2005julaug

July/August 2005

New

Challenges for Physicians In this issue HSA's and HRA's •

Tiered Networks are Back •

Recognizing the Abusive Patient

Bronagh P. Murphy, m.d.

John E. Savage, m.d.

Cancer is one fierce, single-minded unit—so are we.

We are MOHPA. Just as our patients do not fight cancer alone, neither do we. Our single-mindedness is all about determining and delivering the most intelligent, appropriate and effective care possible. Our seven local clinics, 34 top physicians and hundreds of dedicated professionals are supported by the latest advances gathered from throughout our national network. We work as one powerful unit for each individual patient. We are taking the fight well beyond.

www.mohpa.com

CLINICS Burnsville 952.892.7190 Edina 952.928.2900 Maplewood 651.779.7978

Minneapolis Saint Paul Waconia Woodbury

612.863.8585 651.602.5200 952.442.6006 651.735.7414 An Affiliate of US Oncology

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(EALTH 3AVINGS !CCOUNTS (3!S A CENTRAL FOCUS FOR CURING THE NATION S HEALTH CARE PROB LEMS 4HIS APPROACH IS TO EMPOWER INDIVIDU ALS TO MANAGE THEIR OWN MEDICAL EXPENSES BY OFFERING A TAX FREE SAVINGS ACCOUNT THAT CAN BE USED TO COVER MEDICAL EXPENSES 4HESE PLANS ARE MEANT TO PROVIDE BASIC HIGH DEDUCTIBLE INSURANCE WHILE LETTING PEOPLE ACCUMULATE MONEY TAX FREE TO BE SPENT ON MEDICAL SERVICES OR SAVED TO PAY FOR FUTURE HEALTH CARE NEEDS )NDIVIDUALS ARE ALLOWED TO KEEP WHAT IS hLEFT OVERv SHOULD SAVINGS EXCEED COSTS 4HE THEORY IS INDIVIDUALS WILL MORE PRU DENTLY PURCHASE HEALTH CARE IF THE MONEY IN THE (3! COULD BE AVAILABLE TO THE INDIVIDUAL AFTER AGE 4HE INCENTIVE OF TAX FREE IS ALSO AN ATTRACTIVE COMPONENT (3!S WERE ACTUALLY MADE INTO LAW IN LATE AS PART OF THE -EDICARE REFORM LEGISLATION BUT HAVE NOT BEEN EMBRACED TO ANY GREAT EXTENT THUS FAR -ANY BELIEVE INDIVIDUALS ARE VERY RISK ADVERSE WHEN IT COMES TO HEALTH INSURANCE 4HEY WANT AS MUCH COVERAGE AS THEY CAN AFFORD AND VALUE COMPANY SPONSORED HEALTH INSURANCE THAT OFTEN PAYS AS MUCH AS PERCENT OF THE TOTAL PREMIUM -OST INDIVIDUALS HAVE LEARNED TO ACCEPT A CO PAY AS PART OF THIS SECURITY BLANKET FOR THEIR USUAL AND CUSTOMARY CARE %MPLOYERS ARE SLOW TO EMBRACE (3!S AND VERY FEW OFFERED THIS OPTION IN THEIR HEALTH INSURANCE COVERAGE hMENUv DURING EMPLOYEE ENROLLMENT PERIODS 5NITED (EALTH 'ROUP FOR EXAMPLE THE NATION S LARGEST INSURER REPRESENTING MIL LION WORKERS EXPECTS ONLY OF THOSE EMPLOYEES TO CHOOSE (3!S IN !ETNA

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THE SECOND LARGEST UNDERWRITER OF EMPLOYER HEALTH PLANS SAYS ONLY OF THE HUNDREDS OF EMPLOYERS IT COVERS ARE OFFERING (3!S IN

3O WHY SHOULD PROVIDERS EVEN CARE ABOUT (3!S AND HOW MIGHT THEY BE AFFECTED IF (3!S BECOME POPULAR )F THEY AREN T POPULAR TODAY WHAT IS THE CONCERN "ECAUSE IT IS THE BEGINNING OF A TREND 4HE TREND IS TO ALLOW INDIVIDUALS MORE SAY IN WHERE THEY SPEND THEIR HEALTH CARE DOLLARS 4HE FACTS ABOUT HEALTH INSURANCE ARE

4HE THEORY IS INDIVIDUALS WILL MORE PRUDENTLY PURCHASE HEALTH CARE IF THE MONEY IN THE (3!

COULD BE AVAILABLE TO THE INDIVIDUAL AFTER AGE TROUBLING )N THE 5NITED 3TATES MILLION INDIVIDUALS SPEND AS MUCH AS PERCENT OF THEIR PAYCHECK ON HEALTH CARE 4HOSE WITH NO INSURANCE COVERAGE TOTALS PERCENT OF THE POPULATION (OSPITALS IN SOME STATES ARE STILL PRICE GOUGING THE UNINSURED CHARGING THEM THREE TO FOUR TIMES WHAT THEY WOULD ACCEPT AS PAYMENT IN FULL FROM INSURANCE 0ATIENTS WHO HAVE CATASTROPHIC COVER AGE IN ADDITION TO ACCEPTABLE BASIC COVERAGE

DON T OFTEN PARTICIPATE IN COST EFFECTIVE PUR CHASING OF THEIR MEDICAL NEEDS /NLY THOSE

WITH lXED INCOMES OR CHRONIC ILLNESSES HAVE A PERSONAL UNDERSTANDING OF THIS ISSUE )T HITS THEM IN THE POCKETBOOK AND MANY ARE NOT ABLE TO SAVE MUCH IF ANYTHING 4HE TREND EMBRACED BY THE "USH !DMINISTRATION FOLLOWS ALONG THE LINES OF GENERIC DRUGS WHERE INDIVIDUALS CAN SAVE BY PURCHASING A GENERIC MEDICATION INSTEAD OF A COMPANY BRAND AND SUGGESTS INDIVIDUALS ARE WILLING TO PARTICIPATE IN SAVING MONEY WHEN IT COMES TO BUYING HEALTH CARE ! RECENT STUDY BY "LUE #ROSS AND "LUE 3HIELD OF -INNESOTA OF /PTIONS "LUE MEMBERS FROM *ANU ARY TO -ARCH OF FOUND THAT OVERALL MEDICAL UTILIZATION WAS DOWN PERCENT WHILE EMERGENCY ROOM VISITS DECLINED PERCENT %XPERTS SUGGEST THIS IS ONE OF THE lRST SIGNS THE NEW CONSUMER DRIVEN HEALTH PLANS THAT PUT SPENDING DECISIONS IN THE HANDS OF CONSUMERS MIGHT HELP KEEP MEDICAL COSTS DOWN "UT HOW WILL THIS TREND ACTUALLY AFFECT PROVIDERS 7HY SHOULD THERE BE CAUSE FOR CONCERN 4HE BALANCE OF THIS ARTICLE ATTEMPTS TO MORE CLEARLY DElNE THIS ISSUE AND ALSO PROVIDES SOME TOOLS TO PREPARE PROVIDERS FOR MORE CONSUMER DRIVEN HEALTH CARE DECISION MAKING IN THE YEARS TO COME /VER THE PAST YEARS WE HAVE SEEN DRAMATIC CHANGES IN HOW PROVIDERS WERE PAID FOR THEIR SERVICES AND HOW THEY MANAGED THEIR ACCOUNTS RECEIVABLES THE MONEY OWED TO THEM BY PATIENTS AND THIRD PARTY PAYERS /UR COUNTRY HAS GONE FROM PATIENTS PAYING MOST IF NOT ALL OF THEIR MEDICAL BILLS TO INSURANCE REIMBURSING PATIENTS FOR COVERED SERVICES TO INSURANCE COVERING PERCENT OF THE PROVIDERS CHARGES AND DIRECTLY PAYING THE PROVIDER THE PATIENT IS COMPLETELY UNINVOLVED IN THE MIX TO A VERY COMPLICATED AND CON FUSING SYSTEM TODAY $ISALLOWS ALLOWABLES

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CONVERSION FACTORS DEDUCTIBLES ETC ARE NOT VERY PATIENT FRIENDLY -OST PROVIDERS NOW ELECTRONICALLY SEND A CLAIM TO A CARRIER AC CEPT WHATEVER REIMBURSEMENT THEY RECEIVE

AND BALANCE BILL WHEN ALLOWED THE PATIENT FOR THE DIFFERENCE IN THAT ORDER $EPENDING ON WHEN THE PROVIDER DECIDES TO BILL THE CAR RIER OR THE PATIENT TYPICALLY AFFECTS THE SPEED

BY WHICH THEY WILL GET PAID 0ATIENTS HAVE BECOME MORE KNOWLEDGE ABLE AS THEY ATTEMPT TO UNDERSTAND THIS COM PLICATED AND CONFUSING PROCESS OF PAYMENT FOR THEIR MEDICAL CARE 4HEY JUST WAIT 4HEY WAIT UNTIL INSURANCE IS PAID BEFORE THEY PAY THEIR PORTION )T GETS VERY INTERESTING WHEN THERE ARE THREE OR FOUR EPISODES OF CARE REmECTED WITHIN ONE BILLING CYCLE 0ATIENTS DON T KNOW WHAT THEY ACTUALLY OWE AND PROVIDERS HAVE DIFlCULTY ANSWERING PATIENT QUESTIONS ABOUT THEIR BILL 0ROVIDERS HAVE BEEN RELUCTANT TO CHARGE PATIENTS EXTRA WHEN THEY DON T PAY THEIR BILL 4HEY DON T ADD LATE PAYMENT FEES EVEN THOUGH THE LAW ALLOWS IT 0ATIENTS WILL OFTEN PAY THEIR MEDICAL BILLS LAST BECAUSE IT IS THE ONLY BILL THEY RECEIVE THAT DOES NOT AT TACH A PENALTY FOR LATE PAYMENT 4HOSE THAT DO CHARGE THIS FEE OFTEN hWRITE IT OFFv IF THE PATIENT PAYS THE BILL AS A RESULT OF THIS EXTRA hNUDGE v )T SHOULD NOT BE SURPRISING THAT ACCOUNTS RECEIVABLES AFTER EXPERIENCING A REDUCTION IN THE S AND S IN THE TYPICAL PROVIDER S PRACTICE HAVE STARTED TO INCREASE ! BIGGER PROBLEM HAS BEEN THE AGE OF THE RECEIVABLES

i> Ì Ê->Û }ÃÊ VV Õ ÌÃ (EATH SAVINGS ACCOUNTS (3!S ARE TAX EXEMPT INVESTMENT AC COUNTS IN WHICH CONTRIBUTIONS ARE MADE TO PAY FOR FUTURE MEDICAL EXPENSES !NYONE UNDER THE AGE OF MAY USE AN (!3 IN CONJUNC TION WITH A QUALIFYING HIGH DEDUCTIBLE HEALTH INSURANCE PLAN 4HE DElNITION OF A HIGH DEDUCTIBLE PLAN CAN GET COMPLICATED BUT GENERALLY THE PLAN WILL QUALIFY IF THE FAMILY DEDUCTIBLE IS TO

TO FOR SINGLES !SSETS CAN BE WITHDRAWN TAX FREE FROM AN (3! FOR QUALIlED MEDICAL EXPENSES !NY AMOUNT CONTRIBUTED DURING THE YEAR AND NOT WITHDRAWN FOR EXPENSES WILL STAY IN THE ACCOUNT AND GROW TAX FREE #ONTRIBUTIONS CAN BE MADE UNTIL AGE ALTHOUGH THE ACCOUNT OWNER CAN RECEIVE TAX FREE DISTRIBUTIONS TO PAY FOR OR BE REIMBURSED FOR QUALIlED MEDICAL EXPENSES PAST AGE &OR ANNUAL CON TRIBUTIONS TO AN (3! CAN BE MADE UP TO THE LESSER OF PERCENT OF THE DEDUCTIBLE OR FOR FAMILIES FOR SINGLES 2EPRINTED FROM THE -INNEAPOLIS 3TAR 4RIBUNE *ANUARY

0ARTNERS CONSULTANTS ARE SEEING PER CENT OF THE ACCOUNTS RECEIVABLES IN A TYPICAL PROVIDER S PRACTICE MORE THAN DAYS OLD 5NLIKE WINE ACCOUNTS RECEIVABLES DO NOT GET BETTER WITH AGE )T COSTS MORE AND YOU COLLECT LESS WHEN ACCOUNTS RECEIVABLES GET OLD

3O HOW WILL CONSUMER DRIVEN HEALTH CARE SPENDING AFFECT THE TYPICAL PROVIDER S REVENUES 7ELL WITHOUT A BUSINESS LIKE AP PROACH TO COLLECTING FOR SERVICES THE TYPICAL PROVIDER MAY SEE AN INCREASE IN THEIR ACCOUNTS #ONTINUED ON PAGE

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RECEIVABLES AND DECREASE IN CASH mOW AS PA TIENTS BECOME MORE DIRECTLY RESPONSIBLE FOR PAYMENTS 3OME PROVIDERS MAY SEE DRAMATIC INCREASES 7 >ÌÊ > Ê*À Û `iÀÃÊ ¶ 0ROVIDERS SHOULD START BY DEVELOPING A CREDIT POLICY 4HIS POLICY SHOULD ANSWER THESE QUES TIONS s 7HEN DO ) EXPECT TO GET PAID s (OW WILL ) DEAL WITH THE PATIENT S THIRD PARTY COVERAGE s (OW WILL ) DEAL WITH CO PAYS DEDUCTIBLES

OR CO INSURANCE s 7ILL ) CHARGE A LATE PAYMENT FEE s 7ILL ) TURN ACCOUNTS OVER TO A COLLECTION AGENCY AND IF SO WHAT CRITERIA SHALL ) USE s $O ) HAVE A MINIMUM PAYMENT POLICY

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!NSWERS TO THESE AND OTHER QUESTIONS SHOULD BE CONSTRUCTED IN A WRITTEN CREDIT POLICY ! COPY SHOULD BE GIVEN TO EACH PATIENT AND A PATIENT SIGNATURE SHOULD BE ATTAINED INDICATING THEY HAVE READ AND RECEIVED A COPY OF THE POLICY !LSO PROVIDERS SHOULD IMPROVE THEIR PATIENT COMMUNICATION ABOUT MONIES OWED BY UPDATING THEIR BILLING PRACTICES AND IF NECESSARY THEIR BILLING SYSTEMS (ERE ARE SOME GUIDELINES &ILE ALL CLAIMS ELECTRONICALLY EACH NIGHT $ON T WAIT TO COMMUNICATE WITH A THIRD PARTY 4HE GOAL OF ANY MEDICAL PRACTICE SHOULD BE TO POST ALL CHARGES WITHIN HOURS OF SERVICE COLLECT ALL CO PAYS AT THE TIME OF SERVICE AND BILL THE THIRD PARTY THE SAME DAY AS THE CHARGE IS POSTED )T IS ONE OF THE FEW ACCOUNTS RECEIVABLES MANAGE MENT FUNCTIONS CLEARLY IN CONTROL OF THE PRACTICE 0ROVIDE A BREAKDOWN OF ALL CHARGES AND PAYMENTS ON ALL PATIENT STATEMENTS !T LEAST ONCE PER MONTH PATIENTS SHOULD BE SENT A STATEMENT THAT DELINEATES A 4OTAL CHARGES FOR EACH DATE OF SERVICE B 4HE AMOUNT PENDING BECAUSE OF INSUR ANCE hWAITING TO PAY v AND C 4HE AMOUNT NOW DUE BECAUSE INSURANCE HAS PAID THEIR PART 4OTAL AMOUNT OF THE BALANCE INCLUDING PENDING AMOUNTS

AMOUNTS DUE NOW AND ANY PAST DUE AMOUNTS )F YOUR STATEMENT IS NOT CLEAR TO YOUR PATIENTS DON T EXPECT PAYMENT FROM THEM WITHIN YOUR CREDIT TERMS #OMMUNICATE WITH EACH PATIENT STATE MENT A 0RINT YOUR CREDIT POLICY DIRECTLY ON THE STATEMENT E G hAMOUNT INDICATED IN BALANCE DUE COLUMN IS DUE IN OUR OFlCE WITHIN DAYS OF RECEIPT OF THIS STATE MENTv B 0ROVIDE PHONE NUMBER S FOR PATIENTS TO CALL WITH QUESTIONS OR TO SET UP PAYMENT ARRANGEMENTS F $EVELOP A SLIDING SCALE PAYMENT POLICY BASED ON FAMILY SIZE AND FAMILY INCOME 3EE 4ABLE ) D $ON T PRINT AGING CATEGORIES ON THE BOTTOM OF YOUR REGULAR STATEMENT

)F PATIENTS SEE THEIR BALANCE IS IN THE DAY PAST DUE CATEGORY AND THERE ARE AND DAY CATEGORIES ALSO SHOWN ON THE STATEMENT THEY MAY CHOOSE TO WAIT A FEW MONTHS BEFORE PAYING E #HARGE A LATE PAYMENT CHARGE OR BILLING CHARGE )T IS VERY REASONABLE TO BILL A PA TIENT IF YOU HAVE TO SEND THEM A SECOND STATEMENT FOR AN AMOUNT DUE 2EMEMBER IF YOU CAN CLEARLY INDICATE TO THE PATIENT THE AMOUNT THEY OWE YOU TODAY YOU SHOULD EXPECT PAYMENT FROM THEM WITHIN THE LIMITS OF YOUR CREDIT POLICY

V ÕÃ (3!S ARE NOT POPULAR TODAY BUT THE TREND OF CONSUMER DRIVEN HEALTH CARE IS HERE AND WILL GROW 0ATIENTS WILL DIRECT THEIR OWN DOLLARS TO THE CARE THEY NEED AND CHOOSE 0ROVIDERS NEED TO REEXAMINE THEIR BILLING MANAGEMENT POLICIES AND PRACTICES IN ORDER TO BEST POSI TION THEMSELVES TO GET PAID APPROPRIATELY AND ON TIME #URRENTLY PERCENT OF THE POPULATION SPENDS THEIR DOLLARS ON MINOR ILLNESS CARE AND ROUTINE MEDICAL VISITS !LTHOUGH THIS REPRE SENTS PERCENT OF THE TOTAL AMOUNT SPENT ON HEALTH CARE FOR MANY PROVIDERS IT IS PERCENT OF THEIR SERVICES 3OUND POLICIES

EFlCIENT BILLING PRACTICES AND CLEAR PATIENT COMMUNICATION WILL GET PROVIDERS PAID ON TIME

!RTHUR 7 3AUNDERS IS A PRINCIPAL AND DIRECTOR WITH 0ARTNERS (EALTHCARE #ONSULTING )NC (E HAS SERVED AS THE MANAGING PARTNER FOR A HEALTH CARE CONSULTING lRM AND AN INTERIM MANAGER FOR A NETWORK OF MEDICAL PRACTICES (E CONSULTS IN MANAGEMENT AND OPERATIONS OF HEALTH SYS TEM OWNED PHYSICIAN NETWORKS AND PRIVATE MEDICAL PRACTICES PHYSICIAN COMPENSATION AND ACCOUNTS RECEIVABLE MANAGEMENT STRATEGIES -R 3AUNDERS CAN BE REACHED AT OR ASAUNDERS PARTNERSHC COM 2EPRINTED WITH PERMISSION FROM 0ARTNERS (EALTHCARE #ONSULTING )NC

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AND (EALTH 2EIMBURSEMENT !CCOUNTS (2!S WHICH WERE FORMALLY APPROVED BY THE )23 IN 4HE GOOD NEWS ABOUT THESE TWO PLAN DESIGNS IS THEIR CAPABILITY TO ADDRESS THE DOUBLE EDGED SWORD ONCE PHYSICIANS UNDERSTAND THEIR DIFFERENCES AND BENElTS "OTH PHYSICIANS AND EMPLOYEES CAN BE REWARDED lNANCIALLY AND MEDICALLY THROUGH THESE NEW HIGH DEDUCTIBLE PLANS h-Y EXPERIENCE OF USING THESE TWO HIGH DEDUCTIBLE MEDICAL PLANS IS THAT THEY HAVE PROVIDED THE CLINICS ) WORK WITH THE ADVAN TAGE OF DESIGNING A COMPREHENSIVE SOLUTION THAT SHOULD STAND THE TEST OF TIME 7E USE THE (3!

