHING ,ATINO CHILDREN AND PARENTS WHO ARE WITHOUT HEALTH INSURANCE 0ORTICO S OUTREACH WORKERS HOLD OFlCE HOURS IN THE LOBBY OF THE 3T 0AUL Â&#x2C6; 2AMSEY #OUNTY $EPARTMENT OF 0UBLIC (EALTH OFlCE ON #EDAR 3TREET TWICE WEEKLY AND TWO EVENINGS A MONTH TO ASSIST FAMILIES WITH HEALTH CARE PROGRAM AP PLICATIONS $URING THE MONTHS OF !UGUST AND 3EPTEMBER OUTREACH WORKERS ASSIST FAMILIES AT THE 3T 0AUL 0UBLIC 3CHOOLS 3TUDENT 0LACEMENT #ENTER /UTREACH WORKERS ALSO MAKE WEEKLY VISITS TO THE !LLINA 5NITED &AMILY 0RACTICE #ENTER AND (EALTH%AST 3T *OSEPH S (OSPITAL #HEMICAL $EPENDENCY 5NIT IN 3T 0AUL "UILDING "RIDGES IS ANOTHER SUCCESSFUL 0ORTICO OUTREACH EFFORT THAT DRAWS ON THE EXISTING SYSTEMS OF SEVERAL SCHOOL DISTRICTS !S FAMILIES ARE IDENTIlED AS UNINSURED THROUGH EARLY CHILDHOOD SCREENINGS THEY ARE REFERRED TO 0ORTICO (EALTHNET FOR ASSISTANCE IN APPLYING FOR HEALTH CARE COVERAGE 4HESE OUTREACH EFFORTS ARE JUST A FEW OF THE STRATEGIES 0ORTICO EMPLOYS TO REACH FAMILIES IN NEED OF HEALTH COVERAGE 4HE ONLY PROBLEM #ONTINUED ON PAGE

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IS NOT ALL FAMILIES ARE ELIGIBLE FOR -INNESOTA S HEALTH CARE PROGRAMS AND NEW RESTRICTIONS ON ELIGIBILITY FOR -INNESOTA#ARE -EDICAL !SSIS TANCE AND 'ENERAL !SSISTANCE -EDICAL #ARE ARE LEAVING MORE FAMILIES WITHOUT COVERAGE 4HIS IS WHERE 0ORTICO S COVERAGE PROGRAM CAN OFTEN HELP 0ORTICO (EALTHNET S COVERAGE PROGRAM IS A NONPROlT MODEL FOR DELIVERING CARE MANAGE MENT AND PRIMARY PREVENTIVE AND SPECIALTY HEALTH CARE SERVICES TO UNINSURED FAMILIES AND INDIVIDUALS WHO CANNOT AFFORD HEALTH INSUR ANCE AND DO NOT QUALIFY FOR PUBLICLY SPONSORED HEALTH CARE PROGRAMS 0ORTICO S COVERAGE PRO GRAM IS NOT AN INSURANCE PROGRAM NOR IS IT AN (-/ ALTHOUGH IT DOES PAY FOR MEDICAL SER VICES AND PRESCRIPTION DRUGS 0ORTICO DOES NOT GUARANTEE COVERAGE FOR ITS PARTICIPANTS OR PAY FOR HOSPITALIZATION 7HEN 0ORTICO PARTICIPANTS ARE HOSPITALIZED THEIR CARE MANAGER ASSISTS THEM WITH THE PROCESS OF APPLYING FOR -EDICAL !S SISTANCE OR 'ENERAL !SSISTANCE -EDICAL #ARE )N ALMOST ALL CASES THEIR INCOME AND ASSET LEVELS FALL INTO A CATEGORY THAT QUALIlES THEM FOR TEMPORARY ASSISTANCE 5NINSURED PEOPLE WHO RESIDE IN 2AMSEY

7ASHINGTON OR $AKOTA COUNTIES HAVE HOUSE HOLD INCOMES THAT FALL BELOW PERCENT OF FEDERAL POVERTY GUIDELINES AND ARE NOT ELIGIBLE FOR -!

ARE ELIGIBLE FOR THE 0ORTICO (EALTHNET COVERAGE PROGRAM 0ORTICO IS ALSO WORKING DILIGENTLY TO ATTRACT NEW HOSPITAL PARTNERS TO ENABLE THE ORGANIZATION TO EXPAND ITS SERVICE AREA TO OTHER COUNTIES 0ORTICO PARTICIPANTS RECEIVE ONE TO ONE CARE MANAGEMENT THAT INCLUDES EDUCATION ON PREVENTIVE CARE PRACTICES HELP WITH ESTABLISH ING HEALTH RELATED GOALS EDUCATION ON HOW TO NAVIGATE THE HEALTH CARE SYSTEM INCLUDING AD VOCACY SUPPORT WHEN NEEDED REFERRALS TO OTHER COMMUNITY SUPPORTS INTERPRETER SERVICES AND TRANSPORTATION TO MEDICAL APPOINTMENTS AS NEEDED 0ORTICO PAYS FOR PARTICIPANTS VISITS TO PRI MARY CARE CLINICS PRESCRIPTION DRUGS VISITS TO SPECIALTY CARE CLINICS EYE EXAMS AND EYEGLASSES

OUTPATIENT MENTAL HEALTH SERVICES AND OUTPA TIENT HOSPITAL SERVICES INCLUDING DIAGNOSTICS AND TREATMENT %ACH HOUSEHOLD THAT JOINS THE 0ORTICO (EALTHNET PROGRAM MEETS ONE TO ONE WITH A LICENSED SOCIAL WORKER OR hCARE MANAGERv WITHIN

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

DAYS OF ENROLLING IN THE PROGRAM 4HESE MEETINGS SERVE AS AN IMPORTANT OPPORTUNITY TO BEGIN FORGING A RELATIONSHIP AND COMMU NICATION STRUCTURE BETWEEN THE CARE MANAGER AND THE PARTICIPANT 4HIS RELATIONSHIP IS KEY TO PROPER UTILIZATION OF THE PROGRAM S SERVICES !T THE INITIAL MEETING PARTICIPANTS COM PLETE A &AMILY (EALTH !SSESSMENT &(! WITH THEIR CARE MANAGER 4HIS TOOL WAS DEVELOPED BY 0ORTICO TO CAPTURE INFORMATION ABOUT THE FAMILY TO BETTER UNDERSTAND THE CURRENT HEALTH SITUATION OF EACH FAMILY MEMBER AND TO IDEN TIFY HEALTH RELATED GOALS 4HE &(! ALSO CAPTURES OTHER INFORMATION THAT CAN AFFECT THE FAMILY S HEALTH %XAMPLES OF QUESTIONS ON THE SURVEY TOOL INCLUDE h(OW MANY TIMES IN THE PAST YEAR HAVE YOU OR ONE OF YOUR FAMILY MEMBERS VISITED THE EMERGENCY ROOM v h$O YOU HAVE CONCERNS WITH STRESS v OR h$O YOU HAVE ISSUES WITH HOUSING v )N ADDITION TO THE &(!

PARTICIPANTS COMPLETE AN 3& SURVEY AT ENROLLMENT 4HIS IS A NATIONALLY USED SELF ASSESSMENT TOOL THAT IDENTIlES THE PARTICIPANT S PERCEPTION OF THEIR HEALTH 0ARTICIPANTS COMPLETE THE SURVEYS INITIALLY AFTER SIX MONTHS AND THEN ANNUALLY THEREAFTER $URING THE INITIAL MEETING CARE MANAGERS HELP THE FAMILY OR INDIVIDUAL CHOOSE A PRIMARY CARE CLINIC AND EXPLAIN HOW TO ACCESS MEDICAL SERVICES THROUGH THE PROGRAM ! KEY COMPO NENT IN THE LEARNING PROCESS IS THE MONTHLY FEE THAT EACH PARTICIPATING HOUSEHOLD PAYS 4HIS FEE ESTABLISHES CONTEXT FOR PEOPLE WHO ARE UNFAMILIAR WITH HEALTH INSURANCE FOR LATER SUCCESS WHEN THEY MOVE INTO MORE PERMANENT HEALTH COVERAGE SOLUTIONS #ARE MANAGERS ALSO EXPLAIN WHAT MEDICAL SERVICES THE PROGRAM MAY COVER 0ORTICO S CARE MANAGEMENT MODEL REAPS GREAT RESULTS FOR ITS PARTICIPANTS !FTER A YEAR OF ENROLLMENT PARTICIPANT S EMERGENCY ROOM VISITS ARE REDUCED BY PERCENT AS COMPARED TO THE NUMBER OF VISITS THEY MADE PRIOR TO JOINING THE PROGRAM NEARLY PERCENT OF PARTICIPANTS REPORT HAVING UPDATED IMMUNIZATIONS AND ON AVERAGE TO PERCENT OF PARTICIPANTS WHO LEAVE THE PROGRAM DO SO BECAUSE THEY HAVE FOUND PERMANENT HEALTH COVERAGE 3OME LEAVE WITHOUT REPORTING A REASON 4HE -INNESOTA $EPARTMENT OF (EALTH CURRENTLY ESTIMATES THAT APPROXIMATELY

PEOPLE IN THE EAST METROPOLITAN AREA HAVE NO HEALTH INSURANCE /F THOSE APPROXIMATELY PERCENT MAY BE ELIGIBLE FOR -INNESOTA S HEALTH

CARE PROGRAMS 4HAT LEAVES PEOPLE IN THE EAST METRO AREA THAT COULD BE SERVED BY THE 0ORTICO COVERAGE PROGRAM !LTHOUGH 0ORTICO (EALTHNET RECEIVES GENEROUS SUPPORT FROM ITS HOSPITAL PARTNERS AND HAS A HISTORY OF LOW MEDICAL COSTS PER MEMBER PER MONTH THAT INCLUDE MEDICAL

PRESCRIPTIONS AND INTERPRETER SERVICES 0ORTICO HAS A LIMITED AMOUNT OF FUNDS TO PROVIDE SER VICES #URRENTLY 0ORTICO HAS FUNDING TO COVER PARTICIPANT OPENINGS AT ANY GIVEN TIME !S THE PROGRAM STRIVES TO MOVE PEOPLE ONTO MORE PERMANENT HEALTH COVERAGE PROGRAMS 0ORTICO S COVERAGE PROGRAM TYPICALLY SERVES ABOUT

UNINSURED PEOPLE PER YEAR OR PERCENT OF EAST METRO RESIDENTS IN NEED 4HE 0ORTICO (EALTHNET PROGRAM IS A mEX IBLE MODEL THAT CAN BE REPLICATED IN ANY PART OF THE STATE OR IN OTHER PARTS OF THE COUNTRY )T WAS DEVELOPED TO SERVE AS MORE THAN A FUNDING MECHANISM TO PROVIDE HEALTH CARE SERVICES FOR ITS PARTICIPANTS !S THE POPULATION SERVED BY THE PROGRAM IS OFTEN IN A PERIOD OF TRANSITION

FACING MULTIPLE BARRIERS TO SUCCESS THEY REQUIRE MORE THAN A MERE MEDICAL CARD TO ACCESS HEALTH CARE SERVICES APPROPRIATELY AND EFlCIENTLY )F PUBLIC PROGRAMS CONTINUE TO BE TARGETS FOR lNANCIAL CUTS THE HEALTH CARE SAFETY NET WILL NEED TO BE STRENGTHENED -ORE PEOPLE WILL BE UNINSURED AND IN NEED OF PROGRAMS LIKE 0ORTICO (EALTHNET IN ORDER TO REMAIN HEALTHY AND CONTINUE TO CONTRIBUTE TO SOCIETY &OR MORE INFORMATION ON HOW YOU CAN BECOME INVOLVED WITH 0ORTICO (EALTHNET OR FOR GENERAL INFORMATION ABOUT THE PROGRAM CONTACT

(ISTORY OF 0ORTICO (EALTHNET )N (EALTH%AST #ARE 3YSTEM INVITED A GROUP OF INTERESTED PARTIES TO DISCUSS IDEAS FOR DEVELOPING A HEALTH CARE SAFETY NET MODEL TO MITIGATE THE HIGH NUMBER OF UNINSURED PEOPLE WHO WENT TO HOSPITAL EMERGENCY ROOMS FOR HEALTH ISSUES THAT COULD BE BETTER TREATED AND MORE INEXPENSIVELY IN A PRIMARY CARE SETTING !FTER MONTHS OF PLANNING THE -ETRO%AST 0ROGRAM FOR (EALTH PILOT MODEL NOW 0ORTICO (EALTHNET WAS DEVELOPED 7ITH A MISSION hTO REDUCE THE NUMBER OF PEOPLE WITHOUT COVERAGE FOR HEALTH CARE SERVICESv AND A TRACK RECORD FOR DOING SO

JUST FOUR YEARS LATER 0ORTICO ATTRACTED SUP PORT FROM ALL OF THE MAJOR EAST METROPOLITAN HOSPITALS AND HEALTH SYSTEMS (EALTH%AST #ARE 3YSTEM 2EGIONS (OSPITAL 5NITED (OSPITAL

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

AND #HILDREN S (OSPITALS AND #LINICS )N

0ORTICO ADDED ,AKEVIEW (OSPITAL IN 3TILLWATER AS A lFTH PARTNER 4HE HOSPITALS REAP TWO MAJOR BENElTS FROM THEIR PARTNERSHIP WITH 0ORTICO AN OPPORTUNITY TO PROVIDE A TANGIBLE COM MUNITY SERVICE AND AN EFFECTIVE METHOD TO REDUCE THE NUMBER OF CHARITY CARE CASES SERVED

BY THEIR EMERGENCY DEPARTMENTS )N ADDITION TO BEING A MEMBER OF 0OR TICO S 0ARTNERS 'ROUP THE 2AMSEY -EDICAL 3OCIETY PLAYED A MAJOR ROLE DURING THE PILOT PHASE OF THE PROGRAM )N THE 2OBERT 7OOD *OHNSON &OUNDATION AWARDED 0ORTICO (EALTHNET AND THE 2AMSEY -EDICAL 3OCIETY A

FOUR YEAR GRANT TO DEVELOP A VOLUN TEER PHYSICIAN NETWORK FOR UNINSURED PEOPLE IN THE COMMUNITY 4HIS PILOT PROJECT ENABLED 0ORTICO (EALTHNET TO INCORPORATE SPECIALTY CARE SERVICES EARLY IN THE DEVELOPMENT STAGES OF THE PROGRAM 4ODAY SPECIALTY CARE SERVICES REMAIN AN INTEGRAL SERVICE 0ORTICO OFFERS TO ENSURE THAT PARTICIPANTS STAY HEALTHY U $EBRA (OLMGREN - 3 IS PRESIDENT EXECUTIVE DIRECTOR FOR 0ORTICO (EALTHNET

Solitude Found on Wilson Lake

Build your dream lake escape on this end-of-the-road lot on beautiful Wilson Lake. Located in the Superior National Forest near Schroeder, only 20 minutes from Lake Superior. This large wilderness feeling lake has clear water and predominantly public land protecting its shore. Youâ&#x20AC;&#x2122;ll experience unmatched privacy, access to millions of acres of forest land, easy year-round access, power to your lot, and close proximity to the scenic North Shore. This lot has 312 feet of shoreline with 5.3 acres.

Price: $206,500.

Gail Englund, Realtor P.O. Box 938 Grand Marais, MN 55604 e-mail: Info@RedPineRealty.com 800/387-9599 / 218/387/9599 www.RedPineRealty.com

-AY *UNE

#OMMUNITY %DUCATION !DVOCATING FOR #HILDREN

-

-5#( )3 #522%.4,9 +./7. ABOUT THE

DEVELOPMENT OF THE BRAIN IN CHILDREN .EURONS FROM BIRTH TO AGE OR GENERATE TWICE AS MANY DENDRITES THAN THEY WILL EVER NEED 4HUS THE POSSIBILITY FOR LEARNING IS TREMENDOUS 4HEN

AROUND AGE THE METABOLIC RATE OF THE BRAIN REMAINS HIGH AS THE NEURAL NETWORKS BEGIN TO PRUNE THE CIRCUITS THAT HAVE NOT BEEN STIMU LATED OR USED 4HIS PRUNING CONTINUES UNTIL THE lNAL ADULT BRAIN CIRCUITRY IS ESTABLISHED AROUND AGE )T IS ALSO KNOWN THAT ALTHOUGH THERE IS AN ABUNDANCE OF NEURAL NETWORKS IN THE BRAIN IN CHILDHOOD NOT ALL AREAS OF THE BRAIN DEVELOP AT THE SAME TIME &OR EXAMPLE

THE PREFRONTAL CORTEX THE AREA RESPONSIBLE FOR CRITICAL THINKING IS THE LAST TO DEVELOP 0&# DEVELOPMENT BEGINS AROUND AGE OR AND HERALDS ADOLESCENCE 7E AS PHYSICIANS ARE INVITED INTO THE CENTER OF THAT BRAIN DEVELOPMENT 7E GUIDE PARENTS IN THE PHYSICAL AND SOCIAL DEVELOPMENT OF THEIR CHILDREN 7E ARE THERE IN ILLNESS CRISES

AND CELEBRATION 7E WATCH THE PAINFUL FAMILY DYNAMICS OF ADDICTIONS AND DEPRESSION 7HAT MAKES US UNIQUE AS CARE PROVIDERS IS THAT WE CAN UNDERSTAND THE NEUROBIOLOGY BEHIND THE BEHAVIORS OF CHILDHOOD AND ADOLESCENCE AND

THEREFORE GIVE PARENTS A NEUROBIOLOGICAL FRAME WORK TO HELP THEIR DECISION MAKING 4HERE IS SCIENCE BEHIND THE ANTICIPATORY GUIDANCE WE PROVIDE (OWEVER OUR CURRENT CULTURE HAS BE COME A VERY COMPLEX INmUENCE IN THE HEALTH OF CHILDREN AND PRESENTS NEW CHALLENGES TO US FOR HOW TO ADVOCATE ON THEIR BEHALF 4HE PURPOSE OF THIS DISCUSSION IS TO HIGHLIGHT RECENT lNDINGS IN THE NEUROSCIENCE RESEARCH AND CONSIDER HOW THEY IMPACT THE MANNER IN WHICH WE ADVOCATE FOR CHILDREN

"9 -!29 %::/ - $

-AY *UNE

!LTHOUGH CAUSE AND EFFECT ASSOCIATIONS ARE DIFlCULT WHEN A CHILD S BRAIN CHEMISTRY IS IN mUENCED BY SOCIAL FACTORS IT IS WORTH DISCUSSING SOME OF THE MORE WORRISOME RESEARCH lNDINGS 4HE FOUR AREAS THAT WILL BE DISCUSSED ARE 46 AND MEDIA MUSIC ADDICTIONS AND DOMESTIC ABUSE 46 AND -EDIA -OST PHYSICIANS AGREE THAT 46 IS NOT A NEUTRAL FORCE IN BRAIN DEVELOPMENT 4HE !MERICAN !S SOCIATION OF 0EDIATRICS HAS ISSUED SEVERAL CONSIS TENT STATEMENTS PERTAINING TO THE ADVERSE HEALTH EFFECTS OF 46 IN CHILDREN 4HE GROWING BODY OF RESEARCH SUGGESTS THAT 46 CHANGES THE NEU ROCHEMISTRY OF THE BRAIN IN WAYS THAT WE DON T YET COMPLETELY UNDERSTAND 7E ARE CONCERNED ABOUT NEURAL PATHWAYS THAT WILL NOT DEVELOP ADEQUATELY WHEN CHILDREN SPEND LARGE AMOUNTS OF TIME IN FRONT OF THE 46 AS WELL AS DIRECT EF FECTS OF 46 ON BRAIN CHEMISTRY /F THE POTENTIAL ADVERSE EFFECTS OF 46 WE AS PHYSICIANS HAVE HEARD THE MOST ABOUT THE EFFECTS OF 46 VIOLENCE ON AGGRESSIVE BEHAVIORS )N THE !MERICAN !CADEMY OF 0EDIATRICS STATED THAT hMORE THAN SCIENTIlC STUDIES AND REVIEWS CONCLUDE THAT SIGNIlCANT EXPO SURE TO MEDIA VIOLENCE INCREASES THE RISK OF AGGRESSIVE BEHAVIOR IN CERTAIN CHILDREN AND ADOLESCENTS DESENSITIZES THEM TO VIOLENCE

AND MAKES THEM BELIEVE THAT THE WORLD IS A MEANER AND SCARIER PLACE THAN IT IS v 4HOSE WHO DISAGREED CHALLENGED THE !!0 S lNDINGS

BY SUGGESTING THAT MANY OF THESE STUDIES SUF FERED FROM RECALL BIAS Â&#x2C6; THAT IS THAT THE hDOSEv OF 46 WATCHING WAS OFTEN ASSESSED BY ASKING PARTICIPANTS TO RECALL THE AMOUNT THE TIME THEY SPENT IN FRONT OF THE 46 IN YEARS PAST #LEARLY WHAT WAS NEEDED WAS A PROSPECTIVE STUDY IN WHICH CHILDREN S 46 WATCHING WAS RECORDED AS IT WAS PRESENTLY HAPPENING

)N FACT THE RESULTS OF JUST SUCH A YEAR PROSPECTIVE STUDY PUBLISHED IN AFlRMED THE !!0 S CONCLUSIONS !FTER FOLLOWING PARTICI PANTS FROM EARLY ADOLESCENCE TO ADULTHOOD