FOR THE PHYSICIAN SHAREHOLDERS AND THE (2! FOR THE OTHER EMPLOYEES 4HIS CREATES A SOLUTION THAT WORKS FOR ALL CLINIC EMPLOYEES v ACCORDING TO 'EORGE &RALEY EXECUTIVE VICE PRESIDENT OF (EALTHLINK -INNESOTA 9Ê Ê , -

.EW (IGH $EDUCTIBLE -EDICAL 0LANS 0ROVIDE !LTERNATIVES WITH &INANCIAL AND -EDICAL 2EWARDS * > Ê-ÌÀÕVÌÕÀiÊ> `Ê i iwÌÃ (3! AND (2! PLANS ARE BASICALLY STRUCTURED AS FOLLOWS s 0HYSICIAN OWNERS ESTABLISH A HIGH DEDUCTIBLE MEDICAL PLAN FOR ALL ELIGIBLE EMPLOYEES &OR EXAMPLE A TYPICAL PLAN DESIGN WOULD BE A

DEDUCTIBLE FOR SINGLE COVERAGE AND

DEDUCTIBLE FOR FAMILY COVERAGE FOR AN (2! ! TYPICAL (3! PLAN DESIGN WOULD BE A DEDUCTIBLE FOR SINGLE COVERAGE AND A FAMILY DEDUCTIBLE s %ACH EMPLOYEE GETS AN UNDERLYING HEALTH ACCOUNT THAT IS USED TO REIMBURSE MEDICAL EXPENSES AND SATISFY THE HIGH DEDUCTIBLE PLAN s )NDIVIDUALS MANAGE THEIR OWN HEALTH CARE DOLLARS )F THEY HAVE MONEY IN THEIR HEALTH ACCOUNTS AT THE END OF THE YEAR A PORTION CAN BE ROLLED OVER INTO THE NEXT YEAR S PLAN 4HIS REWARDS THE EMPLOYEES WHO STAY HEALTHY LIKE GETTING A YEAR END BONUS 4HESE PLANS OFFER MANY ADVANTAGES TO PHYSICIANS AND EMPLOYEES ALIKE &IRST HEALTH ACCOUNTS ARE PRE TAXED OR EMPLOYER CONTRIB UTED FUNDS WHICH CAN ACCUMULATE FROM YEAR TO YEAR TO HELP FURTHER REDUCE OUT OF POCKET COSTS 3ECOND THESE PLANS HAVE LOWER OUT OF POCKET MAXIMUMS THAN TRADITIONAL PLANS IF THE SAV INGS ACCOUNTS ARE FUNDED APPROPRIATELY 4HIRD

MEDICAL EXPENSES UNDER THE HIGH DEDUCTIBLE

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PLAN SUCH AS PHYSICIAN OFlCE VISITS ARE PAID OUT OF THE HEALTH ACCOUNT lRST NOT EACH INDIVIDUAL S POCKET !ND FOURTH WELLNESS AND PREVENTATIVE COVERAGE PROMOTING BETTER HEALTH IN THE LONG RUN IS PAID AT PERCENT WITHOUT REDUCING THE HEALTH ACCOUNT *Ài«>À }Êv ÀÊ,iÌ Ài i Ì -OST GROUP PLANS DO NOT USUALLY OFFER A RETIREE CLASS DUE TO THE EXPENSE OF INCREASED PREMIUMS FOR ALL EMPLOYEES 4HAT S WHY THE (3! IS AN EXCELLENT OPTION ON WHICH PHYSICIAN OWN ERS CAN BUILD A MEDICAL RETIREMENT PLAN FOR THEMSELVES -ANY PHYSICIANS HAVE MAXIMIZED THEIR RETIREMENT SAVINGS OPTIONS THROUGH PENSION PLANS K S OR OTHER PRE TAX RETIREMENT PLANS !N (3! IS ANOTHER AVENUE TO PUT AWAY ADDITIONAL PRE TAX MONEY THAT MAY BE USED FOR MEDICAL EXPENSES 4HIS IS ESPECIALLY COST EFFEC TIVE FOR THOSE WHO PLAN AN EARLY RETIREMENT AS A WAY TO lLL THE GAP BETWEEN THE END OF GROUP COVERAGE POST #/"2! AND THE BEGINNING OF -EDICARE )N FACT THE (3! ACCOUNT ALLOWS FOR -EDICARE PREMIUM PAYMENTS AS WELL AS MEDI CAL EXPENSES WITHOUT TAX )T ALSO REDUCES THE INSURANCE PREMIUMS BASED ON A HIGH DEDUCT IBLE PLAN

ÌÀ }Ê « ÞiiÊ ÃÌÃ )MMEDIATE SAVINGS IS A KEY BENElT FOR EMPLOYEE MEDICAL PLANS DUE TO THE HIGH DEDUCTIBLE NATURE OF THESE CONSUMER DRIVEN PLANS (OW EVER PHYSICIAN OWNERS NEED TO UNDERSTAND THE MAJOR DIFFERENCE BETWEEN THE TWO OP TIONS AN EMPLOYER S CONTRIBUTION INTO A (2!

NEVER BECOMES VESTED TO EMPLOYEES WHEREAS IT BECOMES IMMEDIATELY VESTED TO EMPLOYEES UNDER THE (3! #ONTINUED ON PAGE

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&OR MEDICAL PRACTICES WITH LARGER STAFFS OR HIGH TURNOVER IT RARELY MAKES SENSE TO FUND AN ACCOUNT AND THEN ALLOW THOSE DOLLARS TO WALK OUT THE DOOR IF AN EMPLOYEE LEAVES SIX MONTHS LATER )N THAT CASE THE (2! WOULD BE THE BETTER OPTION SINCE THE EMPLOYER CONTROLS THE MONEY "UT FOR THOSE OWNERS WITH SMALLER MORE LOYAL STAFFS THE (3! PROVIDES A MORE SUBSTANTIAL BENElT AND ADDED INCENTIVE TO STAY (OWEVER THE BENElTS OF A DUAL OPTION PLAN LIMITED TO CERTAIN CARRIERS IN THE CURRENT MARKETPLACE ALLOWS PHYSICIANS TO HAVE THE BEST OF BOTH WORLDS 4HE (3! PROVIDES GREATER LONG TERM REWARDS FOR PHYSICIAN OWNERS WHILE THE (2! OFFERS A WAY TO CONTROL COSTS IMME DIATELY FOR EMPLOYEE PLANS WHILE MAINTAINING QUALITY BENElTS h7E SELECTED THE DUAL OPTION PLAN PRIMAR ILY FOR THE PREMIUM SAVINGS WHICH IS OFFSET BY THE FUNDING AMOUNT NEARLY AN EVEN TRADE v ACCORDING TO *EFF 3CHACKOR ADMINISTRATOR FOR %DINA %YE 0HYSICIANS 3URGEONS 0! h4HE

PHYSICIANS CAN BUILD A POOL OF DOLLARS FOR INVEST MENT PURPOSES AND HAVE A NEW INCENTIVE TO LOOK AT ALTERNATIVE WAYS TO GAIN THE SAME HEALTH OUTCOMES SUCH AS MEDICATIONS OR THERAPIES v %DINA %YE HAS EMPLOYEES THAT STARTED THE (3! PLAN FOR PHYSICIANS AND (2! PLAN FOR STAFF MEMBERS IN -AY 0HYSICIANS KNOW ALL TOO WELL ABOUT RISING HEALTH CARE COSTS SINCE CLINIC GROUPS TRADITION ALLY ARE UNDERWRITTEN AT HIGHER RATES DUE TO HIGHER UTILIZATION AMONG HEALTH CARE EMPLOY EES 9ET THOSE WHO WORK AROUND SICK PEOPLE DESERVE TO HAVE A RICH COMPREHENSIVE PLAN

WHICH IS POSSIBLE WITH EITHER THE (3! OR (2!

OPTION %ITHER ONE IS A STRONG TOOL FOR ATTRACTION AND RETENTION -ÌÀ>Ìi} VÊ* > }Ê > `Ê `ÕV>Ì 4HIS MOVE TO A CONSUMER DRIVEN PLAN IS CHANG ING THE WAY EMPLOYEES VIEW THEIR HEALTH CARE /F COURSE WITH ANY CHANGE PEOPLE ARE GOING TO BE LEERY )T S NOT UNCOMMON FOR SOMEONE TO ASK h4HIS SEEMS TOO GOOD TO BE TRUE WHAT S THE CATCH v

4HE hCATCHv IS BASED ON EMPLOYEES MAK ING SMARTER HEALTH CARE DECISIONS AND SHARING THE RESPONSIBILITY OF INSURANCE INCREASES FROM YEAR TO YEAR 2ENEWALS MAY STABILIZE AND CAN EVEN REDUCE OVER TIME WHEN UTILIZATION RATES GO DOWN 4HIS ONLY HAPPENS WHEN PEOPLE UNDERSTAND THE REAL COST OF HEALTH CARE AND THE PART THEY CAN PLAY IN KEEPING COSTS DOWN FOR THEMSELVES AND THEIR FELLOW EMPLOYEES 5NDERSTANDING THE CHANGE AND HOW IT WORKS STARTS DURING THE STRATEGIC PLANNING PHASE WITH THE PHYSICIAN OWNERS 4HIS CAN BE A SIX TO MONTH PROCESS FOR GROUPS OVER EMPLOYEES BUT AS LITTLE AS THREE MONTHS FOR SMALLER GROUPS /WNERS NEED A CLEAR UNDER STANDING OF THE BASIC MAJOR MEDICAL OPTIONS AND THE DIFFERENCES IN PREMIUMS COST AND COVERAGE THAT THE (3! AND (2! ALTERNATIVES MAY OFFER THEIR SPECIlC CIRCUMSTANCES 0RIOR TO ANY MEDICAL PLAN CHANGES IT S IMPORTANT TO HOLD AN ALL EMPLOYEE MEETING OR SERIES OF MEETINGS TO EXPLAIN MARKETPLACE INmUENCES AND MAKE EVERYONE AWARE THAT THE PHYSICIAN OWNERS ARE LOOKING AT OPTIONS 4HAT S A GOOD TIME TO DEMONSTRATE HOW A NEW PLAN

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WOULD AFFECT THEM IF THE DECISION WERE MADE TO GO WITH EITHER AN (3! OR (2! 1UESTIONS AND CONCERNS mOW MORE EASILY AS EMPLOYEES FEEL THAT THEIR INPUT IS VALUED /NCE THE DECISION IS MADE TO CHANGE PLANS IT S IMPORTANT TO HOLD GROUP OR INDI VIDUAL MEETINGS ONE MONTH PRIOR TO IMPLEMEN TATION USUALLY DURING OPEN ENROLLMENT TO ANSWER THE FOLLOWING THREE QUESTIONS s 7HAT ARE THE BENElTS TO ME AS AN EMPLOYEE s (OW DOES IT COMPARE WITH THE CURRENT PLAN s (OW DOES IT OPERATE DIFFERENTLY 4HE EDUCATION PROCESS WAS hIMMENSEv AT THE BEGINNING OF A HEALTH CARE PLAN CHANGE IN -ARCH FOR EMPLOYEES AT 3PECIALISTS )N 'ENERAL 3URGERY 3)'S ACCORDING TO THE CLINIC S OFlCE ADMINISTRATOR $ARLA -ORRIS 0REBLE "3. h/UR PHYSICIANS ARE SENSITIVE TO HOW IT THE CHANGE AFFECTS OUR PEOPLE v SAYS -ORRIS 0REBLE &EEDBACK AT THE INITIAL MEETING

WHICH EXPLAINED THE (2! CONCEPT INDICATED THAT EMPLOYEES DID NOT WANT TO BE ACCOUNT ABLE FOR lRST DOLLAR EXPENSES OR THE FULL COST OF PRESCRIPTIONS 4HIS HELPED GUIDE THE PHYSICIAN

OWNERS ON HOW TO STRUCTURE THE (2! 4HE PHYSICIAN OWNERS WERE ALSO MAKING A CHANGE TO AN (3!

0HYSICIANS WERE PRESENT AT THE SECOND EMPLOYEE MEETING AT 3)'S WHICH ALLOWED THE STAFF TO ASK DIRECT QUESTIONS ABOUT SPECIlC CONCERNS DURING A COMPREHENSIVE PRESENTATION 4HIS MADE THE PHYSICIANS MORE ACCOUNTABLE TO EMPLOYEES SAID -ORRIS 0REBLE h4HE PER CEPTION IS THAT YOU RE HIDING SOMETHING BUT ALL THE STAFF WALKED AWAY FROM THE MEETING COMFORTABLE AFTER ALL THE DETAILS OF THE NEW PLAN WERE EXPLAINED v SHE SAID 4HIS EDUCATION COMPONENT INCLUDES THE NEED FOR SIMULTANEOUSLY PROVIDING EMPLOYEE CONSUMERS WITH RELEVANT PHYSICIAN APPROVED INFORMATION ON QUALITY OUTCOMES )NFORMATION THAT PROVIDERS MANAGED CARE COMPANIES AND OTHERS HAVE BEEN ACCUMULATING IS BEGINNING TO BE OFFERED TO CONSUMERS IN MEANINGFUL WAYS TO EDUCATE AND INFORM THEMSELVES BEFORE ACCESSING THE HEALTH CARE SYSTEM 4HE (2! (3! APPROACH IS CERTAINLY ONE SOLUTION TO THE DOUBLE EDGED SWORD FOR PHYSI CIANS BUT IT S NOT A SILVER BULLET )T IS BASED

ON INDIVIDUALS BECOMING ACTIVELY INVOLVED IN MAKING HEALTH CARE DECISIONS AND MORE INFORMED PURCHASES 7ITHOUT EDUCATION AND ONGOING INFORMATION PHYSICIAN OWNERS MAY WIN THE WAR ON HEALTH CARE INCREASES BUT LOSE THE BATTLE DUE TO POOR EXECUTION IF EMPLOYEES ARE UNWILLING TO CHANGE THE WAY THEIR HEALTH CARE INSURANCE IS DELIVERED 4HE BROKER COM MUNITY NEEDS TO RALLY AROUND THESE NEW CONSUMER DRIVEN PLANS BY lLLING THE GAPS IN EDUCATION LEFT BY THE MEDIA /NCE OVER THE HURDLES PHYSICIANS AND THEIR EMPLOYEE GROUPS CAN BETTER APPRECIATE THE lNANCIAL AND MEDICAL REWARDS OF THESE NEW OPPORTUNITIES

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SWEPT ASIDE BY EMPLOYER DEMAND FOR NEW TYPES OF HEALTH PLANS THAT WOULD MANAGE COSTS

BY MANAGING CARE AND NEGOTIATING DISCOUNTS WITH PROVIDERS 4ODAY WE RE KNEE DEEP IN ANOTHER SEA CHANGE 4HE TRANSFORMATION THIS TIME IS FROM MANAGED CARE TO EMPOWERED CONSUMERS 7HETHER YOU ARE A MEDICAL ADMINISTRATOR OR A PRACTICING PROVIDER YOU SHOULD BRACE YOURSELF FOR THIS WAVE IT IS POWERFUL 4HE IMPERATIVES ARE THE SAME AS THEY WERE YEARS AGO IMPROVE QUALITY AND lND SOME WAY TO SLOW DOWN HEALTH CARE COSTS THAT ARE DOUBLING ROUGHLY EVERY NINE YEARS /NCE AGAIN THE DRIVING FORCE IS HEALTH BENElT PURCHASERS GOVERNMENT AND BUSINESS )MPROVED QUALITY IS ESSENTIAL BECAUSE PREVENTION EARLY INTERVENTIONS AND EFFECTIVE CARE ARE BARGAINS )T IS INEFFECTIVE CARE THAT S UNAFFORDABLE AND IT S NOT JUST MEDICAL COSTS ,OST PRODUCTIVITY COSTS THREE TIMES MORE THAN MEDICAL TREATMENT DOES 4HE BUSINESS CASE FOR INCENTIVES THAT DRIVE QUALITY IS A GIVEN AND WE RECOGNIZE THAT QUALITY IMPROVEMENTS TAKE TIME 9ET PURCHASERS MUST HAVE BETTER COST CONTROL IMMEDIATELY ,ET S USE GASOLINE PRICES TO ILLUSTRATE HOW OUT OF CONTROL HEALTH CARE COSTS APPEAR TO THOSE WHO PAY THE BILLS $ESPITE ALL THE HEADLINES

WITH ALL ITS UPS AND DOWNS THE PRICE OF A GALLON OF REGULAR IN -INNESOTA IS UP ABOUT PERCENT SINCE -AY WHEN IT AVERAGED A GALLON "Y CONTRAST EMPLOYERS NATIONWIDE ARE PAYING PERCENT MORE ON AVERAGE FOR HEALTH BENElTS IN THAN THEY WERE FOUR YEARS AGO )N OTHER WORDS IF GAS PRICES KEPT PACE WITH

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HEALTH CARE INmATION WE D BE PAYING A GALLON TODAY iÌÌiÀÊ"ÕÌV iÃ]Ê iÌÌiÀÊ6> Õi )N -AY THE NATIONAL (2 0OLICY !SSOCIATION TOLD A #ONGRESSIONAL HEARING THAT THERE ARE TWO GROWING TRENDS AMONG EMPLOYERS PURCHASING FROM PROVIDERS WHO DELIVER THE BEST CLINICAL OUTCOMES AT THE BEST VALUE AND INSISTING ON PAYMENT SYSTEMS THAT REWARD HIGHER QUALITY MORE EFlCIENT PHYSICIANS CLINICS AND HOSPITALS %MPLOYERS INCREASINGLY ARE PLACING THEIR BETS ON TWO TYPES OF CONSUMER DIRECTED AP PROACHES 3OME PERCENT ALREADY OFFER EM PLOYEES A HIGH DEDUCTIBLE PLAN ACCOMPANIED BY A &LEXIBLE 3PENDING !CCOUNT &3!

A (EALTH 2EIMBURSEMENT !CCOUNT (2! OR A (EALTH 3AVINGS !CCOUNT (3!

4HE SECOND MOST POPULAR CONSUMER DI RECTED STRATEGY IS A TIERED NETWORK !CCORDING TO GLOBAL (2 SERVICE lRM (EWITT !SSOCIATES

PERCENT OF EMPLOYERS USE TIERED NETWORKS NOW /NE THIRD ARE CONSIDERING A TIERED PLAN FOR THE FUTURE EVEN IF COSTS STAY THE SAME 7HY "IG EMPLOYERS CAN SEE EVIDENCE IN THEIR CLAIMS DATA THAT TIERED NETWORKS DO GENERATE BETTER OUTCOMES AND VALUE 4WO THIRDS OF EMPLOYERS ARE INTERESTED IF TIERING CAN DECREASE COSTS BY PERCENT !T -EDICA THERE IS THE POTENTIAL FOR SAVINGS OF TO PERCENT OR MORE OVER TIME +Õ> ÌÞÊ Ài` ÌÃ]Ê"«i Ê VViÃÃ !S HAS HAPPENED SO OFTEN IN OTHER AREAS OF HEALTH CARE -INNESOTA IS A CRADLE OF INNOVA TION FOR TIERED NETWORKS 4HE STATE S lRST TIERED NETWORK EARNED NATIONAL ATTENTION WHEN IT WAS LAUNCHED IN BY THE "UYERS (EALTH #ARE !CTION 'ROUP "(#!'

A COALITION OF MAJOR -INNESOTA EMPLOYERS )N "(#!' SPUN

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OFF 0ATIENT #HOICE TO TAKE OVER MANAGEMENT OF THE TIERED NETWORK )N IN ORDER TO EXPAND AND EVOLVE THE PROGRAM 0ATIENT #HOICE WAS ACQUIRED BY -EDICA )N -AY 0ATIENT #HOICE )NSIGHTS BY -EDICA THE MARKET S lRST THREE TIERED OPEN ACCESS NETWORK WAS ANNOUNCED 4HE ORIGINAL 0ATIENT #HOICE PRODUCT IS CARE SYSTEM BASED MEMBERS DESIGNATE A PRIMARY CARE CLINIC TO COORDINATE THEIR CARE )N THE NEW 0ATIENT #HOICE )NSIGHTS BY -EDICA NETWORK MEMBERS HAVE OPEN ACCESS TO ALL NET WORK PRIMARY CARE PROVIDERS SPECIALISTS AND HOSPITALS REGARDLESS OF TIER WITH NO REFERRALS )N ORDER TO ENCOURAGE DIRECT COMPARABLE COM PETITION THERE ARE THREE TIERS EACH FOR PRIMARY CARE PROVIDERS SPECIALISTS AND FACILITIES 0ATIENTS CAN GET CARE FROM 4IER AND PROVIDERS AT LOWER OUT OF POCKET COSTS )T SHOULD BE POINTED OUT HOWEVER THAT THE LOWEST PRICE IS NOT NECESSARILY THE BEST CHOICE 4HE CONSUMER SHOULD ALSO CONSIDER WHETHER THE PHYSICIAN OR HOSPITAL HAS ADVANTAGES IN TECHNOLOGY EXPERIENCE TRAINING CONVENIENCE OR OTHER FACTORS 0RIMARY CARE PROVIDERS ARE GROUPED INTO THE CARE SYSTEMS WITH WHICH THEY ARE AFlLIATED AND RANKED ACCORDING TO COST QUALITY MEASURES 4HE PROCESS TAKES INTO ACCOUNT THEIR PRICE AND THE PRICE OF THE SPECIALISTS AND HOSPITALS THEY USE -ORE IMPORTANTLY IT TAKES INTO ACCOUNT THEIR ABILITY TO EFFECTIVELY MANAGE RESOURCES

ESPECIALLY FOR CHRONICALLY ILL PATIENTS "ETTER MANAGEMENT OF CHRONIC ILLNESS DOESN T JUST IMPROVE OUTCOMES IT REDUCES TOTAL COST #REDIT TOWARD LOWER TIERS IS ALSO GIVEN FOR QUALITY PROGRAMS AND PERFORMANCE

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3PECIALTY PROVIDERS WITH COMPETITIVE PRICING ARE PLACED IN 4IER 4HOSE WHO HAVE INCORPORATED SPECIAL PROGRAMS OR ADVANCED INFRASTRUCTURE THAT CAN LEAD TO IMPROVED QUAL ITY AND BETTER MANAGEMENT OF RESOURCES ARE MOVED TO 4IER 1UALIFYING EXAMPLES INCLUDE AN EMPHASIS ON EVIDENCE BASED BEST PRACTICE GUIDELINES AND HAVING SYSTEMS FOR ELECTRONIC HEALTH RECORDS OR ELECTRONIC PRESCRIBING 3PE CIALISTS WITH HIGHER PRICING ARE MOVED TO 4IER (IGHER PRICED SPECIALISTS WITH DEMONSTRATED CAPABILITIES TO DELIVER IMPROVED QUALITY AND RE SOURCE USE ARE CONSIDERED FOR 4IER (OSPITALS AND OUTPATIENT FACILITIES ARE TIERED BASED ON OVERALL PRICING FOR CASE MIX ADJUSTED ADMISSIONS COMBINED WITH THEIR PERFORMANCE ON NATIONALLY ACCEPTED QUALITY STANDARDS 4HESE STANDARDS INCLUDE ,EAPFROG AND .ATIONAL 1UALITY &ORUM MEASURES -EDICA S 0ATIENT #HOICE CARE SYSTEM TIER ING METHODOLOGY HAS BEEN PROVEN OVER NEARLY YEARS OF COLLABORATION WITH PROVIDERS WHO SET THEIR OWN REIMBURSEMENT LEVEL /UR EXPE RIENCE IS THAT QUALITY VERY DElNITELY PAYS OFF "ETTER PREVENTIVE PROGRAMS AND BETTER CASE AND DISEASE MANAGEMENT PROGRAMS FOR THE CHRONI CALLY ILL LOWERS TOTAL COSTS WHILE IMPROVING CLINICAL OUTCOMES 7E OFTEN SEE THAT PROVIDERS WITH HIGHER UNIT PRICES BELONG IN A LOWER COST TIER BECAUSE

WHEN PATIENTS ARE IN THEIR CARE THE TOTAL COST OF CARE IS REDUCED - Õ `Ê ÛiÀ i ÌÊ > `>ÌiÊ /À> ë>Ài VÞ¶ 4IERING CAN ONLY BE EFFECTIVE WHEN PROVIDERS

PATIENTS PLANS AND EMPLOYERS COOPERATE TO SHARE MEANINGFUL READILY AVAILABLE AND EASY TO UNDERSTAND COST AND QUALITY INFORMATION 5NTIL RECENTLY THE BASIC INFORMATION NEEDED TO MAKE GOOD INFORMED CONSUMER DECISIONS WAS BEHIND A VEIL 4HAT VEIL IS BEING LIFTED SO THAT PROVIDERS CAN BE REWARDED IN RELATION TO THEIR PERFORMANCE 3OME PHYSICIANS AND HOSPITALS MAY lND THEY MAXIMIZE THEIR INCOME BY CHARGING PRE MIUM PRICES AT A LOWER VOLUME /THERS MAY DECIDE A BETTER STRATEGY IS HIGHER VOLUME AND LOWER PRICES 3OME WILL INVEST IN EFlCIENCY IMPROVEMENTS THAT GENERATE HIGHER MARGINS ÊÊÊÊ Õ ÞÉ Õ}ÕÃÌÊÓääxÊ Ê

AT COMPETITIVE PRICES )N ANY CASE IT S THEIR PREROGATIVE THEIR DECISION #ONSUMERS ARE ENTITLED TO KNOW MORE ABOUT COST AND QUALITY )F NECESSARY ACCORD ING TO A (EWITT SURVEY EMPLOYERS ARE WILLING TO HAVE THE GOVERNMENT STEP IN TO MAKE THIS HAPPEN PERCENT WANT THE GOVERNMENT TO MANDATE QUALITY REPORTING ABOUT PERCENT FAVOR A GOVERNMENT REQUIREMENT THAT PROVIDERS DISCLOSE PRICES 2ESEARCH BY THE +AISER &AMILY &OUNDATION INDICATES THAT CONSUMERS DO WEIGH HEALTH CARE COST AND QUALITY !MONG CONSUMERS WHO SAW QUALITY INFORMATION NEARLY SIX IN USED IT &OUR IN DECIDED THAT FACTORS SUCH AS COST OR LOCA TION WERE MORE IMPORTANT TO THEIR DECISION !RE THE METRICS WE USE TO MEASURE QUALITY AND EFlCIENCY PERFECT .O BUT THEY ARE A GOOD

7ITH HEALTH CARE COSTS FORECAST TO DOUBLE AGAIN

BY ABOUT

THERE IS NO TURNING BACK THE TIDE TOWARD CONSUMER DIRECTED HEALTH COVERAGE START 4HE PROOF IS IN THE LOWER RATE OF INCREASE IN MEDICAL COSTS EXPERIENCED BY 0ATIENT #HOICE EMPLOYERS YEAR OVER YEAR 4HE MODERATING EFFECT IS DUE TO THE MIGRATION OF BOTH PATIENTS AND CARE SYSTEMS INTO LOWER COST TIERS 7ITH HEALTH CARE COSTS FORECAST TO DOUBLE AGAIN BY ABOUT THERE IS NO TURNING BACK THE TIDE TOWARD CONSUMER DIRECTED HEALTH COV ERAGE 4HE ,EAPFROG 'ROUP A COALITION OF MORE THAN &ORTUNE EMPLOYERS AND MAJOR GOVERNMENT UNITS IS URGING ITS MEMBERS TO INSIST ON TRANSPARENCY AND PERFORMANCE BASED CONTRACTS !T LEAST NINE OF THE NATION S MOST SUCCESSFUL NATIONAL AND REGIONAL HEALTH INSURERS ALREADY OFFER TIERED NETWORKS ,EAPFROG REPORTS MORE ARE IN THE WORKS 3OME OF THE MOST PROGRESSIVE EMPLOY ERS IN -INNESOTA AND THE 5 3 '% )"-

#ARGILL (ONEYWELL AND THE 5NIVERSITY OF -INNESOTA ALREADY PROVIDE TIERED NETWORK COVERAGE TO EMPLOYEES 'OVERNMENT EMPLOYERS ARE VERY INTERESTED IN TIERED NETWORKS 4HE STATE OF -INNESOTA USES A TIERED NETWORK MODELED ON "(#!' EFFORTS )N 3IOUX &ALLS 3OUTH $AKOTA

ALL THREE MAJOR LOCAL GOVERNMENT UNITS THE CITY THE COUNTY AND THE SCHOOL SYSTEM ARE 0ATIENT #HOICE CUSTOMERS 4HE SCHOOL DISTRICT ESTIMATES THAT COMPARED TO ITS PREVIOUS PLAN

0ATIENT #HOICE MAY HELP IT SAVE MILLION OR MORE A YEAR )N AN ERA OF PERPETUALLY CASH STRAPPED SCHOOLS THAT S WONDERFUL NEWS 3OME EMPLOYEES MAY ACTUALLY SEE THEIR PREMIUMS GO DOWN )N THE FUTURE BETTER METRICS WILL BE POSSIBLE WITH INPUT FROM LOCAL PROVIDERS AND FROM COOPERATION WITH ORGANIZATIONS SUCH AS THE PRESTIGIOUS .ATIONAL #OMMITTEE FOR 1UALITY !SSURANCE .#1! )T IS CONSIDERING HOW TO HELP CONSUMERS DISTINGUISH BETWEEN PROVIDERS !NOTHER NONPROlT ORGANIZATION WITH CONSID ERABLE BACKING THE .ATIONAL 1UALITY &ORUM .1& WAS CREATED SPECIlCALLY TO DEVELOP AND IMPLEMENT A NATIONAL STRATEGY FOR HEALTH CARE QUALITY MEASUREMENT AND REPORTING -EDICAL SOCIETIES THE ,EAPFROG 'ROUP "RIDGES TO %XCELLENCE AND -INNESOTA S )NSTITUTE FOR #LINICAL 3YSTEMS )MPROVEMENT )#3) ARE OTHER INDUSTRY ORGANIZATIONS THAT CAN AND SHOULD CONTRIBUTE TO THE DEVELOPMENT OF WIDELY ACCEPTED PERFORMANCE MEASURES 4IERED NETWORKS ARE NOT THE END STAGE 4HEY ARE A STEP ON THE PATH TO A LONG TERM

MARKET BASED SOLUTION TO TODAY S UNSURVIVABLY HIGH HEALTH CARE INmATION

!NN 2OBINOW IS VICE PRESIDENT AND GENERAL MANAGER FOR -EDICA S 0ATIENT #HOICE SEGMENT

WHICH DEVELOPS AND MANAGES HEALTH CARE PROGRAMS IN WHICH PHYSICIANS AND HOSPITALS COMPETE FOR PATIENTS BASED ON QUALITY AND COST %ARLIER SHE CO FOUNDED AND SERVED AS PRESI DENT 0ATIENT #HOICE (EALTHCARE )NC UNTIL ITS ACQUISITION BY -EDICA 0RIOR TO FORMING 0ATIENT #HOICE -S 2OBINOW SERVED AS EXECUTIVE DIRECTOR #ARE 3YSTEMS AND &INANCE FOR THE "UYERS (EALTH #ARE !CTION 'ROUP "(#!'

A COALI TION OF LARGE EMPLOYERS COLLABORATIVELY PURCHASING HEALTH CARE SERVICES !T "(#!'

-S 2OBINOW LED THE DESIGN DEVELOPMENT IMPLEMENTATION AND OPERATION OF THEIR NATIONALLY RECOGNIZED IN NOVATIVE AND SUCCESSFUL TIERED NETWORK PROGRAM THAT IS NOW THE MODEL FOR MANY HEALTH PLAN AND PURCHASER INITIATIVES

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&RANK 2HAME AND 2ICHARD 3TURGEON

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(OW HAS YOUR TRAINING AND EXPERIENCE AS AN EDUCATOR INmUENCED YOUR WORK AS A CHIEF MEDICAL OFlCER -ANY OF OUR PHYSICIANS ARE INVOLVED IN THE EDUCATION OF OUR NEXT GENERATION OF PHYSICIANS AND ) AM VERY SUPPORTIVE OF THIS BECAUSE ) THINK TEACHING STIMULATES YOUR OWN LEARNING AND IS VERY ENERGIZING )N ADDITION IN MY POSITION ) HAVE THE PLEASURE OF LEARNING WITH OTHER PHYSICIANS ABOUT THE EXTERNAL FORCES AFFECTING HEALTH CARE PHYSICIAN LEADERSHIP PRINCIPLES AND PROCESS IMPROVEMENT

9OU HAVE HAD POSTGRADUATE TRAINING IN EPIDEMIOLOGY (OW DO YOU CONNECT CLINICAL PROCESS IMPROVEMENT AND POPULATION MANAGEMENT -Y FELLOWSHIP TRAINING IN CLINICAL EPIDEMIOLOGY INVOLVED STUDYING PATTERNS OF DISEASE IN POPULATIONS THE EFFECTIVENESS OF THERAPIES AND EVIDENCE BASED MEDICINE IN GENERAL AND THE IMPACT OF ORGANIZATION ON THE DELIVERY OF CARE )N MEDICINE TODAY THE PHYSICIAN NEVER TRULY WORKS ALONE BUT INSTEAD IS PART OF A TEAM DELIVERING CARE 4HE TECHNIQUES ) HAVE LEARNED ARE PARTICULARLY USEFUL IN LEADING TEAMS IN DESIGNING THE BEST CARE PRACTICES

)N YOUR ROLE IN AN EMPLOYED GROUP PRACTICE YOU ALSO HAVE RELATIONSHIPS WITH INDEPENDENT PHYSICIANS (OW DOES THAT WORK 4HE !LLINA -EDICAL #LINIC HAS APPROXIMATELY PHYSICIANS AND ALLIED HEALTH PROFESSIONALS BUT THIS INCLUDES ONLY A LITTLE OVER SPE CIALTY PHYSICIANS 4HEREFORE WE HAVE MANY IMPORTANT RELATIONSHIPS WITH INDEPENDENT SPECIALTY GROUPS /UR GOAL IS TO MAKE THE HAND OFFS WITH OUR PARTNERS AS SEAMLESS AS POSSIBLE FROM THE PATIENTS PERSPECTIVE AND TO ENSURE HIGH QUALITY OUTCOMES BY HAVING THE RIGHT INFORMATION AVAILABLE WHEREVER THE PATIENT IS BEING SEEN 7E ALSO HAVE VERY GOOD RELATIONSHIPS WITH OTHER INDEPENDENT MULTI SPECIALTY GROUPS 7E SOMETIMES COLLABO RATE ON SERVICES AND SHARE INFORMATION ON PROCESSES WE ARE IMPROVING

7HAT IS THE GOVERNANCE STRUCTURE OF !LLINA -EDICAL #LINICS !S A PHYSICIAN ARE YOU PLEASED WITH THE INPUT OF PHYSICIANS AND NURSES INTO DECISIONS 4HE LEADERSHIP OF THE !LLINA -EDICAL #LINIC !-# IS A PAIRED LEADERSHIP MODEL WHERE A PHYSICIAN LEADER IS PAIRED WITH AN ADMINISTRATIVE LEADER 4HE OVERALL LEADERSHIP OF THE !-# RESTS WITH 4OM (OLETS OUR PRESIDENT

AND WITH ME AS THE CHIEF MEDICAL OFlCER 3IMILARLY EACH OF OUR GEOGRAPHIC DISTRICTS ARE LED BY A DISTRICT MEDICAL DIRECTOR AND A DISTRICT ADMINISTRATIVE DIRECTOR AND EACH CLINIC WITHIN A DISTRICT IS LED BY A LEAD PHYSICIAN AND A CLINIC MANAGER 4HIS MODEL IS A DELEGATED MODEL RATHER THAN A REPRESEN TATIONAL MODEL WHERE LEADERS ARE ELECTED 4HE DELEGATED MODEL IS TYPICAL OF VERY LARGE GROUPS SUCH AS THE !-# "ECAUSE OF THE MODEL HOWEVER

WE HAVE TO WORK VERY HARD TO MAKE SURE THAT THE INDIVIDUAL VOICE OF THE PHYSICIAN AND PROVIDER IS HEARD 7E DO THIS THROUGH AN ELECTED -EDICAL !DVISORY #OUNCIL THAT IS A GROUP OF APPROXIMATELY PHYSICIANS AND PROVIDERS WHO HAVE A VERY IMPORTANT ROLE IN ADVISING THE PRESIDENT AND CHIEF MEDICAL OFlCER MONTHLY ON !-# POLICIES AND PROCEDURES !LSO

WE HAVE A #LINICAL 0RACTICE #OUNCIL THAT CONSISTS OF FRONT LINE PHYSICIANS

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#OLLEAGUE )NTERVIEW #ONTINUED FROM PAGE

NURSES AND MANAGERS WHO MAKE DECISIONS ON !-# WIDE CLINICAL POLI CIES &INALLY EACH SITE LEAD PHYSICIAN AND THE DISTRICT MEDICAL DIRECTORS ARE RESPONSIBLE FOR BRINGING THEIR GROUP S ISSUES OR CONCERNS FORWARD TO SHAPE THE !-# S DIRECTION 4HIS IS A CHALLENGING TASK FOR A MULTI SPECIALTY GROUP OF OUR SIZE PARTICULARLY IN A TOUGH HEALTH CARE ENVIRONMENT WHEN PHYSICIANS ARE FEELING A LOT OF PRESSURE BUT OUR PHYSICIAN SURVEYS SHOW THAT WE ARE MAKING SOME HEADWAY IN THIS AREA

7HAT IS YOUR VIEW FOR HOW THE MAJOR ISSUES IN HEALTH CARE QUALITY COST AND ACCESS WILL BE PROVIDED IN THE NEAR FUTURE -ANY OTHERS HAVE WRITTEN VERY ELOQUENTLY ABOUT THESE ISSUES SO ) WILL HIGHLIGHT ONLY ONE OF OUR GREATEST CHALLENGES !S WE FACE REIMBURSEMENTS THAT DON T KEEP PACE WITH THE COST OF NEW TECHNOLOGY WE MUST REDUCE WASTE AND NEEDLESS COMPLEXITY 4HE WAY HEALTH CARE IS lNANCED RESULTS IN TREMENDOUS ADMINISTRATIVE COSTS INCREASED STAFlNG AND SIGNIlCANT PHYSICIAN AND NURSE TIME SPENT HANDLING PAPERWORK 4HERE MUST BE A WAY TO REDUCE THIS

!S THE AMOUNT OF MEDICAL INFORMATION INCREASES IT BECOMES VERY IMPORTANT TO HAVE THE INVOLVEMENT OF SPECIALISTS IN THE CARE OF PATIENTS WITH SERIOUS ILLNESS 7HAT S THE RIGHT BALANCE OF PRIMARY CARE CLINICIANS AND SPECIALISTS IN OUTPATIENT CARE (OW WILL YOU ACCOMPLISH THIS WITHIN THE !-# 4HE RIGHT BALANCE IS PROBABLY A MIX OF SPECIALISTS AND PRIMARY CARE PHYSICIANS 7ITH THE ADVANCE OF TECHNOLOGY AND THE GROWTH IN THE DEPTH AND BREADTH OF MEDICAL KNOWLEDGE EVEN MORE SPECIALISTS ARE LIKELY TO BE REQUIRED (OWEVER WITH PEOPLE LIVING LONGER AND LIVING WITH MULTIPLE MEDICAL CONDITIONS HIGH QUALITY PRIMARY CARE WILL REMAIN ESSENTIAL 4O MEET THE SPECIALTY NEED ) FORESEE CLOSER RELATIONSHIPS WITH INDEPENDENT SPECIALISTS AND GROWTH OF !-# SPECIALTY PRACTICES

7HAT IN YOUR OPINION ARE THE BENElTS OF MEMBERSHIP IN THE --! AND THE LOCAL COMPONENT SOCIETY -ANY OF OUR PHYSICIANS ARE INVOLVED IN STATE AS WELL AS NATIONAL PRO FESSIONAL ASSOCIATIONS 4HESE ASSOCIATIONS ARE VERY IMPORTANT TO GIVE PHYSICIANS ANOTHER IMPORTANT VOICE TO AFFECT CHANGE IN THE HEALTH CARE SYSTEM 5NFORTUNATELY MEMBERSHIP IN THESE ASSOCIATIONS INCLUDING THE --!