THE STUDY CONCLUDED THERE WAS A SIGNIlCANT ASSOCIATION BETWEEN THE AMOUNT OF TIME SPENT WATCHING TELEVISION DURING ADOLESCENCE AND EARLY ADULTHOOD AND THE LIKELIHOOD OF SUB SEQUENT AGGRESSIVE ACTS AGAINST OTHERS v 4HIS ASSOCIATION REMAINED SIGNIlCANT EVEN WHEN CONTROLLING FOR OTHER RISK FACTORS FOR VIOLENCE INCLUDING PREVIOUS AGGRESSIVE BEHAVIOR CHILD HOOD NEGLECT FAMILY INCOME NEIGHBORHOOD VIOLENCE PARENTAL EDUCATION AND PSYCHIATRIC DISORDERS -ORE RECENTLY PHYSICIANS HAVE SEEN A GROWING LITERATURE ON THE ASSOCIATION BETWEEN NUMBER OF HOURS SPENT IN FRONT OF THE 46 AND BODY MASS INDEX "-) %VER SINCE A SMALL STUDY IN SUGGESTED THAT THE METABOLIC RATE DROPS DURING 46 VIEWING THE 46 OBESITY CONNECTION HAS OFTEN BEEN OVER SIMPLIFIED AS A COMBINATION OF INACTIVITY AND HIGH FAT INTAKE (OWEVER A RECENT 3TANFORD 5NIVERSITY STUDY SUGGESTS THE PATHWAYS ARE MORE COMPLEX AND MULTIFACETED THAN WAS INITIALLY THOUGHT )N THIS RANDOMIZED CONTROLLED TRIAL CHILDREN IN TWO GROUPS WERE SIMILAR AT BASELINE ON NUMBER OF HOURS OF 46 "-) AND A VARIETY OF DEMOGRAPHIC FACTORS /NE GROUP RECEIVED AN EDUCATIONAL INTERVENTION THAT RESULTED IN A REDUCED AMOUNT OF 46 WATCHING .OT SURPRIS INGLY KIDS THAT WATCHED LESS 46 HAD A DECREASE IN "-) 3URPRISINGLY HOWEVER THE CHANGE IN "-) OCCURRED WITHOUT CONCURRENT CHANGES IN THE AMOUNT OF HIGH FAT FOOD INTAKE AMOUNT OF MODERATE TO VIGOROUS PHYSICAL ACTIVITY OR NUMBER OF MEALS IN FRONT OF THE 46 4HIS RE SEARCH SUGGESTS THAT TIME IN FRONT OF A 46 MAY IN ITSELF AFFECT THE CHEMISTRY OF THE BRAIN AND

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

RESULT IN OBESITY IRRESPECTIVE OF ACTIVITY LEVEL AND FOOD INTAKE 7HAT IS IT ABOUT 46 WATCHING THAT ME DIATES CHANGES IN PSYCHOLOGICAL AND PHYSICAL HEALTH OUTCOMES (OW CAN KNOWLEDGE OF BRAIN DEVELOPMENT AND LEARNING THEORY HELP US UNDERSTAND WHAT IS GOING ON /NE UNI FYING EXPLANATION FOR HOW 46 VIEWING CAN RESULT IN ADVERSE PSYCHOLOGICAL AND PHYSICAL HEALTH OUTCOMES FOCUSES ON THE WAY THE BRAIN PERCEIVES MOVEMENT ON A SCREEN %ARLY %%' OBSERVATIONS SUGGEST THAT THE BRAIN PERCEIVES MOVEMENT ON A SCREEN IN THE SAME WAY AS IT PERCEIVES MOVEMENT IN A ROOM 4HIS MEANS THAT AS THE MOVEMENT CALLS OUR BRAIN TO ATTEN TION WE WILL RESPOND BY ACTIVATING OUR ATTEN TION MECHANISMS AND THE SYMPATHETIC NERVOUS SYSTEM 46 PROGRAMMING IS DESIGNED TO CONTINU ALLY GRAB OUR ATTENTION AND KEEP US WATCHING 4HE SIGHT AND SOUND STIMULATE US AND JOLT US BACK TO ATTENTION 0ROGRAMS BECOME LOUDER

MORE GRAPHIC MORE VIOLENT OR MORE SEXUAL IN ORDER TO KEEP US WATCHING $R $AVID 7ALSH AT THE .ATIONAL )NSTITUTE FOR -EDIA AND THE &AMILY EDUCATES US THAT GRABBING ATTENTION IS

THE BASIC MECHANISM OF 46 46 PROGRAMS NEED TO KEEP US WATCHING TO hSELL OUR EYEBALLS TO AD VERTISERS v 7HILE MOST OF THE RESEARCH FOCUSES ON 46 THERE IS A GROWING CONCERN THAT OTHER MEDIA SUCH AS COMPUTER AND VIDEO GAMES CAN ELICIT THE SAME ATTENTIONAL EXCITEMENT -ECHANISMS OF ATTENTION ARE COMPLEX TO UNDERSTAND BUT THEY ARE MEDIATED BY NOR EPINEPHRINE RELEASE FROM THE LOCUS CERULEUS .ORMALLY WHEN WE ARE JOLTED TO RELEASE NOREPI NEPHRINE IN THE mIGHT OR lGHT RESPONSE THERE IS AN OBLIGATORY RELEASE OF CORTISOL FROM THE ADRENAL GLANDS TO MAINTAIN OUR STATE OF READI NESS 4HIS THEORY SUGGESTS THAT THIS STIMULATION OF THE HYPOTHALAMIC PITUITARY ADRENAL (0!

AXIS MAY ACCOUNT FOR SOME OF THE UNDERLY ING CHEMICAL CHANGES THAT 46 CREATES IN THE BRAIN !S CORTISOL IS RELEASED IN (0! AXIS ACTIVA TION IT HAS A SENSITIZING EFFECT ON NEURONS )N LOW AND MODERATE DOSES CORTISOL ASSISTS NEU RON FUNCTION AND HELPS THE NERVE CELL lRE MORE EASILY )T MAKES IT EASIER TO INDUCE LONG TERM POTENTIATION ,40 #ORTISOL THEREFORE POTEN TIATES LEARNING )T IS NO WONDER THAT CHILDREN EASILY LEARN FROM PROGRAMS THAT HOLD THEM IN

ATTENTION -OREOVER IF WE CONSIDER THE AND UNDER AGE GROUP WE ARE REMINDED THAT NEURAL NETWORKS ARE BEING CREATED IN ABUNDANCE AND THAT THERE ARE MORE POTENTIAL LEARNING PATHWAYS DURING THIS TIME THAN WILL EVER BE AVAILABLE AGAIN IN LIFE 4HIS RAPID LEARNING TAKES PLACE WITHOUT THE DISCRIMINATORY GUID ANCE OF THE 0&# WHICH IS NOT DEVELOPED YET 4HEREFORE CHILDREN WITH THEIR ABUNDANCE OF POTENTIAL LEARNING TRACKS AND LACK OF CRITICAL THINKING SKILLS ARE PARTICULARLY VULNERABLE TO LEARNING MEDIA MESSAGES "UT UNFORTUNATELY

ACTIVATING THE (0! AXIS HAS MUCH LARGER HEALTH IMPLICATIONS THAN SIMPLY LEARNING MEDIA MES SAGES #ERTAINLY THERE IS NEED FOR MORE STUDIES ON THE ROLE OF (0! AXIS ACTIVATION AND CORTI SOL IN THE MANY WAYS 46 -EDIA AFFECT HEALTH 7E NEED TO READ RESEARCH LOOKING FOR POSSIBLE DEEPER BIOCHEMICAL ASPECTS OF THE lNDINGS &OR EXAMPLE A CROSS SECTIONAL STUDY SHOWED AN ASSOCIATION BETWEEN SERUM CHOLESTEROL LEV ELS AND TELEVISION VIEWING (IGH DURATION 46 VIEWERS WERE TWICE AS LIKELY TO HAVE HIGH CHO #ONTINUED ON PAGE

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-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

-AY *UNE

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LESTEROL AND MODERATE DURATION VIEWERS WERE TIMES MORE LIKELY TO HAVE HIGH CHOLESTEROL 7HILE IT IS TEMPTING TO EXPLAIN THIS AWAY BY DIETARY CONSUMPTION HABITS WE SHOULD NOT FOR GET THAT CHOLESTEROL IS THE SUBSTRATE MOLECULE REQUIRED FOR ALL STEROID METABOLISM INCLUDING CORTISOL 4HUS AN INCREASED DEMAND FOR COR TISOL WILL ALSO CREATE AN INCREASED NEED FOR ITS SUBSTRATE CHOLESTEROL -USIC -USIC IS ALSO A POWERFUL MODULATOR OF NEURO CHEMICAL BALANCE -USIC THERAPY IS RECOGNIZED FOR ITS BENElCIAL HEALTH EFFECTS BECAUSE IT CAN AFFECT THE NEUROCHEMICAL BALANCE 0%4 SCANS DEMONSTRATE THAT MANY AREAS OF THE BRAIN PROCESS MUSIC INCLUDING THE PREFRONTAL CORTEX -USIC BECOMES A DOMINANT INmUENCE IN ADOLES CENCE AS THEIR DEVELOPING 0&# PROVIDES THEM A GREATER CAPACITY FOR PROCESSING MUSIC )N TWO SOCIAL RESEARCHERS 4OOK AND 7EISS PRESENTED THE CONCEPT OF h(EAVY -ETAL 3YNDROME v (EAVY -ETAL 3YNDROME OCCURS AMONG HIGH DURATION LISTENERS TO HEAVY METAL

MUSIC )T PRESENTS ITSELF IN A CONSTELLATION OF BEHAVIORS WHICH INCLUDES A SMOLDERING CONmICT WITH PARENTS LOWER ACADEMIC PERFORMANCE AND

MOST CONCERNING A VULNERABILITY TO SUICIDE 4HEY REPORTED A HIGHER THAN AVERAGE PROPOR TION OF SUICIDE ATTEMPTS IN THE LAST SIX MONTHS AMONG HEAVY METAL USERS WHEN COMPARED TO GENERAL YOUTH 4HEY RECORDED SUICIDE ATTEMPTS IN PERCENT OF MALE AND PERCENT OF FE MALE HEAVY METAL USERS COMPARED TO SUICIDE ATTEMPTS IN PERCENT MALES AND PERCENT FEMALES AMONG GENERAL YOUTH 4HE RESEARCHERS POSED A QUESTION TO THEIR COLLEAGUES )S THE RELATIONSHIP WE ARE OBSERVING BETWEEN HEAVY METAL RAP MUSIC AND ADOLESCENT TURMOIL REAL OR ARTIFACT )N OTHER WORDS DOES HEAVY METAL MUSIC CONTRIBUTE TO ADOLESCENT TURMOIL AND ANTISOCIAL BEHAVIORS OR MERELY RE mECT MUSICAL CHOICES BY YOUTH WHO ARE ALREADY IN TURMOIL 4HE ANSWER MAY BE hBOTH v /BVIOUSLY

CAUSE EFFECT RELATIONSHIPS ARE DIFlCULT TO PROVE

AND WE ARE REPEATEDLY REMINDED hASSOCIATION DOES NOT MEAN CAUSATION v (OWEVER THE CUR RENT NEUROBIOLOGY OF HEAVY METAL MUSIC SUG GESTS IT CAN ACTIVATE THE NORADRENERGIC SYSTEM

(EAVY METAL MUSIC LIKE TECHNO MUSIC IS FAST TEMPO MUSIC 4ECHNO MUSIC FOR EXAMPLE IS COMPUTER GENERATED AT A RATE OF BEATS PER MINUTE BPM "Y COMPARISON CLASSICAL MUSIC HAS A TEMPO OF BPM 4HE BOTTOM LINE IS THAT FAST TEMPOS ACTIVATE THE (0! AXIS

BY RELEASING .% FROM NERVES 3EVERAL STUDIES ARE IN GENERAL AGREEMENT THAT FAST MUSIC IS ABLE TO ACTIVATE THE NORADREN ERGIC SYSTEM AND THE (0! AXIS MORE THAN SLOW MUSIC %LEVATION OF .% AND CORTISOL AFFECTS OUR EMOTIONAL STATE )T IS IMPORTANT TO RECOGNIZE THAT THIS CHANGE IN BRAIN CHEMISTRY CAN COME BOTH FROM THE SOCIAL TURMOIL AND THE MUSIC ITSELF $EPRESSION WHICH IS IN QUESTION WITH THE HIGH RATE OF SUICIDE ATTEMPTS IS OFTEN ASSOCIATED WITH ELEVATED CORTISOL h-ANY PA TIENTS WITH MAJOR DEPRESSION SHOW EVIDENCE OF OVER ACTIVATION OF THE HYPOTHALAMIC PITUITARY ADRENAL AXIS AS EVIDENCED BY HYPERCORTISOLISM AND ADRENAL HYPERPLASIA v 4HE INmUENCE OF CORTISOL ON DEPRESSION IS SO SIGNIlCANT THAT IT IS STIMULATING NEW RESEARCH INTO THE POSSIBILITY OF CORTISOL RECEPTOR BLOCKERS AS ANTI DEPRESSANTS $EPRESSION ITSELF IS COMPLEX AND ALSO MEDI

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-AY *UNE

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

ATED BY GENETICS AND A VARIETY OF OTHER FACTORS (OWEVER WHEN IT IS PRESENT HYPERCORTISOLISM AFFECTS THE NUCLEUS ACCUMBENS THE VERY CENTER OF OUR PLEASURE REWARD PATHWAY

BY INHIBITING DOPAMINE SYNTHESIS AND TURNOVER THERE )F HIGH RISK KIDS ALREADY HAVE AN INCREASE IN (0!