IS OFTEN LOWER IN LARGE MULTISPECIALTY GROUPS ) THINK IN PART

THIS IS BECAUSE OF A LACK OF UNDERSTANDING AND IN PART IT MAY BE A SENSE THAT THE HEALTH CARE SYSTEMS THAT MULTISPECIALTY GROUPS OFTEN BELONG TO ARE ADVOCATING ON THEIR BEHALF

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7HAT LEGISLATIVE ISSUES ARE IMPORTANT TO YOU AS A PHYSICIAN !S A PHYSICIAN ) AM INTERESTED IN TRAINING OPPORTUNITIES FOR DOCTORS AND OTHER HEALTH CARE WORKERS ) BELIEVE WE NEED SYSTEMATIC APPROACHES TO MEET THE GEOGRAPHIC AND DEMOGRAPHIC REALITIES WE EXPECT OVER THE NEXT YEARS ) AM TROUBLED BY THE CURRENT STATE OF HEALTH CARE FUNDING AT BOTH THE FEDERAL AND STATE LEVELS $WINDLING REIMBURSEMENT AND REDUCTIONS IN ELIGIBILITY HAVE A DETRIMENTAL EFFECT ON PATIENTS AND OUR ABILITY TO SERVE THEM !S ) MENTIONED EARLIER ) AM ALSO CONCERNED ABOUT RED TAPE IN GOVERN MENT 4HERE IS A lNE BALANCE BETWEEN REGULATION THAT IMPROVES PATIENT CARE AND REGULATION THAT DOES NOT ) SUPPORT EFFORTS TO SIMPLIFY ADMIN ISTRATIVE REQUIREMENTS THAT WILL REDUCE COSTS IN THE SYSTEM AND IMPROVE PATIENT CARE ) BELIEVE EFFORTS TO SUPPORT FUNDING AND STANDARDIZATION OF ELECTRONIC MEDICAL RECORDS IS ONE WAY TO SIMPLIFY THE SYSTEM &INALLY ) AM ALSO CONCERNED ABOUT POLICY ISSUES THAT PROMOTE HEALTHY LIFESTYLES AND REDUCE COSTS 7E KNOW THAT CHRONIC DISEASES ACCOUNT FOR NEARLY PERCENT OF HEALTH CARE SPENDING 4OBACCO USE FOR EXAMPLE IS A MAJOR RISK FACTOR FOR HEART DISEASE CANCER STROKE AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE #/0$ FOUR OF THE TOP lVE CHRONIC DISEASE KILLERS )NCREASING THE FEE OF CIGARETTES OR PROMOTING A STATEWIDE SMOKING BAN COULD PROMOTE HEALTHIER LIFESTYLES WHILE HELPING TO REDUCE HEALTH CARE COSTS

7HAT LEGISLATIVE ISSUES ARE IMPORTANT TO !LLINA !LLINA (OSPITALS #LINICS HAS FORMULATED A 0OLICY !DVISORY 'ROUP CHARGED WITH COORDINATING POLICY POSITIONS FOR THE ORGANIZATION !S ONE OF THE LARGEST EMPLOYERS IN THE STATE WE ARE CONCERNED WITH GENERAL BUSINESS ISSUES (OWEVER THE BULK OF OUR POLICY WORK IS ROOTED IN OUR ROLE PUTTING THE PATIENTS lRST "ECAUSE OF OUR MISSION WE ARE INVOLVED IN EVERYTHING FROM COVERAGE FOR THE UNINSURED PATIENT SAFETY AND QUALITY INITIATIVES AND PUBLIC HEALTH ISSUES LIKE SMOKING AND CAR SEATS )N ADDITION !LLINA HAS CHOSEN TWO HEALTH POLICY GOALS TO FOCUS OUR ATTENTION ON OVER THE NEXT lVE YEARS 4HEY INCLUDE lNDING WAYS TO PROVIDE AFFORDABLE QUALITY HEALTH CARE AND ACCESSIBLE MENTAL HEALTH SERVICES 7ITH THESE GOALS IN MIND WE WILL DEVELOP POLICY INITIATIVES THAT IMPROVE THE LIVES OF THE PATIENTS WE SERVE

7HAT ISSUES CAN ORGANIZED MEDICINE AND THE !-# WORK TOGETHER ON TO RESOLVE ) COULD FORESEE COLLABORATION ON ISSUES RELATED TO THE MALPRACTICE CRISIS

MAINTAINING A HEALTH CARE SAFETY NET FOR THE DISADVANTAGED AND THE ADMINISTRATIVE HASSLES THAT ALL PHYSICIANS FACE

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THE LEGISLATIVE SESSION CONTINUES IN ACTIVE DELIBERATION ON MANY HEALTH CARE AND BUDGET ISSUES OF INTEREST TO PHYSICIANS ! SUM MARY OF THESE lNAL DECISIONS WILL BE PRINTED IN THE NEXT ISSUE

/

4(% ,%')3,!4)6% 3%33)/. WENT OUT WITH A lZZLE WITH LITTLE PROGRESS ON MAJOR BUDGET ISSUES AND NO (EALTH AND (UMAN 3ERVICES "UDGET BILL 4HE LEGISLATIVE ELECTION SAW THE (OUSE 2EPUBLICANS LOSE SEATS AND MAIN TAIN A SLIM MAJORITY ! 3ENATE CONTROLLED BY $EMOCRATS AND A 2EPUBLICAN 'OVERNOR MADE COMPROMISE VIRTUALLY IMPOSSIBLE 7HILE THE MAJOR BUDGET BILLS FAILED TO MAKE PROGRESS

THERE WERE SEVERAL MAJOR HEALTH CARE INITIATIVES THAT WERE A MAJOR PART OF THE LEGISLATIVE SESSION 4HE FOLLOWING IS A SUMMARY OF HEALTH CARE ACTION AT THE STATE CAPITOL DURING THE LEGISLATIVE SESSION

ELIGIBILITY FOR THE -INNESOTA#ARE PROGRAM 4HE 3ENATE BILL WOULD SPEND MILLION MORE THAN THE (OUSE BILL 4HERE WAS NO RESOLUTION ON THE HEALTH CARE BUDGET AS OF THE END OF REGULAR SESSION

i> Ì Ê >ÀiÊ Õ`}iÌ !T THE BEGINNING OF THE SESSION THE -INNESOTA ,EGISLATURE FACED AN OVERALL BUDGET SHORTFALL OF MILLION FOR THE BIENNIUM WITHOUT CONSIDERING INmATION 4HE SHORTFALL GROWS TO A BILLION WHEN INFLATION IS TAKEN INTO CONSIDERATION 4HE &EBRUARY FORE CAST INDICATED A SMALLER SHORTFALL BUT STILL SIG NIlCANT 4HE BUDGET DElCIT DECREASED BY MILLION BUT THE 'OVERNOR PROPOSED THAT THE EXTRA FUNDS GO TO + EDUCATION AND NOT TO HEALTH CARE 'IVEN THE DElCIT THE 'OVERNOR S BUDGET PROPOSAL WAS TO SHIFT RECIPIENTS OF 'EN ERAL !SSISTANCE -EDICAL #ARE INTO THE (EALTH #ARE !CCESS &UND AND AT THE SAME TIME CUT -INNESOTA#ARE BENElTS FOR

RE CIPIENTS 4HE (OUSE ADOPTED THE 'OVERNOR S BUDGET BUT THE 3ENATE BILL ACTUALLY INCREASED

>Õ ÌÊ ÕÌ Ê ÃÕÀ> ViÊ VÌÊ $URING THE LEGISLATIVE SESSION TWO BILLS WERE INTRODUCED THAT AFFECTED THE NO FAULT AUTO INSURANCE PROGRAM 4HE lRST BILL WAS 3ENATE &ILE A BILL INTRODUCED BY 3ENA TOR 'EOFF -ICHEL 2 %DINA 3ENATE &ILE WOULD HAVE REPEALED THE NO FAULT AUTO INSUR ANCE PROGRAM AND WOULD HAVE REQUIRED THAT -INNESOTA DRIVERS PURCHASE LIABILITY INSURANCE 4HE BILL ALSO MANDATED THAT AN INSURER MUST PROVIDE AN APPROPRIATE PREMIUM REDUCTION OF AT LEAST PERCENT ON EACH POLICY 4HIS BILL WAS DEFEATED IN THE 3ENATE AND THE (OUSE COMPAN ION DID NOT RECEIVE A HEARING 4HE SECOND BILL INTRODUCED 3ENATE &ILE WAS AUTHORED BY 3ENATOR 3CHEID $&, "ROOKLYN 0ARK 3ENATE &ILE REFORMED THE NO FAULT AUTO INSURANCE PROGRAM BY TYING MEDICAL EXPENSE BENElTS TO THE 7ORKERS #OMPENSATION FEE SCHEDULE AND INCREASING THE INCOME LOSS AND FUNERAL BENElTS 4HIS BILL WAS ALSO DEFEATED IN THE 3ENATE AND THE (OUSE COMPANION WAS NOT HEARD

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7 À iÀÃ½Ê «i Ã>Ì $URING THE LEGISLATIVE SESSION PROVID ERS WORKED OVERTIME TO KILL A PROVISION IN THE

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7ORKERS #OMPENSATION BILL THAT WOULD HAVE PERMITTED A CERTIlED MANAGED CARE PLAN TO COMPENSATE PROVIDERS FOR THEIR SERVICES AND CARE USING hDISCOUNTED FEESv RATHER THAN THE FEES ON THE 7ORKERS #OMPENSATION FEE SCALE 0ROVIDERS FELT THAT THIS LANGUAGE WOULD OPEN THE GATE FOR MANAGED CARE IN THE WORKERS COMPENSATION SYSTEM AND INJURED WORKERS WOULD EVENTUALLY HAVE NO CHOICE BUT TO ACCEPT THE CERTIlED MAN AGED CARE ROSTER FOR EMPLOYERS WHO CONTRACT EXCLUSIVELY WITH THE CERTIlED PLANS !S PROVID ERS WHO ARE UNABLE TO DISCOUNT THEIR FEES DROP OUT OF THE CERTIlED PLAN INJURED WORKERS WOULD HAVE FEWER AND FEWER CHOICES OF PROVIDERS 4HE PROPOSAL WENT RIGHT TO THE WIRE BEFORE BEING DEFEATED IN COMMITTEE THE LAST WEEK OF THE SES SION $URING THE INTERIM PROVIDERS WORKED ON THIS ISSUE WITH THE $EPARTMENT OF ,ABOR AND )NDUSTRY $/,) TO COME UP WITH COMPROMISE LANGUAGE !LL COMPROMISES WERE REJECTED AND THE ISSUE WAS DROPPED FOR THE LEGISLATIVE SESSION 4HE 7ORKERS #OMPENSATION BILL FOR CONTAINED ALL NON CONTROVERSIAL ISSUES

PASSED BOTH BODIES AND WENT TO THE 'OVERNOR FOR HIS SIGNATURE -Ì>ÌiÜ `iÊ- }Ê > -ANY BELIEVED THAT WOULD BE THE YEAR THAT A STATEWIDE SMOKING BAN WOULD BE VOTED ON IN THE -INNESOTA LEGISLATURE (OWEVER

DESPITE EFFORTS BY A LARGE COALITION OF PROVIDERS AND ADVOCATES THE STATEWIDE SMOKING BAN WAS DEFEATED IN THE (OUSE 2EPRESENTATIVE $OUG -ESLOW 2 7HITE "EAR ,AKE AND 3ENATOR 3COTT $IBBLE $&, -INNEAPOLIS CARRIED THE LEGISLATION )N -ARCH OF (ENNEPIN #OUNTY 2AMSEY #OUNTY "LOOMINGTON AND -INNEAPOLIS WENT SMOKE FREE /THER STATES THAT HAVE INSTITUTED A STATEWIDE BAN INCLUDE .EW 9ORK #ALIFORNIA 5TAH &LORIDA #ONNECTICUT AND -AINE #ONTINUED ON PAGE

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,EGISLATIVE 3ESSION #ONTINUED FROM PAGE

>« iÊ À ÛiÊ Ã« Ì> $URING THE LEGISLATIVE SESSION THE LEGISLATURE DIRECTED THE -INNESOTA (EALTH $EPARTMENT TO LOOK AT THE ISSUE OF WHETHER THE COMMUNITY OF -APLE 'ROVE NEEDED A HOS PITAL BUILT 4HE (EALTH $EPARTMENT S lNDINGS INDICATED THAT INDEED THE COMMUNITY OF -APLE 'ROVE WITH ITS GROWING POPULATION DID NEED A HOSPITAL BUILT TO CARE FOR THE COMMUNITY 4HREE SYSTEMS PROVIDED THE (EALTH $EPARTMENT WITH PROPOSALS TO BUILD 4HEY WERE &AIRVIEW 3YS TEMS 4RI #ARE WHICH CONSISTED OF !LLINA

0ARK .ICOLLET AND #HILDREN S (OSPITAL AND .ORTH -EMORIAL -EDICAL #ENTER 4HE STATE OF -INNESOTA HAS A HOSPITAL BED MORATORIUM

SO IF A NEW HOSPITAL IS TO BE BUILT IN -INNESOTA THE LEGISLATURE MUST APPROVE THE BUILDING AND THE BED CAPACITY 3ENATOR ,IMMER 2 -APLE 'ROVE 2EPRESENTATIVE :ELLERS 2 -APLE 'ROVE AND 2EPRESENTATIVE 0EPPIN 2 -APLE 'ROVE INTRODUCED BILLS THAT ALLOWED FOR A MORATORIUM EXCEPTION SO A HOSPITAL COULD BE BUILT (OWEVER NEITHER THE 3ENATE BILL NOR THE

(OUSE BILL SPECIlED WHICH OF THE THREE COMPET ING SYSTEMS WOULD BE ABLE TO BUILD THE HOSPITAL 4HE (OUSE WAS THE lRST TO HEAR THE BILL AND THE (OUSE (EALTH #OMMITTEE CHOSE .ORTH -EMO RIAL -EDICAL #ENTER 4HE 3ENATE BILL INSTEAD OF CHOOSING ONE OF THE THREE COMPETING SYSTEMS

DECIDED TO SEND THE ISSUE BACK TO THE (EALTH $EPARTMENT TO MAKE THE DECISION 4HE 3ENATE BILL LISTED CRITERIA THAT THE HEALTH DEPARTMENT WOULD NEED TO TAKE INTO CONSIDERATION PRIOR TO MAKING THE DECISION ON WHICH SYSTEM COULD BUILD 4HE CRITERIA ADDRESSED ISSUES THE LEGIS LATURE FELT THE HOSPITAL SHOULD ADDRESS SUCH AS MENTAL HEALTH BEDS AND AN EMERGENCY ROOM !S OF THIS WRITING THE TWO BILLS HAD PASSED THEIR RESPECTIVE BODIES AND WERE AWAITING CONFERENCE COMMITTEE ACTION /À> à >Ì ÀÊ-iÀÛ Vià ! BILL WAS INTRODUCED IN THE (OUSE AND THE 3ENATE THAT WOULD MANDATE HEALTH PLANS TO RE IMBURSE PROVIDERS FOR TRANSLATOR SERVICES THEY PROVIDED AT THEIR CLINICS OR HOSPITALS 5NDER THE #IVIL 2IGHTS !CT OF 4ITLE 6)) PROVIDERS ARE REQUIRED TO ARRANGE FOR INTERPRETER SERVICES FOR NON %NGLISH SPEAKING PATIENTS 4HE !CT

$ - + $ & ) % .$ /# + & $ + ) ' $ 0 & + ! &

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DOES NOT HOWEVER PROVIDE A FUNDING MECHA NISM -INNESOTA LAW CURRENTLY REQUIRES MANY PAYERS TO EITHER PROVIDE TRANSLATOR SERVICES OR REIMBURSE CLINICS AND HOSPITALS FOR THESE IMPORTANT SERVICES s 0-!0 REQUIRES PARTICIPATING HEALTH PLANS TO PROVIDE LANGUAGE TRANSLATORS AND PROVIDERS COMPLY BY KEEPING ROSTERS OF TRAINED INTER PRETERS WHO ARE AVAILABLE UPON REQUEST s 7ORKERS #OMPENSATION INSURANCE CARRIERS ARE REQUIRED TO PAY FOR LANGUAGE INTERPRETER SERVICES s .O FAULT AUTO INSURANCE CARRIERS ARE REQUIRED TO PAY FOR LANGUAGE INTERPRETER SERVICES FOR THE BENElT OF PERSONS INJURED IN AUTO AC CIDENTS s -EDICAL !SSISTANCE PAYS A SMALL FEE PER HOUR FOR LANGUAGE INTERPRETER SERVICES FOR ELIGIBLE INDIVIDUALS 4HE BALANCE OF PAYERS INCLUDING HEALTH PLANS SUCH AS -EDICA "LUE #ROSS AND "LUE 3HIELD AND (EALTH0ARTNERS ARE CURRENTLY NOT REQUIRED TO REIMBURSE FOR LANGUAGE INTERPRETER SERVICES 5NREIMBURSED COSTS FOR LANGUAGE INTERPRETER SERVICES FALL DISPROPORTIONATELY ON CLINICS AND HOSPITALS LOCATED IN COMMUNITIES WITH SUBSTANTIAL NUMBERS OF RECENT IMMI GRANTS 4HE BILL WAS HEARD IN THE 3ENATE AND WAS CONTROVERSIAL "OTH THE HEALTH PLANS AND THE #HAMBER OF #OMMERCE OPPOSED THE LEGISLA TION 4HE BILL WAS TURNED INTO A STUDY THAT WOULD BE CONDUCTED BY THE $EPARTMENT OF #OMMERCE IN CONSULTATION WITH THE $EPART MENT OF (EALTH THE $EPARTMENT OF (UMAN 3ERVICES TRANSLATORS HEALTH PLANS AND PRO VIDERS 4HE STUDY BILL PASSED THROUGH SEVERAL COMMITTEES AND WAS PUT INTO THE 3ENATE (EALTH AND (UMAN 3ERVICES /MNIBUS "ILL (OWEVER

IN THE (OUSE THE -INNESOTA #HAMBER OF #OM MERCE STRONGLY OPPOSED THE BILL EVEN AS A STUDY

AND IT DID NOT RECEIVE A HEARING !S OF THIS WRIT ING THE STUDY LANGUAGE REMAINS IN THE 3ENATE (EALTH AND (UMAN 3ERVICES "ILL AND HAS YET TO BE RESOLVED 4HE SPECIAL SESSION WILL DETERMINE WHAT BECOMES OF THE HEALTH CARE BUDGET AND ALL PENDING ISSUES AT THE -INNESOTA LEGISLATURE 4HE STATE NEEDS TO ADOPT ITS BUDGET BY *ULY

IN ORDER TO AVOID A GOVERNMENT SHUT DOWN

.ORA 3TEWART - 0 !