AXIS ACTIVATION THEN ADDITIONAL STIMULATION WITH FAST TEMPO MUSIC FUELS A DANGEROUS lRE !DDICTIONS 2ECENT ADVANCES IN NEUROSCIENCE ALSO HELP US UNDERSTAND WHY THE ADOLESCENT BRAIN IS UNIQUELY VULNERABLE TO ADDICTION &IRST AS THE PREFRONTAL CORTEX 0&# STARTS TO WIRE UP THERE IS AN INCREASE IN IMPULSIVITY THAT ENCOURAGES RISK TAKING AND EXPLORATION OF NEW HORIZONS )NTERESTINGLY THIS IMPULSIVITY AS THE 0&# DEVELOPS IS SEEN IN OTHER ANIMAL SPECIES 3ECONDLY THE REWARD PATHWAY BEGINS MAKING ITS CONNECTIONS WITH THE 0&# AND NEW DOPA MINE RECEPTORS APPEAR 4HIS DEVELOPING NEURAL NETWORK WILL BE INmUENCED BY THE MILIEU OF CHEMICALS IN THE SYNAPSE )N THE PRESENCE OF DRUGS OR ABUSE DOPAMINE RECEPTORS MAY BE ASKED TO PREMATURELY DOWN REGULATE IN THE DEVELOPING REWARD PATHWAY 4HE SET POINT OF THE NEURON IS CHANGED BEFORE IT HAS COMPLETELY DEVELOPED 4HIS IS AN ADOLESCENT WINDOW OF NEURO LOGICAL VULNERABILITY THAT TOO EASILY TRANSLATES INTO LIFE LONG ADDICTION DUE TO PREMATURE DOWN REGULATION OF DOPAMINE RECEPTORS 'RANT AND $AWSON S NATIONAL SURVEY OF

ILLUSTRATES THIS hYOUNG PEOPLE WHO BEGAN DRINKING BEFORE AGE WERE FOUR TIMES MORE LIKELY TO DEVELOP ALCOHOL DEPENDENCE ALCOHOL ADDICTION COMMONLY KNOWN AS ALCOHOLISM THAN THOSE WHO BEGAN DRINKING AT AGE v !MONG THOSE WHO BEGAN DRINKING AT AGE

THERE WAS A PERCENT LIFETIME PREVALENCE ALCOHOL DEPENDENCE 0ARENTS NEED TO BE REPEATEDLY INSTRUCTED ABOUT THIS UNIQUE VULNERABILITY TO ADDICTION DURING ADOLESCENCE AND THE IMPORTANCE OF THE ROLE THEY CAN PLAY IN PREVENTING IT ! PROSPEC TIVE GENETIC STUDY OF TWINS FOUND THAT PARENTAL MONITORING AND A SUPPORTIVE HOME ATMOSPHERE WERE AMONG THE FACTORS THAT PREDICTED WHETHER A CHILD WOULD DRINK OR ABSTAIN FROM ALCOHOL AT AGE !NOTHER CONCERN IS PORNOGRAPHY ADDIC TION )NTERNET PORNOGRAPHY IS NOW WIDELY AVAIL ABLE AND MINIMALLY RESTRICTED FROM YOUTH )T

IS CREATING AN INCREASING PROBLEM AMONG OUR ADOLESCENTS -ORE CASES OF CHILDHOOD SEXUAL ABUSE ARE REPORTED WITH TEENS THAT ARE HEAV ILY INVOLVED IN )NTERNET PORNOGRAPHY AS THE PERPETRATORS 4HERE ARE MANY SOCIAL EFFECTS OF PORNOG RAPHY USE "UT FROM THE NEUROSCIENCE PERSPEC TIVE WE MUST CONSIDER WHAT THE DEVELOPING BRAIN IS LEARNING ABOUT SEXUAL AROUSAL &OR EXAMPLE IF SEXUAL AROUSAL IS LEARNED IN NEURAL CIRCUITS BATHED IN A PLETHORA OF PORNOGRAPHY

WHAT HAPPENS TO THE NEURAL CIRCUITRY OF A MORE RELATIONSHIP BASED AROUSAL !RE THESE PATHWAYS DOWN REGULATED AND PRUNED DURING THIS CRITICAL TIME IN BRAIN DEVELOPMENT WHEN THE SEXUAL RE SPONSE IS BEING LEARNED 7E ARE THE GENERATION OF PHYSICIANS ASKED TO DEAL WITH THIS COMPLEX ISSUE ALMOST AS QUICKLY AS THE INFORMATION IS AVAILABLE TO US 7E NEED TO BE TALKING WITH PARENTS AND KIDS ABOUT WHAT IS KNOWN ABOUT PORNOGRAPHY USE

$OMESTIC 6IOLENCE &INALLY WE CAN ADVOCATE FOR CHILDREN BY MAK ING INTERVENTIONS IN THE HOMES OF DOMESTIC VIOLENCE STANDARD AND ROUTINE #URRENT NEU ROBIOLOGY RESEARCH SUGGESTS THAT CHILDREN WHO WITNESS DOMESTIC ABUSE OR VIOLENCE IN THE HOME MANIFEST SIMILAR PSYCHOLOGICAL EFFECTS TO THOSE CHILDREN WHO ARE DIRECTLY ABUSED 2ESEARCH SUGGESTS THAT WATCHING DOMESTIC VIOLENCE CRE ATES THE SAME HIGH NOREPINEPHRINE LEVELS WITH SUBSEQUENT ELEVATED CORTISOL THAT IS EVIDENCED IN POST TRAUMATIC STRESS DISORDER 043$ IN THE ABUSED PERSON 4HESE CHILDREN ARE AT GREATER RISK FOR ANXIETY AND DEPRESSION OPPOSITIONAL BEHAVIOR AND LOWER ACADEMIC PERFORMANCE )N CLOSING ) AM REMINDED OF THE OLD ADAGE THAT TRUTH IS A MANY FACETED DIAMOND AND IT IS IMPOSSIBLE FOR ONE PERSON TO SEE ALL THE FACETS AT ONCE 4HIS IS PARTICULARLY TRUE WHEN WE ARE TALKING ABOUT SOMETHING AS COMPLEX AS THE SO CIETAL INmUENCES ON NEUROBIOLOGY AND BEHAVIOR AND OUR ROLE IN THE EDUCATION OF CHILDREN AND PARENTS %ACH SPECIALTY CONTRIBUTES A DIFFERENT PERSPECTIVE OF THAT DIAMOND #URRENT CULTURE CREATES NEW CONCERNS AND CHALLENGES FOR US AS PHYSICIANS ) WELCOME DIALOGUE WITH OTHER IN TERESTED PHYSICIANS TO BRING OUR KNOWLEDGE AND EXPERIENCES TOGETHER IN ORDER TO ADVOCATE WISELY AND COURAGEOUSLY FOR THE HEALTH OF CHILDREN U

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

-ARY %ZZO - $ IS A FAMILY PHYSICIAN AT THE !LLINA -EDICAL #LINIC IN 3HOREVIEW -. E MAIL EZZOX TC UMN EDU

&OOTNOTES !MERICAN !CADEMY OF 0EDIATRICS #OMMITTEE ON 0UBLIC %DUCATION h#HILDREN !DOLESCENTS AND 4ELEVISION v 0EDIATRICS

!MERICAN !CADEMY OF 0EDIATRICS #OMMITTEE ON 0UBLIC %DUCATION h-EDIA %DUCATION v 0EDIATRICS

6OL *OHNSON *' #OHEN 0 3MAILES %- +ASEN 3 "ROOK *3 h4ELEVISION VIEWING AND AGGRESSIVE BEHAVIOR DURING ADOLESCENCE AND ADULTHOOD v 3CIENCE -AR 2OBINSON 4. h2EDUCING CHILDREN S TELEVISION VIEW ING TO PREVENT OBESITY A RANDOMIZED CONTROLLED TRIALv *!-! /CT (EALY *ANE %NDANGERED -INDS .EW 9ORK 4OUCH STONE P .ATIONAL )NSTITUTE ON -EDIA AND THE &AMILY

WWW MEDIAFAMILY ORG OR

$R .ORMAN 7EINBERGER AT THE 5NIVERSITY OF #ALI FORNIA )RVINE HAS CREATED AN INTERESTING DATABASE OF MUSIC RESEARCH AT WWW MUSICA UCI EDU 4OOK +* AND 7EISS $3 h4HE RELATIONSHIP BETWEEN (EAVY -ETAL AND 2AP -USIC AND !DOLESCENT 4UR MOIL 2EAL OR !RTIFACT v !DOLESCENCE 6OL

'ERRA ' :AIMOVIC ! &RANCHINI $ ET AL h.EUROEN DOCRINE RESPONSES OF HEALTHY VOLUNTEERS TO @TECHNO MUSIC RELATIONSHIPS WITH PERSONALITY TRAITS AND EMOTIONAL STATEv )NT * 0SYCHOPHYSIOL

$INAN 4 h.OVEL !PPROACHES TO THE TREATMENT OF DEPRESSION BY MODULATING THE HYPOTHALAMIC PITU ITARY ADRENAL AXIS v (UM 0SYCHOPHARMACOL *AN 0ACAK + 4JURMINA / 0ALKOVITS - 'OLDSTEIN $3 ET AL h#HRONIC HYPERCORTISOLEMIA INHIBITS DOPAMINE SYNTHESIS AND TURNOVER IN THE NUCLEUS ACCUMBENS AN IN VIVO MICRODIALYSIS STUDY v .EUROENDOCRINOLOGY 3EP 3PEAR , h-ODELING !DOLESCENT $EVELOPMENT AND !LCOHOL 5SE IN !NIMALSv !LCOHOL 2ESEARCH AND (EALTH 6OL .O

.)( .EWS 2ELEASE WWW NIAAA NIH GOV 2OSE 2* $ICK $- 6IKEN 2* 0ULKKINEN , +APRIO * h$RINKING OR !BSTAINING AT AGE ! GENETIC EPIDEMIOLOGICAL STUDY v !LCOHOL #LIN %XP 2ES .OV *AFFE 0' (URLEY $* 7OLFE $ h#HILDREN S /BSERVA TIONS OF VIOLENCE ) #RITICAL )SSUES IN CHILD DEVELOP MENT AND INTERVENTION PLANNING #AN * 0SYCHIATRY

*AFFE 0' (URLEY $* 7OLFE $ h3IMILARITIES IN BEHAV IORAL AND SOCIAL MALADJUSTMENT AMONG CHILD VICTIMS AND WITNESSES TO FAMILY VIOLENCE v !M * /RTHOPSY CHIATRY 2HEA -( #HAFEY +( $OHNER 6!