IS WITH ,OCKRIDGE 'RINDAL .AUEN 0 , , 0

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COMMON SURGICAL THERAPY PERFORMED IN WOMEN -ORE THAN MILLION ARE PERFORMED EACH YEAR (ISTORICALLY THE USUAL RECOVERY HAS INCLUDED FOUR TO SIX WEEKS OF RESTRICTED ACTIVITY POST OPERATIVELY 4HE ADDITION OF LAPAROSCOPIC HYSTERECTOMY TO THE LIST OF APPROPRIATE METHODS OF PERFORMING HYSTERECTOMY HAS ALLOWED THE RECOVERY PERIOD TO BE MUCH SHORTER AND LESS RESTRICTIVE THEREFORE MAKING IT A LESS DIFlCULT DECISION IN MANY CASES .O DOUBT COMPARED TO TRADITIONAL ABDOMINAL OR VAGINAL HYSTERECTOMY

LAPAROSCOPICALLY ASSISTED VAGINAL HYSTERECTOMY ,!6( WAS A BREAKTHROUGH IN THE S AND EARLY S )T ALLOWED A RECOVERY AT TIMES TO BE IN THE TWO WEEK RANGE FOR RETURN TO WORK

BUT RETURN OF FULL ACTIVITY INCLUDING SEXUAL INTERCOURSE WAS STILL APPROPRIATELY DELAYED SIX WEEKS POST OP .OW WITH THE PROCEDURE BEING DONE COMPLETELY BY THE LAPAROSCOPIC ROUTE RETURN TO FULL ACTIVITY IS OFTEN APPROPRI ATELY JUST SEVEN DAYS /THER BENElTS OF THE LAPAROSCOPIC APPROACH AS WELL AS OTHER DETAILS OF THE LAPAROSCOPIC APPROACH WILL BE DISCUSSED IN THE REST OF THIS ARTICLE %ARLY PLANNED HYSTERECTOMIES WERE DONE AS EARLY AS THE EARLY S AND WERE ALL VAGINAL PROCEDURES DONE AS LIFE SAVING MEASURES FOR THE INFECTED PROLAPSED UTERUS 7HEN ABDOMINAL HYSTERECTOMIES BEGAN BEING DONE LATER IN THAT CENTURY THEY WERE DONE SUPRACERVICALLY BECAUSE LEAVING THE CERVIX WAS EASIER AND SAFER 4OTAL ABDOMINAL HYSTERECTOMY WAS FIRST DONE IN AND BECAME THE USUAL TYPE OF ABDOMINAL HYSTERECTOMY BECAUSE REMOVING THE CERVIX DE CREASED THE RATE OF SUBSEQUENT CERVICAL CANCER 4HE ADVENT OF WIDESPREAD AND EFFECTIVE CERVICAL

9Ê " Ê- "//Ê - ]Ê ° °]Ê ° ° °"° °

CANCER SCREENING WITH THE 0AP SMEAR GREATLY DECREASED THE CERVICAL CANCER RATE AND MADE IT LESS CRUCIAL TO REMOVE THE CERVIX 4HE SUPRACERVICAL HYSTERECTOMY WHETHER DONE ABDOMINALLY OR LAPAROSCOPICALLY IS MAK ING A COMEBACK FOR SEVERAL REASONS &IRST IT IS EASIER BECAUSE THE MOST DIFlCULT DISSECTION IS OFTEN IN THE AREA BELOW THE UTERINE VESSELS DOWN TO THE VAGINA 4HIS IS ALSO THE AREA WHERE MOST COMPLICATIONS OCCUR BECAUSE OF PROXIMITY TO THE URETERS BLADDER AND BOWEL !VOIDING THIS AREA IS ALSO THEREFORE SAFER !VOIDING ENTRANCE INTO THE VAGINA MAKES THE RISK OF INFECTION

ESPECIALLY CUFF CELLULITIS A RARE OCCURRENCE 0RO LONGED DELAY IN POST OPERATIVE SEXUAL ACTIVITIES IS ALSO NOT NECESSARY BECAUSE THERE IS NO VAGINAL INCISION THAT NEEDS HEALING #OMPARISONS WITH THE OTHER TYPES OF HYSTERECTOMY YIELD SOME USEFUL INFORMATION !

RECENT REPORT IN THE *OURNAL OF -INIMALLY )NVA SIVE 'YNECOLOGY BY (OFFMAN SHOWED INCREASED MAJOR COMPLICATIONS INCREASED POST OP VAGINAL BLEEDING EPISODES REQUIRING READMISSION AND OVERALL INCREASED NEED FOR READMISSION AS WELL AS THE LONGER HOSPITALIZATION LONGER RECOVERY

AND LONGER USE OF POST OP NARCOTICS IN PATIENTS WITH TOTAL ABDOMINAL HYSTERECTOMIES COMPARED WITH LAPAROSCOPIC SUPRACERVICAL HYSTEREC TOMY PATIENTS ,3( 4HE LANDMARK PAPER BY

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4HOMAS ,YONS PUBLISHED IN COMPARED ,3( PATIENTS WITH ,!6( PATIENTS AND FOUND SHORTER OPERATING TIME QUICKER RETURN TO WORK QUICKER RETURN TO hNORMALv AS WELL AS SHORTER LENGTH OF STAY LESS BLOOD LOSS AND LESS EXPENSE WITH THE ,3( *ENKINS PUBLISHED A REVIEW ARTICLE IN THE !MERICAN *OURNAL OF /B 'YN IN COMPARING ,3( WITH ,!6( AND REPORTED LESS BLOOD LOSS AND SHORTER HOSPITAL STAY IN ALL OF THE ARTICLES AND LOWER COMPLICA TION RATE SHORTER /2 TIME FASTER RETURN TO WORK AND TO NORMAL ACTIVITY IN MOST OF THE ARTICLES WITH ,3( AS OPPOSED TO ,!6( ,3( WAS ALSO LESS EXPENSIVE IN THAT STUDY /N THE SAFETY SIDE THERE ARE LESS SURGICAL COMPLICATIONS INCLUDING URETERAL AND BLADDER INJURIES AS WELL AS LESS INFECTIONS WITH ,3( (OSPITALIZATION IS CLEARLY SHORTER WITH EITHER SAME DAY SURGERY OR OVERNIGHT STAY BEING THE NORM 0AIN IS MUCH LESS AS WOULD BE EXPECTED WITH PATIENTS HAVING ONLY THE SMALL LAPAROSCOPIC INCISIONS 4HE AVERAGE POST OP NEED FOR PAIN MEDICINE IS THREE DAYS 3UB CUTANEOUS USE OF -ARCAINE IN THE INCISIONS AND THE USE OF POST OP 4ORADOL HAS AIDED IN THIS REGARD 4HE AVERAGE RETURN TO WORK IS DAYS AND TO SEXUAL RELATIONS IS TWO WEEKS 3EXUAL FUNCTIONING AFTER HYSTERECTOMY HAS BEEN MUCH SPOKEN OF RECENTLY WITH A FAIR AMOUNT OF DISCUSSION ABOUT LOSS OF ORGASM AND LIBIDO AFTER REMOVAL OF THE CERVIX WITH HYSTER ECTOMY 4HERE IS ESSENTIALLY NO SCIENTIlC DATA TO SUPPORT SUCH CLAIMS BUT NEVERTHELESS THIS ISSUE IS COMMONLY BROUGHT UP BY PATIENTS )T IS SAFE TO SAY THAT THE SUPRACERVICAL APPROACH WOULD REMOVE THAT AS A CONCERN !LSO THE ISSUE OF PELVIC SUPPORT AND SUBSEQUENT PELVIC RELAX ATION BASED ON WHETHER THE CERVIX IS REMOVED OR NOT IS NOW POPULAR 4HERE IS STILL QUESTION #ONTINUED ON PAGE

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WHETHER A TOTAL HYSTERECTOMY PREDISPOSES TO LATER PELVIC RELAXATION BUT LEAVING THE PELVIC mOOR INTACT AS WITH A SUPRACERVICAL PROCEDURE

ALSO MAKES THAT A NON ISSUE )F THERE IS ALREADY PELVIC mOOR DESCENT THE SUPRACERVICAL APPROACH IS NOT INDICATED /THER ,3( hDISQUALIlERSv ARE HISTORY OF HIGH GRADE CERVICAL DYSPLASIA LARGE LOWER UTERINE SEGMENT MYOMAS LARGE CALCIlED MYOMAS OR SEVERE PELVIC ENDOMETRIOSIS AND THE ADHESIVE DISEASE THAT IT CAUSES !NOTHER FREQUENTLY ASKED QUESTION IS

hWHY WOULD YOU LEAVE MY CERVIX v 4HE MOST APPROPRIATE ANSWER IS hWHY WOULD ) TAKE IT OUT v 4HE RATIONALE OF ROUTINELY REMOVING THE CERVIX TO NEGATE ANY LATER RISK OF CERVICAL CANCER IS NOW GENERALLY THOUGHT TO BE OUTDATED AND UNNECESSARY BECAUSE THE INCIDENCE IS SO LOW IN A SCREENED POPULATION AND IS NO DIFFERENT THAN PATIENTS WITHOUT A HYSTERECTOMY -OST OF THE PATIENTS WHO HAVE ,3( ARE IN THEIR S STILL HAVE THEIR OVARIES AND THEREFORE SHOULD HAVE ANNUAL EXAMS ANYWAY ) BELIEVE THERE ARE THREE REASONS WHY LAPAROSCOPIC HYSTERECTOMY HAS NOW BECOME SO MUCH MORE POSSIBLE &IRST IS THE INCREASING SKILL OF GYNECOLOGISTS IN ADVANCED LAPAROSCOPIC

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SURGERY 4HE OTHER TWO REASONS ARE TECHNOLOGI CAL ADVANCES WHICH WHEN ADDED TO PREVIOUSLY ACQUIRED SKILLS ENABLE THE MINIMALLY INVASIVE APPROACH 4HE POWER SOURCE USED TO DO THE SURGICAL SEPARATION OF TISSUES AND ACQUIRE HEMOSTASIS IS VERY IMPORTANT 4HERE ARE MANY OPTIONS INCLUDING UNIPOLAR CAUTERY BIPOLAR CAUTERY 9!' LASER STAPLES AND EVEN SUTURING TECHNIQUES BUT THE TOOL THAT ) THINK IS MOST EFFECTIVE IS THE (ARMONIC SCALPEL 4HIS POWER SOURCE WORKS WITH THE CONCEPT OF ULTRASOUND VIBRATION VIBRATING APPROXIMATELY

TIMES PER SECOND AND SEPARATING AND COAGU LATING TISSUE USING THAT ENERGY )T IS NOW &$!

APPROVED TO MANAGE VESSELS UP TO MM IN DIAMETER WHICH INCLUDES THE UTERINE VESSELS ,ITTLE LATERAL SPREAD OF THE ENERGY SOURCE OCCURS SO LESS OTHER TISSUE IS DAMAGED 4HE SAFETY FACTOR IS THEREFORE INCREASED ) THINK THIS LACK OF COLLATERAL TISSUE DESTRUCTION PROBABLY IS A MAIN REASON FOR THE DECREASED PAIN WITH THIS PROCEDURE 6ERY SELDOM IS ANOTHER ENERGY SOURCE NECESSARY FOR HEMOSTASIS 4HE OTHER IM PORTANT TOOL FOR THIS PROCEDURE IS THE ELECTRIC MORCELLATOR MADE BY 'YNECARE 4HIS EFFECTIVELY ALLOWS REMOVAL OF THE UTERUS IN PIECES THRU A MM LAPAROSCOPIC PORT THUS MAKING LARGE INCISIONS UNNECESSARY -OST ,3( PROCEDURES ARE DONE EITHER FOR INTRACTABLE UTERINE BLEEDING PELVIC PAIN

DYSMENORRHEA OR PAIN AND BLEEDING SECONDARY TO MYOMATOUS UTERUS ! PRIMARY RATIONALE FOR THIS THERAPY IS TO BE ABLE TO REPLACE ABDOMINAL PROCEDURES WITH THE LESS INVASIVE ,3( 0RETREAT MENT OF LARGE lBROIDS WITH THE ANTI GONADO TROPIN ,UPRON HAS BEEN SUCCESSFUL IN SHRINKING lBROIDS PRE OPERATIVELY TO AN ACCEPTABLE SIZE TO MAKE ,3( POSSIBLE &IBROID UTERUSES UP TO WEEKS SIZE CAN BE TREATED THIS WAY #YCLIC BLEEDING POST OPERATIVELY IS THE MOST FREQUENTLY REPORTED COMPLICATION OF ,3( BUT SHOULD BE ABLE TO BE AVOIDED WITH AGGRESSIVE CAUTERY OF THE ENDOCERVICAL CANAL IN THE REMAINING CERVICAL STUMP #ASE REPORTS OF ENDOMETRIOSIS AND PARASITIZED MYOMETRIAL TISSUE TO THE PERITONEUM HAVE BEEN REPORTED AND THEREFORE EMPHASIZE THE NEED FOR COPIOUS WASHING OF THE PERITONEAL CAVITY AND METICU LOUS REMOVAL OF ALL FRAGMENTS OF THE UTERUS %NDOMETRIAL BIOPSY IS A PRECAUTION WISELY USED PRE OPERATIVELY TO AVOID THE POSSIBILITY OF MORCELLATING A UTERUS THAT CONTAINS CANCER !NOTHER WISE PRECAUTION IS A DISCUSSION WITH

THE PATHOLOGY DEPARTMENT PRIOR TO BEGINNING TO SEND MORCELLATED SPECIMENS TO THEM 4HE CATEGORY OF LAPAROSCOPIC HYSTERECTOMY ALSO INCLUDES TOTAL LAPAROSCOPIC HYSTERECTOMY THAT INCLUDES REMOVAL OF THE CERVIX ALSO 4HIS PROCEDURE TAKES MUCH LONGER HAS HIGHER BLOOD LOSS INCREASED CUFF CELLULITES AND MORE SURGICAL COMPLICATIONS THAN ,3( %XPENSE IS ALSO MUCH HIGHER BECAUSE OF THE LENGTH OF SURGICAL TIME (YSTERECTOMY IN GENERAL HAS BEEN A MUCH MALIGNED PROCEDURE THROUGH THE END OF THE S BECAUSE OF PATIENT DISABILITY PAIN AND COST ESPECIALLY IN THE CONTEXT OF COST SAVING MANAGED CARE INITIATIVES 4HE NEWS MEDIA AND TALK SHOWS INCLUDING /PRAH AND +ATIE #OURIC WERE FREQUENTED BY TESTIMONIALS FROM WOMEN WHOSE LIVES HAVE BEEN hRUINEDv

BY HYSTERECTOMY .OW THESE TESTIMONIALS SEEM TO BE GOING THE OTHER WAY AND WITH LESS PAIN

QUICKER RECOVERY AND WITH THE SUCCESSFUL ALLEVIATION OF PRE OPERATIVE SYMPTOMS MORE PATIENTS ARE ACTIVELY TELLING OTHERS OF THEIR POSI TIVE EXPERIENCES )N CONCLUSION THERE ARE MANY FAIRLY COMPELLING REASONS TO CONSIDER THIS MINIMALLY INVASIVE ALTERNATIVE TO TRADITIONAL METHODS OF HYSTERECTOMY 4HESE INCLUDE SMALLER INCISIONS

LESS PAIN FASTER RECOVERY SHORTER HOSPITAL STAY LESS DISRUPTION OF THE PELVIC mOOR LESS LIKELIHOOD OF NEGATIVELY AFFECTING SEX AND LESS OPERATIVE COMPLICATIONS -OTIVATED AND INFORMED PATIENTS NEEDING A HYSTERECTOMY ARE INCREASINGLY SEEKING THIS OPTION

*ON 3COTT .IELSON - $ & ! # / ' IS THE CHIEF EXECUTIVE OFlCER MANAGING PARTNER AND MEDI CAL DIRECTOR OF THE MENOPAUSE CLINIC AT /AKDALE /BSTETRICS AND 'YNECOLOGY 0 ! (IS PRIMARY INTERESTS INCLUDE INNOVATIONS IN HEALTH CARE SUCH AS MINIMALLY INVASIVE AND ENDOSCOPIC SURGERIES

AND THE MANAGEMENT OF MENOPAUSAL PROBLEMS $R .IELSON COMPLETED HIS UNDERGRADUATE DEGREE DOCTORATE IN MEDICINE AND RESIDENCY IN /BSTETRICS AND 'YNECOLOGY AT THE 5NIVERSITY OF -INNESOTA AND ITS AFlLIATED HOSPITALS (E IS BOARD CERTIlED IN /BSTETRICS AND 'YNECOLOGY AND A CLINICAL ASSOCIATE PROFESSOR IN THE 5NIVER SITY OF -INNESOTA S DEPARTMENT OF /BSTETRICS AND 'YNECOLOGY (E IS ALSO ACTIVE IN LEADERSHIP AS A MEMBER OF .ORTH -EMORIAL (OSPITAL S "OARD OF 4RUSTEES AND AS #HAIR OF THE -INNESOTA 7OMEN S (EALTH #ONSORTIUM

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PAIN MEDICINE IS THAT THE PRACTITIONER MUST BE ALERT FOR SCAMMERS I E DRUG ABUSERS DIVERTERS 4HESE PEOPLE ARE A SMALL BUT SIGNIlCANT AND TROUBLESOME PORTION OF ANY PAIN PATIENT POPU LATION 4HEY CAN BE EXTREMELY SOPHISTICATED AND INGENIOUS IN THEIR APPROACH TO THE PRACTITIONER

AND THE FACT IS ANY PRACTITIONER WHO DOES ANY REAL QUANTITY OF PAIN MANAGEMENT IS GOING TO BE SCAMMED AT ONE TIME OR ANOTHER )T IS

THEREFORE NECESSARY FOR THE PRACTITIONER TO TAKE SOME PRECAUTIONS IN THIS REGARD RECOGNIZING THAT EVEN THE MOST EXPERIENCED CLINICIAN WILL OCCASIONALLY BE DECEIVED BUT THAT THE OBJECTIVE IS TO MAKE SURE THAT ONE S PRACTICE IS NOT A TARGET FOR SCAMMERS 4O DO THIS ONE MUST BE ABLE TO )DENTIFY THE ABUSER DIVERTER (AVE MEDICALLY AND LEGALLY APPROPRIATE MECHANISMS FOR DEALING WITH THEM 4HE PURPOSE OF THIS ARTICLE IS TO PROVIDE GUID ANCE IN THE RECOGNITION OF PATIENTS WHO ABUSE OR DIVERT PAIN MEDICATIONS AND TO SUGGEST METHODS TO APPROPRIATELY AND EFFECTIVELY HANDLE THEM 4O BEGIN WITH WE AS PRACTITIONERS MUST UNDERSTAND THE PROBLEMS SURROUNDING MISUSE

ABUSE AND DIVERSION 4HESE AUTHORS RECOMMEND REVIEW OF THE lRST ARTICLE IN THIS SERIES REGARDING THE REGULATIONS GOVERNING PRESCRIBING OF CON TROLLED SUBSTANCES AND THE USE OF A THOROUGH AND CONSISTENT CLINICAL METHODOLOGY INCLUDING DOCUMENTATION WHEN WORKING UP ANY PATIENT ,EGITIMATE PATIENTS WITH PAIN SHOULD NOT SUFFER BECAUSE PRACTITIONERS ARE FEARFUL OF LAW ENFORCE MENT

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7E MUST RECOGNIZE THE TENETS OF LAWFUL PRESCRIBING ,AWFUL PRESCRIPTION FOR A CON TROLLED SUBSTANCE MUST BE ISSUED FOR A LEGITIMATE MEDICAL PURPOSE

BY AN INDIVIDUAL PRACTITIONER ACTING IN THE USUAL COURSE OF THE PROFESSIONAL PRACTICE AND DOCUMENTED IN THE MEDICAL RECORD !N EXAMPLE WOULD BE A DENTIST PRESCRIBING AN OPIATE TO AN ADULT PATIENT FRIEND FOR LOW BACK PAIN -EDICAL EXPERTS WOULD TESTIFY THAT EVEN THOUGH THIS WAS A LEGITIMATE MEDICAL PURPOSE

IT WAS OUTSIDE THE USUAL COURSE OF PROFESSIONAL PRACTICE 4HE $RUG !BUSE 7ARNING .ETWORK SUGGESTS THAT PRESCRIPTION DRUGS ACCOUNT FOR ABOUT TO PERCENT OF ALL DRUG ABUSE 4HIS HAS BEEN A STABLE lGURE OVER SEVERAL YEARS %X AMPLES OF MISUSE INCLUDE SEX FOR DRUGS MONEY FOR DRUGS AND DRUGS FOR DRUGS 3EX FOR DRUGS IS SELF EXPLANATORY SINCE THERE IS NO OBVIOUS JUSTIlCATION -ONEY FOR DRUGS INCLUDES FEES FOR THE PRESCRIPTIONS BASED ON STREET VALUE OF THE DRUGS SOUGHT 3ELLING BLANK PRE SIGNED PRE SCRIPTIONS IS ALSO INCLUDED UNDER THIS CATEGORY $RUGS FOR DRUGS WOULD INCLUDE SPLITTING lLLED PRESCRIPTIONS WITH THE DIVERTER OR EXCHANGING PRESCRIPTION DRUGS FOR STREET DRUGS !BUSE POTENTIAL IS NOT DIRECTLY TIED INTO THE SCHEDULE OF THE NARCOTIC 3CHEDULE )) ABUSE IS NOT AS WIDESPREAD AS SCHEDULE ))) OR SCHED ULE )6 ABUSE BECAUSE SCHEDULE ))S ARE GENERALLY MONITORED MORE CLOSELY CAN T BE RElLLED AND CAN T ROUTINELY BE PRESCRIBED BY TELEPHONE 0ROTECTING YOURSELF FROM DIVERSION INCLUDES BEING A CAREFUL THOUGHTFUL PRACTITIONER IN WHICH DOCUMENTING VERY CAREFULLY THE HISTORY AND PHYSICAL EXAMINATION SPECIlCALLY APPRO PRIATE TO THE COMPLAINT /NE SHOULD LOOK FOR SIGNS OF DRUG ABUSE SUCH AS INmAMED NARES

PERFORATED SEPTUM NEEDLE TRACTS hSKIN POP PINGv SCARS IRREGULAR OR ROUND LIKE SMALLPOX VACCINATION SCARS 9OU SHOULD CONSIDER REFERRAL

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FOR CASES OUTSIDE OF YOUR EXPERTISE )T IS USEFUL TO REQUIRE PHOTO )$S FROM THE NEW PATIENTS AND EVEN A COPY OF THE PHOTO OR HAVE A PHOTO TAKEN BY DIGITAL CAMERA OR 0OLAROID TO HAVE INSIDE THE CHART 4HE PRACTITIONER SHOULD AVOID BEING A hHERMIT v AND BE PART OF YOUR HEALTH CARE COMMUNITY PARTICIPATING IN ASSOCIATIONS THAT DEAL WITH PAIN MANAGEMENT 0RACTITIONERS SHOULD ALSO ASK IF THE PATIENT IS RECEIVING ANY OTHER PRESCRIPTION DRUGS FROM ANY OTHER PRAC TITIONERS 7HEN lLLING OUT A PRESCRIPTION DESIGNATE THE NUMBER OF RElLLS EVEN IF IT IS NONE !LSO CONSIDER TAMPER COPY RESISTANT PADS 7RITE OUT BOTH ALPHA AND NUMERIC QUANTITY DOSAGE AND STRENGTH $RUG SEEKING BEHAVIOR WOULD INCLUDE s 7ANTS APPOINTMENT TOWARD END OF OFlCE HOURS OR TELEPHONES OR ARRIVES AFTER REGULAR BUSINESS HOURS s )NSISTS ON BEING SEEN IMMEDIATELY OR DE MANDS IMMEDIATE ACTION SAYS THEY ARE IN A HURRY TO CATCH A PLANE OR LATE FOR A BUSINESS MEETING s .OT INTERESTED IN HAVING PHYSICAL EXAMINA TION OR UNDERGOING DIAGNOSTIC TESTS s 5NWILLING TO GIVE PERMISSION TO OBTAIN PAST OR CURRENT MEDICAL RECORDS s 5NABLE TO RECALL HOSPITAL OR CLINIC WHERE PAST RECORDS ARE KEPT OR STATES THAT THE PREVI OUS HOSPITAL OR CLINIC IS NOW OUT OF BUSINESS OR HAS hBURNED DOWN v s 5NWILLING OR UNABLE TO GIVE NAMES OF PAST HEALTH CARE PROFESSIONALS s #LAIMS TO BE OUT OF TOWN OR HAD LOST PRE SCRIPTION FORGOTTEN TO PACK MEDICATION OR STATES THAT IT WAS STOLEN

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ADD BLOOD TO URINE SPECIMEN 2ECITES TEXTBOOK SYMPTOMS OR GIVES VERY VAGUE MEDICAL HISTORY (AS NO INTEREST IN REFERRAL WANTS A PRESCRIP TION NOW 3HOWS UNUSUAL KNOWLEDGE OF CONTROLLED SUBSTANCES 2EQUESTS A SPECIlC DRUG UNWILLING TO TRY ANY OTHER TREATMENT WITH NO MEDICAL JUS TIlCATION #LAIMS ALLERGIES TO NON OPIATE ANALGESICS WITH NO MEDICAL JUSTIlCATION

4HERE ARE VARIOUS DRUG SCAMS THAT PRACTITIONERS SHOULD BE AWARE OF AS WELL s 0RACTITIONER PRESCRIBES FOR DECEASED PATIENT AND THEN PICKS UP MEDICATION FOR PERSONAL ABUSE s !BUSER POSING AS A PHARMACIST OR REGULATOR

CALLS RECEPTIONIST TO OBTAIN $%! NUMBERS OF ALL THE PRESCRIBERS IN THE PRACTICE

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NOT WE CAN SAFELY TREAT A PREVIOUSLY CHEMICALLY DEPENDENT PAIN PATIENT 4HIS CAN BE DONE IF THE RULES ARE SET UP PRIOR TO THE TREATMENT PROGRAM 4HE CLINICIAN SHOULD INSIST ON FREQUENT VISITS

LIMITING SUPPLY OF MEDICATION AND MANAGING PRIMARILY WITH LONG ACTING OPIOIDS PREFERABLY WITH LOW STREET VALUE &REQUENT URINE TOXICOLOGY SHOULD BE EMPLOYED IN THE CASE OF A HIGH RISK PATIENT 4HE PATIENT WITH A CHEMICAL DEPEN DENCY HISTORY SHOULD BE IN A RECOVERY PROGRAM OR A PSYCHOTHERAPY PROGRAM SO THAT THE ISSUES CAN BE ADDRESSED FROM OTHER VIEWPOINTS 0AS SIK 3 $

,i i` iÃÊv ÀÊÌ iÊ LÕÃ ÛiÊ*>Ì i Ì )F THE PATIENT HAS COMMITTED FORGERY OR DIVER SION OF A SCHEDULED MEDICATION YOU MUST REPORT THIS TO THE APPROPRIATE AUTHORITIES 4HE CONTRACT IS THE GUIDE TO APPROPRIATE USE OF THE MEDICATION 4HE PRACTITIONER MUST USE JUDGMENT AS TO HOW TO HANDLE INFRACTIONS OF THE CONTRACT 3EVERITY OF THE BREECH OF CONTRACT CAN BE TAKEN INTO CONSIDERATION )F THE PATIENT HAS BEEN TREATED FOR A LONG TIME AND A TRUST LEVEL HAS BEEN ESTABLISHED MINOR INFRACTIONS SHOULD BE AGGRESSIVELY ADDRESSED BUT MAY NOT WARRANT DISMISSAL &AILURE OF A URINE DRUG TEST COULD BE GROUNDS FOR DISCHARGE HOWEVER A BLOOD SCREEN FOR VERIlCATION SHOULD BE DONE IF THE PATIENT PROTESTS THE URINE TEST RESULTS )F THE DRUG SCREEN REVEALS STREET DRUG USAGE THE PATIENT SHOULD BE REFERRED TO A CHEMICAL DEPENDENCY TREATMENT CENTER $ISCHARGE FROM YOUR CARE SHOULD BE DONE ACCORDING TO YOUR CONTRACT 2EPORTS FROM FAMILY FRIENDS A PHARMACY OR OTHER AGENCY INDICATING POSSIBLE ABUSE

WOULD NECESSITATE A DRUG SCREEN AND REFERRAL FOR A CHEMICAL DEPENDENCY EVALUATION )F THE TREATING DOCTOR IS SUSPICIOUS OF AN ABUSIVE BEHAVIOR AN EVALUATION BY A CHEMICAL DEPENDENCY COUNSELOR SHOULD BE ORDERED )F THE #$ REPORT DOES NOT INDICATE ADDICTION

FURTHER TREATMENT CAN BE CONSIDERED WITH STRINGENT GUIDELINES 7HEN A PATIENT HAS VIOLATED YOUR CONTRACT

AND DISMISSAL IS WARRANTED YOU MUST THEN ES TABLISH A DECREASING TITRATION SCHEDULE 4HIS CAN BE DONE BY DECREASING THE DOSAGE OF THE OPIOID BY n PERCENT PER WEEK 0RESCRIP TIONS SHOULD BE GIVEN FOR ONE WEEK AT A TIME DURING THIS TAPERING PERIOD 2ECOMMENDATION

TO A TREATMENT FACILITY FOR CHEMICAL DEPENDENCY SHOULD BE DONE AT DISCHARGE -Õ >ÀÞ 4HE PRIMARY PURPOSE OF ADMINISTERING OPIOID THERAPY TO PATIENTS WITH INTRACTABLE PAIN WOULD BE TO INCREASE THEIR FUNCTION IN LIFE INCREAS ING QUALITY OF LIFE ! TRIAL OF OPIOID THERAPY IS APPROPRIATE FOR CHRONIC NON CANCER PAIN PATIENTS ESPECIALLY IN CONJUNCTION WITH OTHER THERAPIES SUCH AS PHYSICAL THERAPY PSYCHO THERAPY MUSCLE RELAXANTS AS WELL AS OTHER MEDICATIONS THAT HAVE BEEN SHOWN TO HAVE AN EFFECT ON NEUROPATHIC PAIN 4HE EMPHASIS SHOULD BE PLACED ON INCREASING FUNCTION WITH DOCUMENTATION OF THE PATIENT S ABILITY TO PERFORM VARIOUS ACTIVITIES OF DAILY LIVING )T IS ALWAYS HELPFUL TO HAVE INPUT FROM FAMILY MEMBERS WHO CAN VERIFY THE BEHAVIORS AND FUNCTION OF THE PATIENT IN FAMILY AND SOCIAL SETTINGS !GAIN THE EMPHASIS IS ON THE SOUND USE OF CLINICAL METHODOLOGY AND DOCUMENTA TION DOCUMENTATION DOCUMENTATION 0RACTITIONERS MUST REALIZE THAT SCAMMERS

I E DRUG ABUSERS DIVERTERS ARE A TALENTED AND PERSISTENT SUBSET OF ALL PAIN PATIENT POPULA TIONS 4HE CONSISTENT AND RIGOROUS USE OF SOUND CLINICAL METHODOLOGY AND THOROUGH DOCUMEN TATION ARE THE BEST TOOLS AVAILABLE FOR IDENTIFYING THEM 4HE DIAGNOSIS OF hDRUG ABUSER DIVERTERv WILL EMERGE FROM THE CLINICAL PROCESS THROUGH TIME JUST LIKE ANY PHYSICAL DISEASE OR CONDITION CAPABLE OF PRODUCING PAIN 4HE OBJECTIVE OF THE PRACTITIONER SHOULD BE TO AVOID BEING THE TARGET OF SCAMMERS NOT TO ENSURE THAT THEY ARE NEVER SCAMMED AND TO KNOW WHAT TO DO WITH THESE PATIENTS WHEN THEY ARE ENCOUNTERED

!LFRED 6 !NDERSON - $ $ # IS A PAIN MAN AGEMENT AND MANIPULATIVE MEDICINE SPECIALIST AND IS ALSO A LICENSED CHIROPRACTOR (E OPERATES THE 0AIN !SSESSMENT 2EHABILITATION #ENTER ,TD IN %DINA (E IS A $IPLOMAT IN 0AIN -ANAGEMENT

THE !MERICAN !CADEMY OF 0AIN -ANAGEMENT $R !NDERSON SERVES ON THE "OARD OF $IRECTORS OF THE -INNESOTA 0HYSICIAN 0ATIENT !LLIANCE AND ON THE "OARD OF -EDICAL 0RACTICE FROM THE SECOND CONGRESSIONAL DISTRICT 2ICHARD , !ULD 0H $ HAS SERVED AS THE ASSISTANT EXECUTIVE DIRECTOR AT THE "OARD OF -EDICAL 0RACTICE SINCE (E IS PRIMARILY RESPONSIBLE FOR CONSTIT UENT OUTREACH POLICY AND PLANNING EDUCATIONAL DEVELOPMENT AND LEGISLATIVE MATTERS

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HAVE AN INTERESTING PERSPECTIVE ON HEALTH CARE IN THE TWO COUNTRIES ) LOVE #ANADA )T HAS BEAUTIFUL GEOGRAPHY AND WIDE OPEN SPACES )TS PEOPLE ARE GENERALLY FRIENDLY AND KIND "UT WHEN ) REALIZED THAT THE GOVERNMENT WAS INTERFERING IN THE TYPE QUALITY AND AMOUNT OF MEDI CAL CARE THAT ) COULD DELIVER AS A RADIOLOGIST IT BECAME TOO MUCH TO BEAR AND ) MOVED TO THE 5NITED 3TATES THREE YEARS AGO $ESPITE HAVING SOME PROBLEMS WITH RISING COSTS AND AN INCREAS ING NUMBER OF UNINSURED 5 3 HEALTH CARE REMAINS THE BEST IN THE WORLD AND IS VASTLY SUPERIOR TO THAT WHICH IS DELIVERED WITH GOVERN MENT PROVIDED UNIVERSAL HEALTH INSURANCE IN #ANADA 4HIS IS DEM ONSTRATED WITH A CHILLING PERSONAL EXAMPLE WHEN MY BROTHER AND ) DEVELOPED SIMILAR CLINICAL SYMPTOMS )N $ECEMBER ) DEVELOPED AN UNUSUAL STUFFY SENSATION IN MY LEFT EAR 4RAINED AS A NEURORADIOLOGIST ) WAS AWARE THAT SUCH A SYMPTOM COULD INDICATE THE PRESENCE OF A MASS IN MY NASOPHARYNX $ENYING THE SYMPTOMS THEY PERSISTED FOR A FEW MONTHS AND ) lNALLY CONCEDED THAT ) NEEDED MEDICAL ATTENTION /NCE ) HAD MADE THE DECI SION TO DO SO ) MADE AN APPOINTMENT TO SEE AN %AR .OSE AND 4HROAT SPECIALIST 4HE APPOINTMENT WAS BOOKED AND ) IMMEDIATELY HAD AN APPOINTMENT (E PERFORMED A THOROUGH EXAM INCLUDING DIRECT VISUAL INSPECTION OF MY NASOPHARYNX .O MASS WAS VISUALIZED !LSO AN -2) WAS PERFORMED 4HE TEST WAS COMPLETELY NORMAL ) WAS RELIEVED 4HE STUFFY SENSATION WAS MERELY A NUISANCE BUT IT WOULD NOT KILL ME -Y BROTHER IN #ANADA HAS NOT BEEN SO FORTUNATE 5NBEKNOWNST TO ME IN -ARCH HE DEVELOPED A STUFFY SENSATION IN ONE EAR )T BECAME WORSE AFTER AN AIRLINE mIGHT .OT MEDICALLY TRAINED HE WAS NOT AWARE OF THE POTENTIAL SIGNIlCANCE OF SUCH A SYMPTOM !PPARENTLY

NEITHER WAS HIS DOCTOR $ESPITE REPEATED VISITS TO HIS DOCTOR NOTHING WAS DONE UNTIL .OVEMBER AT WHICH TIME HE lNALLY WAS AS SESSED BY AN %AR .OSE AND 4HROAT SPECIALIST ! SMALL TUBE WAS PLACED THROUGH THE EARDRUM TO RELIEVE THE STUFFY SENSATION BUT NO PHYSICAL EXAM WAS PERFORMED AND THE CAUSE WAS NOT ADDRESSED %ARLY IN $ECEMBER MY MOTHER MENTIONED MY BROTHER S NEED FOR AN EAR TUBE FOR A PERSISTENT STUFFY SENSATION 7ITH NO OTHER INFORMATION CANCER OF THE NASOPHARNYX IMMEDIATELY LEAPT TO MY MIND -Y BROTHER BEGAN TO LOSE WEIGHT AND HIS NECK LYMPH NODES BECAME MASSIVELY SWOLLEN .OW COMPLAINING OF SEVERE HEAD AND NECK