4ERRAGO 2 h4HE SILENT VICTIMS OF DOMESTIC VIOLENCE n WHO WILL SPEAK v * #HILD !DOLESC 0SYCHIATR .URS

-AY *UNE

0AY FOR 0ERFORMANCE 7ON T )MPROVE 1UALITY OR 2EDUCE #OSTS FOR -OST 3ERVICES

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CARE ADVOCATES HAVE LATELY BEGUN TO PROMOTE A METHOD OF PAYING DOCTORS KNOWN AS hPAY FOR PERFORMANCE v ,AST YEAR THE #ENTERS FOR -EDI CARE AND -EDICAID 3ERVICES ANNOUNCED UNDER A MANDATE FROM #ONGRESS IT WOULD CONDUCT A THREE YEAR PAY FOR PERFORMANCE DEMONSTRATION PROJECT STARTING IN !LSO IN THE )NTEGRATED (EALTHCARE !SSOCIATION A COALITION OF SEVEN #ALIFORNIA PLANS ANNOUNCED A PAY FOR PERFORMANCE PROJECT THAT WILL ISSUE ITS lRST REPORT CARDS ON PHYSICIANS IN )N -IN NESOTA THE LARGEST FOUR HEALTH PLANS HAVE ALL ANNOUNCED PAY FOR PERFORMANCE PROGRAMS 4HE PHRASE hPAY FOR PERFORMANCEv IS USU ALLY USED TO MEAN hPAYING DOCTORS TO IMPROVE QUALITY OF CARE v (OWEVER INSURANCE INDUSTRY OFlCIALS OFTEN DElNE THE PHRASE TO MEAN NOT ONLY PAYING TO IMPROVE QUALITY BUT ALSO hPAYING TO DENY SERVICES v )N THIS ARTICLE PAY FOR PER FORMANCE 0&0 IS ASSUMED TO MEAN PAYING TO IMPROVE QUALITY ONLY !LTHOUGH 0&0 IS TOUTED AS A QUALITY IM PROVEMENT TOOL ITS PRIMARY ATTRACTION TO ITS PROPONENTS IS ITS ALLEGED ABILITY TO CONTROL COST !S $AN -C,AUGHLIN AND "RIAN #AMPION PUT IT IN AN ARTICLE IN THE /CTOBER -INNESOTA 0HYSICIAN h!DVOCATES SAY THAT PAY FOR PERFOR MANCE PROGRAMSxCAN GENERATE BOTH SAVINGS AND IMPROVED PATIENT OUTCOMES v "UT AT THIS DATE THERE IS VERY LITTLE EVIDENCE THAT 0&0 CAN IMPROVE QUALITY MUCH LESS REDUCE COST 4HERE ARE SEVERAL REASONS FOR THIS THE MOST IMPOR TANT OF WHICH IS THE VERY LOW PROBABILITY THAT EXPERTS WILL EVER DEVELOP ACCURATE REPORT CARDS FOR MOST MEDICAL SERVICES 4HE REASON ACCURATE REPORT CARDS ARE REQUIRED FOR 0&0 IS OBVIOUS !N INSURER CANNOT PAY DOCTORS FOR BETTER OR

"9 +)0 35,,)6!.

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WORSE PERFORMANCE UNLESS THE INSURER CAN GRADE PERFORMANCE 2EPORT CARDS ARE BASED ON ONE OR BOTH OF TWO TYPES OF QUALITY MEASURES MEASURES OF OUTCOMES AND MEASURES OF PROCESSES USED IN TREATMENT !N EXAMPLE OF AN OUTCOME MEA SURE IS MORTALITY RATES AMONG PATIENTS WHO HAD CORONARY ARTERY BYPASS SURGERY !NOTHER EXAMPLE IS CHOLESTEROL LEVELS WHICH FALLS INTO A CATEGORY LABELED BY SOME AS hINTERMEDIATE OUT COMES v %XAMPLES OF PROCESS MEASURES INCLUDE PRESCRIBING BETA BLOCKERS FOR PATIENTS WHO HAVE SUFFERED A HEART ATTACK AND ORDERING BLOOD TESTS TO CHECK CHOLESTEROL LEVELS IN DIABETICS /UTCOME MEASURES ARE VERY EXPENSIVE IN TERMS OF DOLLARS AND LOST PRIVACY BECAUSE THEY HAVE TO BE ADJUSTED TO REmECT DIFFERENCES IN PATIENT HEALTH AND OTHER FACTORS BEYOND PHYSI CIAN CONTROL A PROCESS COMMONLY CALLED hRISK ADJUSTMENT v AND LESS COMMONLY CALLED hCASE MIX ADJUSTMENT v 0ROCESS MEASURES ARE USU ALLY EXPENSIVE BECAUSE THEY REQUIRE AGREEMENT ON STANDARDS OF CARE WHICH DO NOT EXIST FOR THOUSANDS OF MEDICAL SERVICES 3OME PROCESS MEASURES MUST ALSO BE RISK ADJUSTED 2EPORT CARDS BASED ON OUTCOME MEASURES /UTCOME MEASURES ARE EXPENSIVE AND INVADE PATIENT PRIVACY BECAUSE THEY MUST BE RISK ADJUSTED IN ORDER TO BE ACCURATE !DJUSTING FOR DIFFERENCES IN PATIENT HEALTH NEARLY ALWAYS REQUIRES ACCESS TO PATIENT MEDICAL RECORDS AS OPPOSED TO hADMINISTRATIVE DATA v TYPICALLY DE lNED AS DATA FOUND IN CLAIM FORMS COLLECTED BY INSURERS AND OR DISCHARGE REPORTS PREPARED BY HOSPITALS 4HE .EW 9ORK 3TATE $EPARTMENT OF (EALTH REPORT CARD ON CARDIAC SURGEONS IS A GOOD EXAMPLE OF AN OUTCOME BASED REPORT CARD THAT REQUIRES RISK ADJUSTMENT )T USES MORTALITY RATES FOLLOWING CORONARY ARTERY BYPASS GRAFTS

AN OUTCOME MEASURE AS THE MEASURE OF QUAL ITY AND IT ADJUSTS FOR RISK USING PATIENT MEDI CAL RECORDS %XAMPLES OF hPATIENT RISK FACTORSv THAT ARE TAKEN INTO ACCOUNT BY THE .EW 9ORK $EPARTMENT OF (EALTH INCLUDE EJECTION FRAC TION HEART ATTACK WITHIN THE LAST SEVEN DAYS

CONGESTIVE HEART FAILURE AND THE PRESENCE OF SEVERAL COMORBIDITIES INCLUDING DIABETES AND OBESITY 2ISK ADJUSTMENT OF OUTCOME MEASURES THAT WILL BE USED TO PUNISH OR REWARD PHYSI CIANS EITHER WITH ADJUSTMENTS TO REIMBURSE MENT OR TO MARKET SHARE IS NECESSARY PRIMARILY TO PROTECT PATIENTS AND SECONDARILY TO ENSURE FAIR TREATMENT OF DOCTORS )F RISK ADJUSTMENT IS INSUFlCIENTLY ACCURATE OR IF IT IS EVEN PERCEIVED

BY PHYSICIANS TO BE INSUFlCIENTLY ACCURATE PHY SICIANS WILL BE UNDER PRESSURE TO AVOID SICKER PATIENTS (OWEVER FEW OF THE REPORT CARDS NOW TOUTED BY THE INSURANCE INDUSTRY AND LARGE EM PLOYER GROUPS ARE ADJUSTED FOR ANYTHING OTHER THAN AGE AND SEX 4HE FEW RELIABLE STUDIES THAT HAVE IN VESTIGATED THE IMPACT OF POORLY RISK ADJUSTED REPORT CARDS HAVE CONlRMED WHAT THEORY AND COMMON SENSE PREDICT INACCURATE REPORT CARDS PUT GREAT PRESSURE ON HEALTH CARE PROFESSIONALS TO CHERRY PICK 9UJING 3HEN REPORTED IN (EALTH 3ERVICES 2ESEARCH THAT PROVIDERS OF SUBSTANCE ABUSE TREATMENT AVOIDED SICKER PATIENTS FOLLOW ING -AINE S IMPLEMENTATION OF hPERFORMANCE BASED CONTRACTING v A SYSTEM THAT THREATENED LOW SCORING PROVIDERS WITH LOSS OF THEIR CON TRACTS AND PROMISED HIGH PERFORMING PROVIDERS MORE FUNDING 4HE SCORES THAT -AINE USED TO ASSESS PERFORMANCE WERE NOT ADJUSTED FOR RISK "UT EVEN REPORT CARDS WITH SOPHISTICATED RISK ADJUSTMENT MAY CAUSE SOME PROVIDERS TO AVOID THE SICKEST PATIENTS 4HE .EW 9ORK REPORT CARD ON HEART SURGEONS AS SOPHISTICATED AS IT IS MAY NOT BE ACCURATE ENOUGH TO TAKE THE PRESSURE OFF

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

SURGEONS TO CHERRY PICK )N ANY CASE SOME HEART SURGEONS IN .EW 9ORK THINK IT IS NOT AND AS A RESULT THERE IS SOME EVIDENCE THAT QUALITY OF CARE FOR THE SICKEST PATIENTS HAS DECLINED AS SURGEONS WHO DO NOT TRUST THE RISK ADJUSTMENT METHODOLOGY lND WAYS TO AVOID SICK PATIENTS IN ORDER NOT TO HAVE THOSE PATIENTS DRIVE THEIR MORTALITY RATES UP 3OME EXPERTS HAVE SUGGESTED THAT OUT COMES CANNOT BE MEASURED ACCURATELY ENOUGH TO ELIMINATE THE INCENTIVE TO REJECT SICKER PA TIENTS (OFER ET AL EXAMINED THE ACCURACY OF AN OUTCOME MEASURE COMMONLY USED IN PHYSICIAN REPORT CARDS TODAY Â&#x2C6; HEMOGLOBIN ! # (GB ! C LEVELS IN PATIENTS WITH TYPE DIABETES !F TER ADJUSTING THE (GB ! C LEVELS FOR DIFFERENCES IN PATIENT HEALTH AND SOCIOECONOMIC STATUS AD JUSTMENTS FAR MORE SOPHISTICATED AND EXPENSIVE THAN THOSE USED BY THE AVERAGE INSURER TODAY