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PAIN THIS FORMER WORKHORSE LAWYER COULD BARELY GET OFF THE COUCH 4HIS MAN WHO RARELY COMPLAINED OF ANYTHING WAS LABELED WITH DIFFER ING DIAGNOSES SUCH AS SINUSITIS STRESS AND CHRONIC FATIGUE SYNDROME -Y BROTHER S WIFE PHONED ME IN DESPAIR WITH DETAILS OF HIS DE TERIORATION ) STATED THAT MALIGNANCY HAD TO BE RULED OUT 4HE FAMILY DOCTOR WAS CONSULTED AGAIN !LTHOUGH THE LOCAL VETERINARY COLLEGE HAS AN -2) FOR ANIMALS WITH THE GOVERNMENT CONTROLLING HUMAN HEALTH CARE RESOURCES THERE IS NO -2) FOR PEOPLE IN HIS CITY OF !N hURGENTv -2) WAS ARRANGED FOR SEVERAL WEEKS LATER IN THE NEAREST COMMUNITY WITH THIS EQUIPMENT 4IME PASSED WITHOUT DIAGNOSIS 4HE PAIN BECAME UNBEARABLE (E WAS SO SICK HIS WIFE FEARED HE WAS DYING $ESPITE HAVING THREE SMALL CHILDREN ON #HRISTMAS MORNING HE WAS TAKEN TO THE HOSPITAL IN 7ATERLOO #ANADA WHICH IS THE NEAREST CITY WITH AN -2) 4HIS ONE PUBLIC -2) SERVES ABOUT PEOPLE 4HE -INNEAPOLIS 3T 0AUL SUBURB OF %DINA HAS EIGHT WITH A POPULATION OF 4HE 7ATER LOO -2) OPERATES A M TO P M DURING THE WEEK )T IS NORMALLY UNAVAILABLE ON WEEKENDS AND HOLIDAYS 4HERE IS NO ONE ON CALL FOR EMERGENCIES AFTER HOURS !FTER APPLYING A GREAT DEAL OF PRESSURE

BEGRUDGINGLY AN -2) WAS PERFORMED THE DAY AFTER #HRISTMAS )T WAS INCORRECTLY INTERPRETED AS hSINUSITIS v 4HIS DIAGNOSIS DIDN T MAKE SENSE 7ITH WEIGHT LOSS ENLARGED LYMPH NODES AND NOW AN INABILITY TO WORK HIS TONGUE AND A DROOP ING EYELID ) FEARED THE WORST DESPITE THE BENIGN DIAGNOSIS ) mEW TO SEE HIM ) REVIEWED THE -2) AN AREA IN WHICH ) HAVE HAD EXTENSIVE TRAINING (E HAD A TUMOR THE SIZE OF A BASEBALL BETWEEN HIS NOSE AND HIS SKULL BASE 4HE MASS WAS ERODING HIS SKULL AND COATING MULTIPLE CRANIAL NERVES ) BECAME THE PROPHET OF DOOM AND HAD TO TELL MY OWN BROTHER THAT HE HAS ADVANCED NASOPHARYNGEAL CANCER (E HAS A STAGE )6 CANCER THE WORST OF FOUR POSSIBLE STAGES (IS CHANCE OF LONG TERM SURVIVAL HAS BEEN REDUCED CONSIDERABLY 4HE TREATMENT HE NOW REQUIRES IS SO AGGRESSIVE THAT SERIOUS MORBIDITY IS GUARANTEED 4HE EXTENT OF RADIOTHERAPY REQUIRED WILL ABOLISH HIS SENSE OF TASTE AND ANNIHILATE SALIVATORY FUNCTION )T MAY CAUSE SOME HEARING LOSS AND CARRIES A PERCENT CHANCE OF BLINDNESS (E MUST ALSO UNDERGO CHEMOTHERAPY SIMULTANEOUSLY WITH RISK OF SERIOUS IMMUNOSUPPRESSION )F HIS ILLNESS HAD BEEN RECOGNIZED EARLIER A SMALLER RADIOTHERAPY lELD COULD HAVE BEEN EMPLOYED AND CHEMOTHERAPY MAY HAVE NOT BEEN NECESSARY 4HE FACT THAT MY BROTHER HAS UNIVERSAL HEALTH CARE COVERAGE HAS NOT HELPED HIM MUCH ) HAVE SEEN THE UNINSURED IN !MERICA RECEIVE BETTER CARE THAN THE INSURED IN #ANADA !LTHOUGH THERE IS A MARGINAL -ETRO$OCTORSÊÊ/ iÊ ÕÀ > Ê vÊÌ iÊ i i« Ê> `Ê,> ÃiÞÊ i` V> Ê- V iÌ iÃ

BEEN WORKING AT IT FOR DECADES IN #ANADA AND THEY JUST CAN T MAKE IT COST SAVINGS TO THE #ANADIAN SYSTEM #ANADIANS RECEIVE LITTLE FOR THEIR WORK #ANADIANS DON T GET IT CENTRALIZED GOVERNMENT PLANNING OF THE MONEY !LTHOUGH hFREE v IT IS PAID FOR BY THE PEOPLE IN THE FORM OF TAX ECONOMY SIMPLY DOES NOT WORK 4HE IMPOVERISHMENT PRODUCED IN THE DOLLARS 7ITH SUCH A SYSTEM INDIVIDUALS COMPLETELY LOSE CONTROL OF 5 3 3 2 #UBA #HINA AND .ORTH +OREA SHOULD HAVE PROVEN THIS ONCE HOW THEIR OWN MONEY IS SPENT AND FOR ALL /N AVERAGE THE 5 3 SPENDS ABOUT PER CAPITA ON HEALTH CARE PER YEAR #ANADA SPENDS ABOUT #ND PER CAPITA 3O WHERE 4HERE IS AN ASSUMPTION IN #ANADA THAT ALTHOUGH RESOURCES ARE LIMITED THOSE MOST IN NEED WILL GET THE ATTENTION THEY NEED (AV IS THE BIG SAVINGS )N FACT SOME #ANADIAN PROVINCES AND TERRITORIES ING WORKED IN #ANADA FOR YEARS ) SAW LITTLE EVIDENCE OF THIS /FTEN SPENT VASTLY MORE 4HE TERRITORY OF .UNAVUT SPENDS PER CAPITA PEOPLE DID NOT GET INTO THE HEALTH CARE SYSTEM UNTIL CATASTROPHICALLY 3UCH lGURES ALSO NEGLECT TO MENTION THAT THERE IS VERY LITTLE HEALTH ILL PERHAPS WITH NO CHANCE OF REDEMPTION !S A RADIOLOGIST READING CARE RESEARCH AND DEVELOPMENT IN #ANADA 7ITH PRESCRIPTION DRUG #!4 SCANS AND -2) SCANS ) WAS SICKENED BY THE WAIT PEOPLE HAD TO COSTS IN #ANADA TIGHTLY REGULATED BY GOVERNMENT AND PROlT MOTIVE ENDURE UP TO MONTHS FOR AN -2) SCAN AND SEVEN MONTHS FOR A SQUELCHED 2 AND $ FOR DRUGS IN #ANADA IS ALMOST ZERO &URTHERMORE

#!4 SCAN 4HE FAULTY ARGUMENT IS THAT THE MOST URGENT CASES SHOULD MY BROTHER S PRODUCTIVITY MAY BE TERMINATED WITH AN ATTENDANT LOSS TO BE SCANNED lRST BUT THEY FORGET THAT IF ) KNEW THE RESULTS OF A PATIENT S THE ECONOMY OF TENS OF THOUSANDS OF DOLLARS ANNUALLY 4HE ADVOCATES TEST THEY WOULD NOT NEED THE TEST .OW WORKING IN !MERICA ) SLEEP OF UNIVERSAL HEALTH INSURANCE NEVER ACCOUNT FOR THESE COST FACTORS BETTER AT NIGHT WORKING IN A SYSTEM WHERE TESTS ARE LIBERALLY ORDERED )N #ANADA WITHOUT COMPETITION AND WITH THE GOVERNMENT AND PERFORMED MAINTAINING AN IRON GRIP ON THE AVAILABILITY OF RESOURCES SERVICE 4HE #ANADIAN HEALTH CARE SYSTEM IS A DISGRACE AND YET THERE ARE IS PAINSTAKINGLY SLOW AND OF POOR QUALITY 7ITH DOCTOR SHORTAGES THOSE IN !MERICA THAT WANT THE SAME SYSTEM !S THE SAYING GOES BE ENGINEERED BY THE GOVERNMENT TO SAVE COSTS THE lELD IS VULNERABLE TO CAREFUL WHAT YOU WISH FOR 9OU JUST MIGHT GET IT INCOMPETENCE 7ITH DIRE PHYSICIAN MANPOWER SHORTAGES ANYONE WITH A PULSE WILL BE GAINFULLY EMPLOYED ,EE +URISKO - $ &2#0# IS WITH #ONSULTING 2ADIOLOGISTS ,TD 7ITHOUT THE ACCOUNTABILITY OF THE FREE MARKET COSTS ARE INmATED AND DOLLARS ARE NOT SPENT EFlCIENTLY "UT OF COURSE THIS IS THE SAME IN THE 5NITED 3TATES WHERE PERCENT OF THE POPULACE IS INSURED SUCH THAT SOMEONE ELSE OTHER THAN THE PATIENT IS FOOTING THE MAJORITY OF THE BILL 7ITHOUT DIRECT INDIVIDUAL CONSUMER PRES SURE TO KEEP COSTS DOWN COSTS IN THE 5 3 ARE MASSIVELY INmATED ABOVE THEIR OBJECTIVE MARKET VALUE )T WAS AN ACT OF #ONGRESS NOT THE FREE MARKET THAT MANDATED THAT BILLINGS BE DIRECTED i3FNBSLBCMF QBUJFOU TBUJTGBDUJPO GSPN RVBMJUZ PRIMARILY TO THE INSURANCE CARRIER RATHER THAN TFSWJDF DPOWFOJFODF BOE FYDFMMFOU SFTVMUTw THE PATIENT 4HIS DISTORTION OF THE FREE MARKET AND THE FACT THAT CONSERVATIVELY PERCENT i&YDFQUJPOBM DBSF GPS OF !MERICAN HEALTH CARE COSTS ARE ALREADY BMM TLJO QSPCMFNTw PAID BY THE GOVERNMENT PROVES THAT THE 5 3 SYSTEM SUFFERS FROM THE SAME DISEASE AS THAT OF $IBSMFT & #ANADA TOO MUCH GOVERNMENT INTERFERENCE $SVUDImFME *** . % )T IS PREPOSTEROUS TO BELIEVE THAT GOVERNMENT #PBSE $FSUJmFE %FSNBUPMPHJTU COVERING PERCENT OF HEALTH CARE COSTS WOULD MAGICALLY SOLVE THE WOES OF 5 3 HEALTH 1TPSJBTJT CARE

)T IS FREE MARKET CAPITALISM THAT FEEDS US

"DOF 4QFDJBMJTU CLOTHES US AND PROVIDES US WITH ENTERTAINMENT )T PRODUCES THE HIGHEST STANDARD OF LIVING THAT 5PXO $FOUSF %SJWF 4VJUF THE WORLD HAS EVER SEEN 0ERHAPS WE SHOULD TRY :PVS 1BUJFOUT XJMM &BHBO ./ SOMETHING NEW AND GIVE IT A TRY IN HEALTH CARE -PPL (PPE 'FFM (SFBU !DVOCATES OF GOVERNMENT HEALTH CARE IN "QQPJOUNFOUT XJUI #FBVUJGVM 4LJO BOTH COUNTRIES CLAIM THAT RESOURCES CAN BE hRA

TIONALIZEDv AND REDUNDANT SERVICES ELIMINATED XXX $SVUDImFME%FSNBUPMPHZ DPN !VAILABILITY OF RESOURCES DOESN T SEEM VERY 1SPNQU "QQPJOUNFOUT WJB 1IZTJDJBO 3FRVFTUT RATIONAL IN #ANADA DESPITE ASSIDUOUS ATTEMPTS

BY BUREAUCRATS TO MAKE IT SO 4HEY HAVE

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7(%. 4(% &,5 3(/4 #2)3)3 OCCURRED IN /CTOBER OF THE 6ISITING .URSE !SSOCIA TION OF !MERICA 6.!! HAD ALREADY ESTABLISHED CLOSE RELATIONSHIPS WITH THE #ENTER FOR $ISEASE #ONTROL AND !VENTIS 0ASTEUR 4HE RELATIONSHIP WAS FORGED ON A HIGH DEGREE OF CREDIBILITY AS HIGH RISK PROVIDERS AND hCOMMUNITY IMMU NIZERS v 6ISITING .URSE !SSOCIATIONS 6.!S ACROSS THE COUNTRY PROVIDE HOME CARE SERVICES AND IMMUNIZATIONS TO THE HOMEBOUND ELDERLY AS WELL AS VACCINES TO THE COMMUNITY AT LARGE -ANY OF THE OTHER LARGE IMMUNIZATION PROVID ERS DO NOT PROVIDE SERVICES TO THE HOMEBOUND ELDERLY WHICH HELPED TO MAKE THE 6.!S A VIABLE VENUE FOR VACCINE DISTRIBUTION DURING THE mU CRISIS

h)MMEDIATELY WHEN WE HEARD THE #HIRON VACCINE WASN T COMING WE KNEW WE HAD A PROBLEM 7E WORKED DAY AND NIGHT TO GET OUT A SURVEY TO ALL OF OUR 6.!S ACROSS THE COUNTRY TO DETERMINE WHAT THE NEED WAS FOR EACH STATE S HIGH RISK POPULATIONS AND TO PROVIDE THE #$# AND !VENTIS 0ASTEUR WITH THE DATA THAT WOULD BE CRITICAL TO DETERMINING THE LEVELS OF VACCINE NEEDED FOR EACH STATE S HIGH RISKv SAID *EAN %LLIS

VICE PRESIDENT OF MEMBER SERVICES AND BUSINESS DEVELOPMENT AT 6.!! #$# AND !VENTIS 0AS TEUR MADE AVAILABLE MILLION DOSES TO DISTRIB UTE TO THE LOCAL 6.! S THROUGHOUT THE COUNTRY FOR THEIR STATES HIGH RISK VACCINATION NEEDS

4HE -INNESOTA 6ISITING .URSE !GENCY -6.! WORKED CLOSELY WITH THE -INNE SOTA $EPARTMENT OF (EALTH TO DETERMINE THE HIGH RISK NEED IN -INNESOTA AND SUBMITTED THEIR DATA ALONG WITH A REQUEST FOR VACCINE TO THE 6.!! )T WAS DETERMINED THAT -6.!

SHOULD BE ONE OF THE RECIPIENT S OF VACCINE FOR ITS -INNESOTA HIGH RISK RESIDENTS -6.!

RECEIVED DOSES FROM THE 6.!! AND AN ADDITIONAL DOSES FROM 3UPER6ALU 0HAR MACIES AT THEIR COST TO HELP AVERT THE VACCINE SHORTAGE CRISIS )F -6.! HAD NOT PARTICIPATED OR REQUESTED VACCINE THIS ALLOTMENT WOULD HAVE BEEN DISTRIBUTED ELSEWHERE TO OTHER STATES

"Y THE END OF THE mU SEASON -6.!

COMPLETED CLINICS AND WORKED CLOSELY WITH THE -INNESOTA $EPARTMENT OF (EALTH AND 0UBLIC (EALTH !GENCIES IN COUNTIES TO MASS IMMUNIZE THE HIGH RISK POPULATIONS -6.! SOLD AT COST VACCINE TO ENTITIES IN -INNESOTA INCLUDING VIALS OF VACCINE TO PHYSICIAN OFlCES

VIALS TO -. HOSPITALS

VIALS TO PUBLIC HEALTH AGENCIES AND VIALS TO ASSISTED LIVING FACILITIES AND OTHERS IN NEED -6.! ALSO SOLD VIALS OF VACCINE AT COST TO NINE ENTITIES OUT OF STATE INCLUDING PHYSICIAN OFlCES PUBLIC HEALTH AGENCIES AND CORRECTIONAL FACILITIES 4HE COMBINED PARTNERING THAT THE

NON PROlT -6.! DID WITH THE STATE PUBLIC HEALTH AGENCIES PRIVATE AND OTHER COMMUNITY SERVICE PROVIDERS IN RESULTED IN -INNESOTA BEING RANKED AS HAVING ONE OF THE HIGHEST RATES OF VACCINATED HIGH RISK PERSONS AGES AND OLDER IN THE ENTIRE COUNTRY h-6.! WAS GLAD TO BE ABLE TO WORK SIDE BY SIDE WITH EACH OF OUR PEERS TO PROVIDE FOR THE GREATER GOOD OF EACH OF OUR COMMUNITY S RESIDENTS THROUGHOUT THE STATE 7E COULDN T HAVE DONE IT WITHOUT THE TEAMWORK AND COOPERATION THAT EVERYONE PROVIDED )T WAS A JOINT PROJECT WELL DONE v SAID -ARY !NN "LADE

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LEGISLATIVE HISTORY IS HELPFUL !LTHOUGH RELATIVELY NEW TO MANY PHYSICIANS AND PATIENTS mEXIBLE SPENDING ACCOUNTS &3!S WERE LEGISLATED INTO EXISTENCE IN (EALTH 3AVINGS !CCOUNTS (3!S WERE LEGISLATED lRST IN AS A DEM ONSTRATION PROJECT 3UBSEQUENTLY THE 4REASURY $EPARTMENT IN AUTHORIZED EMPLOYERS TO ESTABLISH AND CONTRIBUTE TO THEIR EMPLOYEES (EALTH 2EIMBURSEMENT !CCOUNTS (2!S 4HE -EDICARE -ODERNIZATION !CT OF GRANTED TAX PROVISIONS FOR THOSE EMPLOYEES WHO HAVE AN (3! AND A (IGH $EDUCTIBLE (EALTH 0LAN ($(0 4HE INSURANCE INDUSTRIES INTRODUCTION OF THESE PRODUCTS IS AN ATTEMPT TO INVOLVE THE PATIENT IN THEIR HEALTH CARE DECISIONS )T IS CALLED CONSUMER DRIVEN HEALTH CARE AND RELIES ON TRANSFERRING VARIOUS ASPECTS OF THE lNANCIAL RESPONSIBILITY TO THE PATIENT )NSURERS LEGISLA TORS EMPLOYERS AND MANY OTHERS ANTICIPATE THAT THIS APPROACH WILL REDUCE HEALTH CARE COSTS SPENDING AND UTILIZATION !LTHOUGH THERE IS A PLETHORA OF ARTICLES WRITTEN AND BEING WRITTEN ABOUT THESE HEALTH INSURANCE COVERAGE PRODUCTS MANY OF MY COLLEAGUES PHYSICIANS AND OTHER HEALTH PRO FESSIONALS AND ) STILL HAVE MANY QUESTIONS AND LEGITIMATE CONCERNS 4HE MORE ) READ AND TRY TO UNDERSTAND ABOUT THESE PRODUCTS THE MORE ) REALIZE THE THEORETICAL ASPECTS OF THEIR GOALS MIGHT NOT BE ACHIEVABLE 4HE WELL COM PENSATED HEALTHY WORKER WHO OBTAINS THEIR INSURANCE THROUGH A GROUP PLAN NOW WILL HAVE ANOTHER MECHANISM TO SAVE FOR RETIREMENT (OWEVER THESE PRODUCTS ARE NOT APPLICABLE TO THE UNEMPLOYED WITHOUT HEALTH INSURANCE )N ADDITION IT IS ESTIMATED THAT RELATIVELY FEW BY PERCENTAGE PERSONS WHO ARE EMPLOYED WITHOUT HEALTH INSURANCE WILL BUY INTO THESE PRODUCTS