THE INVESTIGATORS FOUND THAT PHYSICIANS WOULD STILL BE BETTER OFF GETTING RID OF THEIR ONE TO THREE SICKEST PATIENTS OUT OF AN AVERAGE DIABETIC BASE OF ABOUT PATIENTS PER DOCTOR $OING SO WOULD IMPROVE THEIR SCORE hDRAMATICALLY v SAID THE AUTHORS h4HIS ADVANTAGE FROM GAM ING COULD NOT BE PREVENTED BY EVEN DETAILED CASE MIX ADJUSTMENT v THEY CONCLUDED 2EPORT CARDS BASED ON PROCESS MEASURES 0ROCESS MEASURES E G DID THE SURGEON PRESCRIBE A BETA BLOCKER FOR THE HEART ATTACK PATIENT OFTEN DO NOT REQUIRE RISK ADJUSTMENT

AND FOR DIAGNOSES FOR WHICH A STANDARD OF CARE HAS BEEN REACHED ARE THEREFORE LIKELY TO BE LESS EXPENSIVE THAN OUTCOME MEASURES 4HIS IS TRUE

HOWEVER ONLY WHERE THE PATIENT POPULATION EXAMINED IS LIMITED TO PATIENTS WHO ACTUALLY SAW A DOCTOR &OR EXAMPLE A PROCESS MEASURE THAT MEASURED WHETHER A DOCTOR ADVISED A PATIENT TO QUIT SMOKING WOULD NOT NEED TO BE RISK ADJUSTED AS LONG AS THE STUDY WAS LIMITED TO PATIENTS WHO VISITED THE DOCTOR "UT A PROCESS MEASURE THAT USED ALL PATIENTS ASSIGNED TO A CLINIC BY AN (-/ AS THE DENOMINATOR WOULD HAVE TO BE RISK ADJUSTED FOR BOTH HEALTH AND SOCIOECONOMIC FACTORS THAT INmUENCE PATIENTS ABILITY AND INCLINATION TO SEE A DOCTOR 4HESE FACTORS ARE PARTIALLY OR WHOLLY OUTSIDE THE DOCTOR S CONTROL AND IF UNCONTROLLED COULD BIAS PHYSICIAN hSCORES v (OWEVER EVEN PROCESS MEASURES THAT DO NOT REQUIRE RISK ADJUSTMENT PRESENT A HURDLE

THAT IS ALMOST AS DAUNTING AS RISK ADJUSTMENT

NAMELY THE NEED FOR AN AGREED UPON STANDARD OF CARE THAT APPLIES TO ALL PATIENTS WITH A GIVEN DIAGNOSIS 2ELATIVE TO THE THOUSANDS OF MEDICAL SERVICES RENDERED IN !MERICA TODAY EVIDENCE BASED STANDARDS ARE FEW 4HE PROPORTION OF MEDICAL SERVICES FOR WHICH A SCIENCE BASED CONSENSUS ON STANDARD OF CARE EXISTS IS APPAR ENTLY NO MORE THAN TO PERCENT !CCORDING TO AN ARTICLE BY ,ANDON ET AL IN A EDITION OF *!-! h;&=EW MEDICAL SPECIALTIES HAVE AN EVIDENCE BASE THAT IS ROBUST AND COMPREHENSIVE ENOUGH TO SUPPORT 0#0! ;PHYSICIAN CLINICAL PERFORMANCE ASSESSMENT= v 2EPORT CARDS BASED ON PATIENT SURVEYS -ANY ADVOCATES OF REPORT CARDS HAVE EXPRESSED THE HOPE THAT PATIENT SURVEYS WILL PROVE TO BE AN INEXPENSIVE ALTERNATIVE TO REPORT CARDS BASED ON RISK ADJUSTED OUTCOME MEASURES OR PROCESS MEASURES )T IS NO DOUBT TRUE THAT MOST OF THE SURVEY BASED REPORT CARDS BEING PUBLISHED TODAY ARE RELATIVELY INEXPENSIVE

BUT UNFORTUNATELY THEY ARE NOT ACCURATE AND SHOULD NOT BE USED BY PATIENTS 3URVEYS FACE THE SAME PROBLEMS OUTCOME AND PROCESS BASED REPORT CARDS FACE )F THE SURVEY QUESTION SEEKS INFORMATION ON OUTCOMES THE hGRADEv HAS TO BE RISK ADJUSTED THAT IS THE RESPONDENTS HEALTH STATUS MUST BE TAKEN INTO ACCOUNT )T IS WELL ESTABLISHED THAT SICKER PATIENTS ARE MORE CRITICAL OF THEIR CAREGIVERS )F THE SURVEY QUESTION SEEKS INFORMATION ABOUT PROCESSES OF CARE THE PROCESS BEING MEASURED MUST BE SHOWN TO HAVE A ROBUST RELATIONSHIP WITH HIGH QUALITY OUTCOMES )T IS NOT CLEAR THAT QUESTIONS COMMONLY ASKED IN PATIENT SURVEYS MEET THESE CRITERIA )N SUM

PATIENT SURVEYS DO NOT PROVIDE A LOW COST METHOD OF DERIVING ACCURATE REPORT CARDS ON PHYSICIAN SERVICES #ONCLUSIONS 4HE PRIMARY OBSTACLE OUTCOME BASED REPORT CARDS MUST OVERCOME IS THE DIFlCULTY OF ACCU RATE RISK ADJUSTMENT 4HE PRIMARY PROBLEM WITH PROCESS MEASURES IS THAT THEY REQUIRE CONSENSUS ON STANDARDS OF CARE AND SUCH CONSENSUS DOES NOT EXIST FOR THE GREAT MAJORITY OF MEDICAL SER VICES -OREOVER SOME PROCESS MEASURES MUST BE RISK ADJUSTED &INALLY PATIENT SATISFACTION SURVEYS ARE NOT A SHORT CUT TO ACCURATE REPORT CARDS 4HEY TOO MUST BE RISK ADJUSTED

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

&OR THESE AND OTHER REASONS MANY EXPERTS BELIEVE THAT ACCURATE PHYSICIAN REPORT CARDS FOR MOST MEDICAL SERVICES WILL NEVER APPEAR !S ,ANDON ET AL PUT IT IN A EDITION OF *!-! h!T THE CURRENT TIME GIVEN THE STATE OF TECHNOLOGY AND THE EXISTING INFRASTRUCTURE TO SUPPORT PERFORMANCE ASSESSMENT BROAD BASED MANDATORY CLINICAL PERFORMANCE ASSESSMENT FOR INDIVIDUAL PHYSICIANS AS A MEANS OF DETERMINING THE COMPETENCE OF INDIVIDUAL PHYSICIANSxAP PEARS TO BE INFEASIBLE v )F ACCURATE REPORT CARDS FOR MOST SERVICES ARE NOT FEASIBLE THAT MEANS 0&0 FOR MOST SERVICES IS NOT FEASIBLE 4HAT IN TURN MEANS 0&0 CANNOT IMPROVE QUALITY FOR MOST SERVICES WHICH IN TURN MEANS 0&0 CANNOT REDUCE COSTS FOR MOST SERVICES U +IP 3ULLIVAN IS A MEMBER OF THE BOARD OF THE -INNESOTA 0HYSICIAN 0ATIENT !LLIANCE (E IS THE AUTHOR OF SEVERAL REPORTS BY -00!

INCLUDING A PAPER ON PAY FOR PERFORMANCE 4HESE MAY BE VIEWED AT WWW PHYSICIAN PATIENT ORG (E HAS WRITTEN EXTENSIVELY ABOUT HEALTH POLICY

-AY *UNE )NDEX TO !DVERTISERS !LLINA (EALTH 3YSTEMS !LLINA (EALTH 3YSTEMS !LLINA (EALTH 3YSTEMS #RUTCHlELD $ERMATOLOGY (EALTHCARE "ILLING 2ESOURCES -EDICAL "ILLING 0ROFESSIONALS --)# -INNESOTA (EALTHCARE .ETWORK 0ARENT 0ROFESSIONAL 0ROPERTIES ,,# 2APID 2ETURN )NSIDE "ACK #OVER 2#-3 )NC 2ED 0INE 2EALTY 5 OF - #-% /UTSIDE "ACK #OVER 6EHICLE !DVANTAGE )NSIDE &RONT #OVER 7EBER ,AW /FlCE 7HITESELL -EDICAL ,OCUMS ,TD

-AY *UNE

'OVERNMENT 0RESCRIBED h"EST 0RACTICESv .OT 7HAT THE $OCTOR /RDERED

-

-)..%3/4! ,%')3,!4/23 APPEAR DETER

MINED TO CREATE A STATE GOVERNMENT COOKBOOK OF MEDICINE )F THE PROPOSED BILLS BECOME LAW

PHYSICIANS WILL ESSENTIALLY WORK FOR THE GOVERN MENT lRST AND THE PATIENT SECOND (OUSE &ILE "RADLEY 2 2OCHESTER AND 3ENATE &ILE "ERGLIN $ -PLS AU THORIZE STATE GOVERNMENT TO ISSUE A LIST OF hBEST PRACTICESv FOR PATIENT CARE STARTING WITH DIABE TES AND CONGESTIVE HEART FAILURE 4HROUGH COL LABORATION WITH HEALTH PLANS AND THE )NSTITUTE FOR #LINICAL 3YSTEMS )MPROVEMENT )#3) STATE HEALTH OFlCIALS WILL TRACK AND PUBLICLY REPORT PHYSICIAN ADHERENCE TO THIS LIST OF GOVERNMENT PRESCRIBED MEDICAL TREATMENTS 0AYMENT WITH HOLDS BASED ON ADHERENCE WILL BE ALLOWED FOR PHYSICIANS TREATING PUBLIC ASSISTANCE PATIENTS 4HE (OUSE HAS ALREADY PASSED THE BILL 4HIS IS DANGEROUS LEGISLATION h)T IS NOT STRETCHING THINGS TOO FAR TO SAY THAT WHOEVER CONTROLS PRACTICE POLICIES CONTROLS MEDICINE v CAUTIONS $- %DDY IN *!-! 0RACTICE GUIDE LINES ARE USEFUL TO PHYSICIANS AND PATIENTS AS LONG AS GUIDELINES ARE ONLY GUIDELINES !S SOON AS THEY BECOME ENFORCEABLE BY LAW GUIDELINES BECOME GOVERNMENT DIRECTIVES 4HE LEGISLATION DOES NOT DElNE hBEST PRAC TICES v LEAVING THE -INNESOTA $EPARTMENT OF (EALTH TO WRITE ITS OWN DElNITION 4HIS IS AN INVITATION TO DISASTER -EDICAL PRACTICE WILL BE DElNED BY THOSE WITH THE MOST POWER TO PER SUADE STATE OFlCIALS ALLOWING POLITICAL AGENDAS

RATIONING SCHEMES AND DISCRIMINATORY VALUE JUDGMENTS TO SET THE SCOPE AND PARAMETERS OF PATIENT CARE 0ATIENTS MAY NOT UNDERSTAND THE TERM hBEST PRACTICES v BUT ONCE THEY LEARN THAT IT MEANS THEIR PHYSICIAN IS TAKING ORDERS FROM

"9 47),! "2!3% 2.

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-AY *UNE

SOMEONE ELSE THEIR TRUST IN TREATMENT DECISIONS WILL BE SHAKEN 'OVERNMENT DIRECTED MEDICAL PRACTICE CONTINUES TO HAVE BROAD SUPPORT IN #ONGRESS 0RACTICE GUIDELINES WERE PART OF THE #LINTON (EALTH 0LAN 4HE -EDICARE !CT INCLUDES A PAY FOR PERFORMANCE PROJECT AUTHORED BY 3EN .ORM #OLEMAN 2 -. !ND FEDERALLY FUNDED EVIDENCE BASED PRACTICE CENTERS ARE CHURNING OUT PRACTICE GUIDELINES 4HE )NSTITUTE OF -EDICINE )/- PRIMAR ILY FUNDED BY #ONGRESS SUPPORTS THE DISSEMI NATION OF MEDICAL PRACTICE GUIDELINES THROUGH A .ATIONAL (EALTH )NFORMATION )NFRASTRUCTURE .()) #LINICAL DECISION SUPPORT SYSTEMS ARE AN ESSENTIAL ELEMENT ACCORDING TO A RECENT )/- REPORT ON PATIENT SAFETY .OT ONLY WILL hEVIDENCE BASEDv GUIDELINES BE TRANSMITTED TO EXAM ROOM COMPUTERS THE .()) CAN INmUENCE MEDICAL DECISION MAKING BY v LINKING PATIENT OUTCOMES WITH THOSE RE SPONSIBLE FOR THOSE OUTCOMES v MEASURING PHYSICIAN PERFORMANCE v MONITORING COMPLIANCE WITH BEST PRAC TICES v RANKING DOCTORS AND HOSPITALS v PROVIDING lNANCIAL REWARDS BASED ON PER FORMANCE AND

v PERMITTING STATE AND FEDERAL GOVERNMENT HEALTH SURVEILLANCE 3TATE 3ENATOR ,INDA "ERGLIN LIKES THE IDEA 3& WILL REQUIRE ALL CLINICS HOSPITALS AND HEALTH PLANS TO HAVE A GOVERNMENT APPROVED ELECTRONIC MEDICAL RECORD SYSTEM BY 4HE MICROMANAGEMENT OF TREATMENT THROUGH ESTABLISHMENT AND MONITORING OF hBEST PRACTICESv IS PROBLEMATIC FOR SEVERAL REASONS &IRST BIAS ABOUNDS 4HE )/- ACKNOWL EDGES h4HERE ARE GAPS AND INCONSISTENCIES IN THE MEDICAL LITERATURE SUPPORTING ONE PRACTICE VERSUS ANOTHER AS WELL AS BIASES BASED ON THE PERSPECTIVE OF THE AUTHORS WHO MAY BE SPECIAL ISTS GENERAL PRACTITIONERS PAYERS MARKETERS OR PUBLIC HEALTH OFlCIALS v 3ECOND hEVIDENCE BASED MEDICINEv %"- Â&#x2C6; THE PURPORTED UNDERGIRDING OF hBEST PRACTICESv Â&#x2C6; REMAINS CONTROVERSIAL !S 3EAN ,YNCH WRITES h) FEEL THAT THE @!CHILLES (EEL OF SOME CURRENT USES OF %"- IS THE SELECTION OF THE EVIDENCE AND WHETHER CERTAIN DATA OR STUDIES CONSTITUTE EVIDENCE v 4HIRD MONITORING PHYSICIANS MAY PROVE COUNTERPRODUCTIVE 4HE )/- WARNS THAT A hCYCLE OF FEARv MAY LEAD TO PHYSICIAN DEFEN SIVENESS GAMING THE SYSTEM OR SYSTEMATIC MANIPULATION OF THE DATA 0RACTICE GUIDELINES BASED ON SKEWED DATA WILL BE UNRELIABLE AND UNSAFE !ND lNALLY hBEST PRACTICESv REQUIREMENTS MAY LEAD TO A MYOPIC FOCUS ON SPECIlED CONDI TIONS WITH INSUFlCIENT ATTENTION TO THE OTHER PRESSING NEEDS OF PATIENTS )N THE )/- RECOMMENDED PRIORITY AREAS FOR EVIDENCE COLLECTION PRACTICE GUIDELINE CREATION AND PER FORMANCE MEASUREMENT DEVELOPMENT -YRIAD CONDITIONS AND MYRIAD ITERATIONS OF CONDITIONS EXPERIENCED BY PATIENTS ARE NOT ON THE LIST -INNESOTA S GOVERNOR AND POWERFUL SPECIAL INTEREST GROUPS SUPPORT GOVERNMENT

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

PRESCRIBED hBEST PRACTICES v )N HIS 3TATE OF THE 3TATE ADDRESS 'OVERNOR 4IM 0AWLENTY SAID HIS ADMINISTRATION WOULD hFORCE HEALTH CARE PRO VIDERS TO USE BEST PRACTICES v !ND ACCORDING TO AN E MAIL FROM 2EP "RADLEY h4HE PROVI SIONS ARE SUPPORTED BY THE -INNESOTA -EDICAL !SSOCIATION 4HE -INNESOTA (OSPITAL !SSOCIA TION 4HE -INNESOTA #HAMBER OF #OMMERCE

4HE "USINESS 0ARTNERSHIP AND A WIDE VARIETY OF EMPLOYER PROVIDER HEALTH PLAN CONSUMER GROUPSv (EALTH PLANS UNDOUBTEDLY HOPE THAT GOVERNMENT ISSUED PRACTICE DIRECTIVES WILL SERVE AS A PROTECTIVE SHIELD AGAINST MEDICAL MALPRAC TICE LITIGATION /N -ARCH THE #ITIZENS #OUNCIL ON (EALTH #ARE ##(# HELD A PRESS CONFERENCE TO ANNOUNCE THAT MORE THAN PHYSICIANS HAD ALREADY SIGNED THE ##(# 0HYSICIAN 0ETITION TO OPPOSE THE LEGISLATION /N !PRIL

2EP -ARK /LSON 2 "IG ,AKE ATTEMPTED TO DELETE hBEST PRACTICESv AND hDISEASE MANAGE MENTv FROM (& (IS AMENDMENT FAILED

4HE -INNESOTA LEGISLATURE HAS DECIDED TO MAKE GOVERNMENT PRESCRIBED hBEST PRACTICESv THE LAW OF THE LAND 4HE NEWS MEDIA HAVE REFUSED TO INFORM THE PUBLIC (OW PHYSICIANS RESPOND NOW WILL DETERMINE THE INTEGRITY OF MEDICAL PRACTICE FOR GENERATIONS TO COME U 4WILA "RASE 2.

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IS 0RESIDENT OF THE #ITI ZENS #OUNCIL ON (EALTH #ARE A 3T 0AUL BASED

INDEPENDENT FREE MARKET HEALTH CARE POLICY ORGANIZATION 4HE 0HYSICIAN 0ETITION IS ONLINE AT HTTP WWW CCHCONLINE ORG &OOTNOTES h%DDY $- #LINICAL DECISION MAKING FROM THEORY TO PRACTICE 0RACTICE POLICIES n GUIDELINES FOR METHODS *!-!

4ITLE 6 3UBTITLE ! h1UALITY -ANAGEMENT AND )M PROVEMENT v (EALTH 3ECURITY !CT N D 4HE -EDICARE !CT 3 INCLUDES 3ENATOR .ORM #OLEMAN S h-EDICARE 0AYMENT FOR 1UALITY AND 6ALUE !CT OF v 3 h0ATIENT 3AFETY !CHIEVING A .EW 3TANDARD FOR #ARE v #OMMITTEE ON $ATA 3TANDARDS FOR 0ATIENT 3AFETY )N STITUTE OF -EDICINE OF THE .ATIONAL !CADEMIES

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-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

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! 4RIBUTE TO $EMETRE - .ICOLOFF - $ !UGUST n !UGUST

). !5'534 OF

THE 4WIN #ITIES AREA AND THE STATE OF -INNESOTA MOURNED THE PASSING OF $EMETRE - .ICOLOFF

- $ 0H $ AT AGE $URING HIS YEAR TENURE HE SERVED IN BOTH THE ACADEMIC AND PRIVATE PRACTICE OF CARDIOVASCULAR AND THORACIC SURGERY

GARNERING A REPUTATION AS -INNESOTA S PREMIER CARDIOVASCULAR SURGEON (E THRIVED AS A BUSI NESSMAN AND INVENTOR SERVED HUMANITY WITH MANY VOLUNTEER ACTIVITIES AND INVENTED NUMER OUS DEVICES TO IMPROVE THE HUMAN CONDITION

! FAMILY MAN $R .ICOLOFF KNOWN BY ALL AS .IC WAS MARRIED FOR YEARS TO HIS WIFE !RDE SHARING A MUTUALLY SUPPORTIVE AND LOVING RELATIONSHIP RAISING THREE CHILDREN !LEX

3TEPHANIE AND -ARK

!S A PHYSICIAN $R .ICOLOFF PERFORMED OVER OPEN HEART SURGICAL PROCEDURES ON PATIENTS RANGING IN AGE FROM ONE DAY TO OVER YEARS (E WAS A MASTER OF BOTH CONGENITAL AND ACQUIRED CARDIAC DISEASE (E ALWAYS MADE TIME AND WAS NEVER TOO BUSY TO CARE FOR A PATIENT "ECAUSE OF HIS CARING ATTITUDE AND HIS ABILITY TO LISTEN MANY OF HIS PATIENTS BECAME MORE THAN PROFESSIONAL ACQUAINTANCES FOLLOWING THEIR SURGICAL INTERVENTION (E SERVED AS THE FOUNDER AND LEADER OF A SURGICAL PRACTICE THAT BECAME ONE OF THE LARGEST IN THE COUNTRY AND SET THE TONE FOR QUALITY OF CARE AND INTELLECTUAL CURIOSITY (E WAS A FOUNDING PARTNER OF THE 3T 0AUL (EART AND ,UNG )NSTITUTE AND THE -INNEAPOLIS (EART )NSTITUTE ORGANIZATIONS THAT EPITOMIZE QUALITY CARDIAC CARE

!S A THINKER HIS ABILITY TO DISSECT A PROBLEM ELIMINATE NONESSENTIAL ELEMENTS AND FOCUS ON THE CORE ISSUE TO CREATE A SOLUTION WAS LEGENDARY 4HIS ABILITY NOT ONLY EXTENDED TO SOLVING ACADEMIC PROBLEMS BUT ALSO TO SOLVING PROBLEMS OF DIAGNOSTICS AND THERAPEUTICS IN THE COURSE OF THE TREATMENT OF HIS PATIENTS DEALING WITH BUSINESS AND ETHICAL ISSUES IN THE MOST UP HANDED FASHION AND CREATING NEW IDEAS FOR MEDICAL DEVICES OR OPERATIVE PROCEDURES (IS LEADERSHIP SKILLS WERE SOUGHT BY MANY IN HIS VARIED INTERESTS OF MEDICINE BUSINESS AND ADMINISTRATION SERVING IN THE MANAGEMENT AND BOARDS OF DIRECTORS OF MEDICAL INSTITUTIONS

PUBLIC CORPORATIONS AND NON PROlT CHARITABLE ORGANIZATIONS

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!S AN INVENTOR $R .ICOLOFF S ACCOMPLISH MENTS HAD GLOBAL IMPACT (E WAS CO INVENTOR OF THE 3T *UDE -EDICAL HEART VALVE WHICH HAS SET THE STANDARD FOR ARTIlCIAL HEART VALVES AND HAS BEEN IMPLANTED IN OVER

PATIENTS OVER NEARLY YEARS (E DESIGNED THE PERMA mOW GRAFT RESEARCHED THROUGH 0OSSIS -EDICAL #ORPORATION TO PROVIDE NEW CARDIAC CIRCULATION IN ELIGIBLE PATIENTS (E SERVED DESIGNED AND FOSTERED THE DEVELOPMENT OF MULTIPLE SURGICAL PROCEDURES AND PUBLISHED OVER MANUSCRIPTS IN THE MEDICAL LITERATURE AS WELL AS TWO FULL TEXTS

!S A BUSINESSMAN $R .ICOLOFF SERVED ON THE BOARD OF DIRECTORS OF RESEARCH ADVISORY BOARDS FOR NUMEROUS CORPORATIONS DIRECTING THEIR BUSINESS TO THE BETTERMENT OF HIS PATIENTS

DESIGNING AND IMPROVING MEDICAL DEVICES

CONDUCTING MEDICAL RESEARCH OR DRIVING THE ACCEPTANCE OF MEDICAL DEVICES AND PROCEDURES TO IMPROVE PATIENT CARE (E WAS A CO FOUNDER OF SEVERAL PROMINENT -INNESOTA CORPORATIONS INCLUDING 3T *UDE -EDICAL AND !43 -EDICAL

DIRECTED AN EQUITIES MUTUAL FUND AND SERVED AS A DIRECTOR OF OTHER INVESTMENT FUNDS

!S A HUMANITARIAN $R .ICOLOFF PLAYED A ROLE IN OUTREACH IN INTERNATIONAL AID PROGRAMS (E CONTRIBUTED TO MEDICAL RESEARCH AND SERVED AS PRESIDENT FOR MANY LOCAL AND REGIONAL SOCIETIES INCLUDING THE -INNESOTA !CADEMY OF -EDICINE !MERICAN (EART !SSOCIATION

-INNESOTA !FlLIATE THE -INNEAPOLIS 3URGICAL 3OCIETY AND THE 3T 0AUL 3URGICAL 3OCIETY (E LED FOUR MEDICAL MISSIONS TO #HINA BRINGING A SURGICAL TEAM AND SUPPLIES TO CORRECT CONGENITAL HEART DEFECTS IN CHILDREN AND WAS A SUPPORTER OF OTHER MISSIONS THROUGH #HILDREN S (EART,INK

AS WELL AS BEING CHAIRPERSON OF THE #HILDREN S (EART,INK ORGANIZATION

7E HAVE LOST A SPECIAL PERSON THIS YEAR 6ERY FEW MEN OF SUCH CHARACTER AND VITALITY ARE FOUND AND FOR THOSE OF US WHO KNEW HIM WE ARE GRATEFUL FOR THIS OPPORTUNITY 7E ARE LEFT WITH HIS LEGACY IN OUR COMMUNITY INSPIRED BY HIS TEACHING OF EXCELLENT SURGICAL TECHNIQUE

CREATIVE THINKING AND THE APPLICATION OF NEW SURGICAL TECHNIQUES AND TECHNOLOGY TO THE BET TERMENT OF OUR PATIENTS

$R .ICOLOFF WAS A MEMBER OF THE -IN NESOTA -EDICAL !SSOCIATION AND THE 2AMSEY -EDICAL 3OCIETY U 7RITTEN BY 2OBERT 7 %MERY *R - $ #ARDIAC 3URGICAL !SSOCIATES

0AWLENTY !PPOINTS 4HREE TO "OARD OF -EDICAL 0RACTICE 'OVERNOR 4IM 0AWLENTY RECENTLY ANNOUNCED THE APPOINTMENT OF $RS 2EBECCA * (AFNER

FAMILY PHYSICIAN !VON "RADLEY 3 *OHNSON

FAMILY PHYSICIAN 7OODBURY AND %RNEST 7 ,AMPE )) GENERAL SURGEON -ANKATO TO THE "OARD OF -EDICAL 0RACTICE 4HE "OARD OF -EDICAL 0RACTICE IS RESPON SIBLE FOR LICENSING AND DISCIPLINING PHYSICIANS AS WELL AS THE REGULATION OF ACUPUNCTURISTS

ATHLETIC TRAINERS PHYSICIAN ASSISTANTS AND RESPIRATORY CARE PRACTITIONERS 4HE BOARD IS MADE UP OF MEMBERS APPOINTED BY THE 'OVERNOR U 'OT 4IX (AVE YOU EVER FOUND YOURSELF WITH TICKETS TO A GAME CONCERT OR THEATER PERFORMANCE THAT YOU COULDN T USE .OBODY LIKES TO LET THOSE EXPERIENCES GO TO WASTE .OW THERE IS AN EASY WAY FOR YOU TO MAKE GOOD USE OF THOSE TICKETS WHILE MAKING A WORTHWHILE CONTRIBUTION TO THE COMMUNITY 4IX FOR 4OTS IS A 3T 0AUL BASED NONPROlT ORGANIZATION THAT GETS UNUSED TICKETS TO CHIL DREN IN NEED IN THE 4WIN #ITIES AREA 9OUR CONTRIBUTION CAN ENABLE A DISADVANTAGED CHILD TO MARVEL AT THE -ETRODOME MEET 'OLDY 'OPHER OR DELIGHT IN THE MAGIC AND WONDER OF THE THEATER 4HE PROCESS IS SIMPLE 9OU CAN MAIL YOUR TICKETS TO 4IX FOR 4OTS AT 0 / "OX

3T 0AUL -. )T IS PREFERRED THAT TICKETS ARRIVE SEVEN DAYS PRIOR TO THE EVENT

BUT TICKETS ARE WELCOME TO BE RECEIVED AS LATE AS THE DAY PRIOR TO THE EVENT 4IX FOR 4OTS WILL PLACE YOUR EVENT TICKETS WITH ONE OF MORE THAN PARTNER ORGANIZATIONS SERVING NEEDY CHILDREN IN THE 4WIN #ITIES COMMUNITY 9OU WILL RECEIVE A RECEIPT OF YOUR TAX DEDUCTIBLE CONTRIBUTION IN THE MAIL -ORE IMPORTANTLY

YOU WILL GIVE THE OPPORTUNITY TO EXPERIENCE NEW WORLDS TO CHILDREN WHO MAY OTHERWISE NEVER GET THE CHANCE &OR MORE INFORMATION

VISIT WWW TIXFORTOTS ORG U

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

6OLUNTEERS .EEDED FOR 0ROJECT # 5 2 % !S PART OF ITS COMMUNITY LEADERSHIP PROJECT

A SEVEN MEMBER TEAM FROM THE 3AINT 0AUL !REA #HAMBER OF #OMMERCE S ,EADERSHIP 3AINT 0AUL PROGRAM WILL BE ASSISTING IN THE LAUNCH OF 0ROJECT # 5 2 % S 4WIN #ITIES OPERATIONS 0ROJECT # 5 2 % IS THE REGIS TERED TRADEMARK OF THE "ENEVOLENT (EALTH CARE &OUNDATION A C NON PROlT

HUMANITARIAN RELIEF ORGANIZATION THAT COLLECTS MEDICAL SURPLUS AND DONATES IT TO DEVELOP ING COUNTRIES 3INCE 0ROJECT # 5 2 % HAS DELIVERED DONATED MEDICAL SUPPLIES AND EQUIPMENT TO THE MOST DESPERATELY ILL AND NEEDY PEOPLE LIVING IN MORE THAN COUN TRIES AROUND THE WORLD 0ROJECT # 5 2 % IS CURRENTLY THE WORLD S LARGEST DISTRIBUTOR OF DONATED MEDICAL SUPPLIES AND EQUIPMENT 0ROJECT # 5 2 % )NTERNATIONAL (EADQUARTERS OFlCE IS IN #ENTENNIAL #OLORADO #OLLEC TION AND $ISTRIBUTION #ENTERS ARE LOCATED IN $ENVER #/ (OUSTON 48 ,OS !NGELES

#! .ASHVILLE 4. 0HOENIX !: ,ONDON

5+ AND NOW -INNEAPOLIS 3T 0AUL -.

4HIS YEAR 0ROJECT # 5 2 % ANTICIPATES DELIVERING MORE THAN CARGO CONTAIN ERS VALUED AT MORE THAN MILLION TO THE WORLD S MOST NEEDY PEOPLE /NE DAY

ONE HOSPITAL ONE PATIENT AT A TIME 0ROJECT # 5 2 % IS CHANGING THE WORLD

'LOBAL (EALTH -INISTRIES 'LOBAL (EALTH -INISTRIES HAS A YEAR HISTORY OF SUPPORT FOR HEALTH CARE PROGRAMS OF THE ,UTHERAN #HURCHES IN DEVELOP ING COUNTRIES THROUGH SHIPPING OF NEEDED MEDICAL SUPPLIES AND EQUIPMENT FUNDING OF PROJECTS AND RECRUITMENT OF NEEDED PERSON NEL 0RESENTLY THERE ARE PARTNERS IN MORE THAN COUNTRIES )N RESPONSE TO GROWING DEMAND IN RECENT YEARS THE ORGANIZATION HAS DOUBLED THE NUMBER OF SHIPMENTS IN SUPPORT OF HOSPITALS AND CLINICS IN COUNTRIES SUCH AS ,IBERIA 4ANZANIA )NDONESIA -ADAGASCAR

0APUA .EW 'UINEA 4HAILAND #AMEROON

AND "ANGLADESH )N ADDITION 'LOBAL (EALTH -INISTRIES WILL FUND PROJECTS THIS YEAR TOTALING NEARLY IN ASSISTANCE TO SUSTAIN SERVICES TO THE POOR AND STRATEGICALLY ENHANCE THE CAPACITIES OF HEALTH CARE SYSTEMS %ACH SHIPMENT FROM 'LOBAL (EALTH -INISTRIES IS BASED ON A COMPREHENSIVE ASSESSMENT OF SUPPLIES AND EQUIPMENT NEEDED TO SUSTAIN HEALTH CARE DELIVERY AND TO ENHANCE THE LEVEL OF CARE 4HE DONATED SUP PLIES SAVE THE PARTNERS CONSIDERABLE EXPENSE

6OLUNTEERS .EEDED IN THE 4WIN #ITIES 0ROJECT # 5 2 % VOLUNTEERS Â&#x2C6; MORE THAN

IN TOTAL Â&#x2C6; ARE CRITICAL TO EVERY STEP OF THE PROCESS ! SORTING DISTRIBUTION CEN TER IN 3T 0AUL HAS BEEN OPENED AND SEEKS INDIVIDUALS AND GROUPS OF ALL AGES AND LEVELS OF EXPERIENCE TO SERVE AS VOLUNTEERS !LSO

0ROJECT # 5 2 % SEEKS TO lLL SEVERAL VOLUN TEER MANAGERIAL POSITIONS IN THE FOLLOWING AREAS FUNDRAISING VOLUNTEER COORDINATION

DEVELOPMENT PROCUREMENT WAREHOUSING

TRANSPORTATION AND OPERATIONS &OR MORE INFORMATION ABOUT 0ROJECT # 5 2 % VISIT WWW PROJECTCURE ORG OR TO INQUIRE ABOUT VOLUNTEER OPPORTUNI TIES PLEASE CONTACT 2ICHARD "RUNKOW AT RICHARD PROJECTCURE ORG OR U

-ETRO$OCTORS 4HE *OURNAL OF THE (ENNEPIN AND 2AMSEY -EDICAL 3OCIETIES

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