BECAUSE THE BENElTS OF THE ($(0S ARE LESS ATTRACTIVE THAN THE USUAL INSURANCE PRODUCT

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!NOTHER CONCERN IS HOW THESE NEW PRODUCTS WILL AFFECT THE PATIENT PHYSICIAN RELATIONSHIP .OW THE PATIENT WILL BECOME EVEN MORE RESPONSIBLE FOR PAYING THE COSTS OF THEIR HEALTH CARE )NSTEAD OF CO PAYMENTS THE PATIENT WILL BE RESPONSIBLE FOR TOTAL PAYMENT OF THEIR MEDICAL EXPENSES UP TO THEIR DEDUCTIBLE )S THE SERVICE A COVERED SERVICE ALLOWABLE UNDER THE (3! (OW MUCH MONEY IS AVAILABLE IN THE (3! (OW MUCH MONEY DOES THE PATIENT STILL HAVE TO SPEND BEFORE THE ($(0 ACTIVATES 4HE INSURER WILL PROBABLY NOT BE RESPONSIBLE FOR THE MAJORITY OF THE COSTS OF ROUTINE OR OFlCE CARE AND WILL BE ELIMINATED AS THE MIDDLE ENTITY BE TWEEN THE PHYSICIAN AND THE PATIENT (OW WILL THE PATIENTS VIEW THESE NEW PAYMENT ARRANGE MENTS 7ILL ADVERSARIAL RELATIONSHIPS DEVELOP BETWEEN PATIENTS AND PHYSICIANS LIKE THOSE THAT EXIST BETWEEN INSURERS AND PHYSICIANS 7ILL THE PATIENT FORGO ROUTINE OR RECOM MENDED MEDICAL CARE AND EMERGENCY CARE BE CAUSE OF THE EXPENSES 4HIS WILL APPLY TO BOTH OUT PATIENT AND IN PATIENT CARE 4HE SCENARIO GOES AS FOLLOWS THE PATIENT IN THE OFlCE OR THE %$ WHO IS RECOMMENDED TO BE OBSERVED OR ADMITTED TO THE HOSPITAL TO RULE OUT ISCHEMIC CARDIAC DISEASE 7ILL THE PATIENT CHOSE TO IGNORE THE PHYSICIAN S ADVICE FOR THE SAKE OF LESSENING HEALTH COSTS 7ILL THE PATIENT DEFER THE RECOM MENDED TREATMENT AND CHOOSE A LESS COSTLY WAY OF MANAGING THEIR CARE 7ILL THE HEALTH CARE SYSTEM WE CURRENTLY HAVE ADAPT TO MEET THE MARKET DEMANDS 3HOULD ) EVEN MENTION THE LIABILITY CONCERNS INVOLVED IN THIS NEW TYPE OF CONSUMER PATIENT DRIVEN HEALTH CARE SYSTEM ) HAVE BEEN PRACTICING MEDICINE FOR YEARS AND HAVE SEEN MANY APPROACHES TO TRY TO DECREASE THE COSTS OF HEALTH CARE 3HOULD ) REMAIN SKEPTICAL OF THE GOALS OF THIS NEW INI #ONTINUED ON PAGE

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2-3 &OUNDATION (APPENINGS

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34 0!5, 3 !2,).'4/. ()'( 3#(//,

WAS GRANTED

BY THE 2AMSEY -EDICAL 3OCIETY &OUNDATION TO HOST THEIR lRST (EALTH AND %NVIRONMENT &AIR FOR 3T 0AUL THIRD GRADERS -AY

)T IS THE GOAL OF THE &OUNDATION THAT !RLINGTON S SUCCESS WILL BECOME A MODEL FOR OTHER 3T 0AUL HIGH SCHOOLS IN FUTURE YEARS 4HE GRANT MONEY WAS USED TO DEFRAY THE COSTS OF HIRING SUB STITUTE TEACHERS FOR HIGH SCHOOL CLASSES WHILE STAFF MEMBERS SUPERVISED THE (EALTH AND %NVIRONMENT &AIR ALSO IT WAS USED TO OFFSET COSTS FOR MATERIALS USED IN PRESENTATIONS

,ED BY LEAD TEACHER -ICHAEL 3HAW AND HIS (EALTH AND %NVIRONMENT &OCUS !REA STAFF APPROXI MATELY HIGH SCHOOL STUDENTS WERE THE DESIGNERS AND INSTRUCTORS FOR APPROXIMATELY INTERACTIVE

EDUCATIONAL BOOTHS )N TWO DAYS TWO MINUTE SESSIONS EACH DAY THIRD GRADERS WERE EXPERTLY EDUCATED AND ENTERTAINED PROVING THAT LEARNING CAN BE FUN 6ARIOUS OUTSIDE HEALTH AND EDUCATION ORGANIZATIONS ALSO PARTICIPATED INCLUDING THE 5 OF - %XTENSION 0ROGRAM 3T 0AUL 0UBLIC 3CHOOLS

2AMSEY #OUNTY 0UBLIC (EALTH $EPARTMENT THE !MERICAN 2ED #ROSS 3T 0AUL AND THE !MERICAN ,UNG !SSOCIATION

4HE STUDENTS BOOTHS COVERED A RANGE OF HUMAN AND ENVIRONMENTAL HEALTH ISSUES SUCH AS NUTRITION THE ILL EFFECTS OF SMOKING TOBACCO

ANATOMY AND PHYSIOLOGY EXERCISES TO IMPROVE BALANCE AND STRENGTHEN MUSCLES THE EYE THE CARDIO VASCULAR SYSTEM THE TONGUE AND ITS TASTE BUDS AND

HOW AND WHY OUR BODIES SWEAT POND ORGANISMS OBSERVED UNDER MICROSCOPES HYDROPOWER WHAT

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ENVIRONMENTAL FACTORS LEAD TO THE EXTINCTION OF CERTAIN WILDLIFE AND THE LIFE CYCLE OF TREES

/NE TABLE IN PARTICULAR ATTRACTED A FASCI NATED AND SOMETIMES SQUEAMISH AUDIENCE !

CAT DISSECTION STATION OFFERED INSTRUCTION IN HIGH DElNITION OF THE SIMILARITIES BETWEEN HUMAN AND FELINE ANATOMY 4HIRD GRADERS WERE INVITED TO TOUCH THE INTESTINES THE HEART AND LUNGS AND OTHER VITAL ORGANS AFTER PUTTING ON SURGICAL TYPE GLOVES OF COURSE 4HE OLDER STUDENTS COMMENTED THAT THEY WERE IMPRESSED WITH THE YOUNGER STUDENTS KNOWLEDGE OF ANATOMY AND PHYSIOLOGY

4HE 3T 0AUL 0UBLIC 3CHOOLS 3003 4HIRD 'RADE (EALTH &AIR WAS ORIGINALLY A PROJECT FOR CLOSE TO YEARS OF THE 2-3 !LLIANCE WHOSE MEMBERSHIP WAS COMPRISED OF PHYSICIANS SPOUSES 4HE BASIC MISSION WAS TO HELP IMPROVE THE HEALTH OF THE COMMUNITY HEALTH EDUCATION WAS A PRI ORITY ,AST YEAR THE 2-3 !LLIANCE AFTER YEARS DISBANDED BECAUSE OF DWINDLING MEM BERSHIP AND DONATED MORE THAN TO THE 2-3 &OUNDATION FORMER !LLIANCE MEMBERS SIT ON THE &OUNDATION "OARD AND HELP TO GUIDE ITS COMMUNITY SERVICE PROJECTS

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!T THE lNAL 2-3 !LLIANCE (EALTH &AIR IN

AN !RLINGTON (IGH 3CHOOL TEACHER WHO WAS SUPERVISING HER STUDENT VOLUNTEERS SUGGESTED THAT HER DEPARTMENT STUDENTS COULD CONTINUE THE TRADITION 0LANNING FOR THIS BEGAN BEFORE THE END OF WHEN 2-3 &OUNDATION BOARD MEMBERS MET WITH !RLINGTON S STAFF

!NOTHER PART OF CONTINUING WITH TRADITION !S WAS THE PRACTICE OF THE 2-3 !LLIANCE !RLING TON STAFF WORKED CLOSELY WITH THE 3003 7ELLNESS $EPARTMENT IT IS PLANNED BY THAT DEPARTMENT THAT THE LESSONS LEARNED BY THE THIRD GRADERS DURING THIS YEAR S (EALTH AND %NVIRONMENT &AIR WILL BE INCORPORATED INTO THE CURRICULUM WITH THE AID OF A RECENTLY RECEIVED lVE YEAR NATIONAL GRANT 34%03 TO A (EALTHIER 5 3 !LSO AS IT HAS SINCE THE 3003 4RANSPORTATION $EPARTMENT PAID FOR BUSING THE THIRD GRADERS TO !RLINGTON (IGH 3CHOOL

4HE VALUE OF HEALTH EDUCATION IS RECOGNIZED AND SUPPORTED BY MANY PARTNERS THROUGHOUT THE COMMUNITY 4HE 2-3 &OUNDATION IS PROUD TO HELP THIS VALUABLE SERVICE THRIVE

.ICOLA + (YSER AND #AROLE .IMLOS ARE BOTH MEMBERS OF THE 2AMSEY -EDICAL 3OCIETY &OUNDATION "OARD

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2-3 &OUNDATION 'OLF #LASSIC -IDLAND (ILLS #OUNTRY #LUB A M 2EGISTRATION A M ,UNCH P M 3HOTGUN 3TART 0LEASE CALL IF YOU ARE INTERESTED IN PARTNERING WITH US BY BECOMING A SPONSOR OR DONATING A GIFT FOR THIS EVENT #ONTACT 2AMSEY -EDICAL 3OCIETY &OUNDATION AT ,> ÃiÞÊ i` V> Ê- V iÌÞ

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3ATURDAY /CTOBER

2-3 &OUNDATION /KTOBERFEST (OME OF #ATHY $E#OURCY IN 3UNlSH ,AKE P M 0ROCEEDS FROM THESE FUNDRAISERS WILL PROVIDE GRANTS TO THE (EALTH #ARE FOR THE (OMELESS (MONG 2EFUGEE 0ROJECT AND 3T 0AUL 0UBLIC 3CHOOLS FOR (EALTH %DUCATION FOR +IDS 7ATCH YOUR MAIL FOR FURTHER INFORMATION OR CALL

* /Ê Ü>À`ÃÊ- i ÀiiÊ À> ÌÊÌ Ê, 4HE "OARD OF $IRECTORS OF THE -INNESOTA 0ARTNERSHIP FOR !CTION !GAINST 4OBACCO -0!!4 APPROVED GRANTS FOR NEW RESEARCH AND TO ASSIST THE WORK OF COMMUNITY OR GANIZATIONS IN SUPPORT OF LOCAL SMOKE FREE INITIATIVES h4HE GRANTS AWARDED BY THE "OARD REmECT -0!!4 S VISION TO ELIMINATE THE HARM CAUSED BY TOBACCO IN -INNESOTA v SAID -ICHAEL 6EKICH -0!!4 BOARD CHAIR h-0!!4 HAS MADE TREMENDOUS PROG RESS WITH OUR STOP SMOKING PROGRAMS ANY -INNESOTA ADULT WHO WANTS TO QUIT USING TOBACCO NOW HAS ACCESS TO EFFECTIVE AS SISTANCE v EXPLAINED $AVID 7ILLOUGHBY

-0!!4 #%/ h"UT TOBACCO IS A HIGHLY ADDICTIVE SUBSTANCE AND NO ONE STRATEGY WILL ELIMINATE THE HARM OF TOBACCO 4HAT S WHY THE EXPERTS SUCH AS THE #ENTERS FOR $ISEASE #ONTROL AND 0REVENTION RECOM MEND IMPLEMENTING COMPREHENSIVE STRATE GIES TO ADDRESS TOBACCO S HARMS INCLUDING INDIVIDUAL STOP SMOKING SERVICES RESEARCH AND COMMUNITY BASED INITIATIVES TO REDUCE

EXPOSURE TO SECONDHAND SMOKE v !S OF

-0!!4 HAD AWARDED MILLION IN STOP SMOKING GRANTS MILLION IN RESEARCH GRANTS MILLION IN GRANTS TO SUPPORT LOCAL SMOKE FREE INITIATIVES AND MILLION IN GRANTS TO REDUCE THE HARM OF TOBACCO IN DIVERSE COMMUNITIES 4HE 2EQUESTS FOR 0ROPOSALS FOR THESE GRANTS WERE ANNOUNCED BY -0!!4 IN 3EPTEMBER AND *ANUARY 'RANT APPLICATIONS PASSED THROUGH A RIGOROUS INDE PENDENT REVIEW PROCESS BEFORE BEING SUBMIT TED TO THE -0!!4 "OARD FOR APPROVAL h%ACH YEAR TOBACCO USE CAUSES MORE THAN DEATHS IN -INNESOTA AND IS ESTIMATED TO COST BILLION IN HEALTH CARE COSTS AND BILLION IN LOST PRODUCTIVITY COSTS v SAID 6EKICH h4HE DIRECT HEALTH CARE COSTS ALONE AMOUNT TO ALMOST FOR EVERY MAN WOMAN AND CHILD IN THE STATE "Y IMPLEMENTING A COMPREHENSIVE STRATEGY TO ADDRESS TOBACCO USE -0!!4 S PROGRAMS WILL RESULT IN IMPROVED HEALTH AND REDUCED HEALTH CARE COSTS FOR ALL -INNESOTANS v

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-0!!4 HAS BEEN AWARDING COMPETI TIVE GRANTS SINCE ITS ESTABLISHMENT BY THE 2AMSEY #OUNTY $ISTRICT #OURT IN 4HE RESEARCH GRANTS WILL CONTRIBUTE TO THE BODY OF SCIENTIlC KNOWLEDGE ON TOBACCO RELATED ISSUES AND WILL HELP INFORM -0!!4 S FUTURE WORK ON REDUCING THE HARM OF TOBACCO IN -INNESOTA 4HE INTERVENTION GRANTS WILL SUPPORT LOCAL CITIZEN PARTICIPATION EFFORTS TO PROTECT WORKERS AND THE PUBLIC FROM THE HARM OF SECONDHAND SMOKE ,OCAL ORGANI ZATIONS RECEIVING FUNDING WILL BE ABLE TO STRENGTHEN LOCAL TOBACCO CONTROL COALITIONS

EDUCATE THE PUBLIC ABOUT THE DANGERS OF SEC ONDHAND SMOKE AND ASSESS THE COMMUNITY READINESS FOR POLICY CHANGE /NE OF THE GRANTS AWARDED BY -0!!4 WAS TO THE 2AMSEY -EDICAL 3OCIETY SERVING 2AMSEY $AKOTA AND 7ASHINGTON #OUNTIES 4HE ONE YEAR GRANT NOT TO EXCEED

IS AWARDED TO SUPPORT A PHYSICIAN DRIVEN CITIZEN PARTICIPATION EFFORT TO BUILD A DIVERSE COALITION OF STRATEGIC PARTNERS THAT SUPPORT SMOKE FREE POLICIES IN $AKOTA #OUNTY

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£ÃÌÊ9i>ÀÊ Ê*À>VÌ Vi *ULIE 3EIM #RONK - $ 5NIVERSITY OF -INNESOTA -EDICAL 3CHOOL $ERMATOLOGY $ERMATOLOGY #ONSULTANTS 0 !

,iÌ Ài`Ê* ÞÃ V > Ã 6INCENT 2 (UNT - $ 5NIVERSITY OF -INNESOTA -EDICAL 3CHOOL &AMILY -EDICINE

,ià `i ÌÊ* Þà V > à *OSE 4 "ARNARD - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE $EBORAH # "OHN +IETZER - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE *AMES " #HRISTENSON - $ 5NIVERSITY OF -INNESOTA -EDICAL 3CHOOL 0SYCHIATRY 5 OF -. 'RADUATE 3CHOOL OF -EDICINE +IMBERLY 2 #OCHRAN - $ 5NIVERSITY OF !LABAMA 3CHOOL OF -EDICINE 0EDIATRICS )NTERNAL -EDICINE 5 OF -. 'RADUATE 3CHOOL OF -EDICINE

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6!,%.4).% / -!,,%9 - $ DIED *UNE OF HEART FAILURE AT THE AGE OF (E GRADUATED FROM THE 5NIVERSITY OF -INNESOTA -EDICAL 3CHOOL $R / -ALLEY PRACTICED INTERNAL MEDI CINE AND CARDIOLOGY IN 3T 0AUL FOR YEARS AND DEDICATED MUCH OF HIS LIFE TO PUBLIC HEALTH

SERVING AS $EPUTY #OMMISSIONER OF (EALTH FROM TO (E WAS THE #HIEF OF 3TAFF OF 3T *OSEPH S (OSPITAL FROM $R / -ALLEY WAS A #APTAIN IN THE !RMY DURING THE +OREAN #ONmICT AND RETIRED FROM THE -IN NESOTA .ATIONAL 'UARD AS A "RIGADIER 'ENERAL IN (E REMAINED ACTIVE IN MEDICINE AFTER RETIREMENT AND WAS CURRENTLY WORKING FOR THE -INNESOTA $EPARTMENT OF (EALTH AS A MEDICAL CONSULTANT REVIEWING CHARTS OF PEOPLE WHO RECEIVED DISABILITY BENElTS (E JOINED 2-3 IN

/DETTE #HAWKI %L (ELOU - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE :IAD - %L :OGHBY - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE +ENDRA , 'RAM - $ 5NIVERSITY OF -INNESOTA -EDICAL 3CHOOL 0EDIATRICS 5 OF -. 'RADUATE 3CHOOL OF -EDICINE !LYA 3ANTOS *AWAID - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE -ICHAEL (YOUNG 3ON +IM - $ 5NIVERSITY OF -INNESOTA -EDICAL 3CHOOL $ONNA - +ONING - $ 5NIVERSITY OF -INNESOTA -EDICAL 3CHOOL 5 OF -. 'RADUATE 3CHOOL OF -EDICINE .AMRATA !RUN -AGAR - $ ,OKMANYUA 4ILAK -UN -EDICAL #OLLEGE "OMBAY &AMILY -EDICINE 5 OF -. 'RADUATE 3CHOOL OF -EDICINE 'ERVAIS 0 -OCHE - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE +RISTINE ! 3CHULTZ - $ ,OYOLA 5NIVERSITY 3TRITCH 3CHOOL OF -EDICINE 0EDIATRICS 9ELENA 3LININ - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE "ENJAMIN % 3OLOMON - $ 5NIVERSITY OF -INNESOTA -EDICAL 3CHOOL .EUROLOGY 5 OF -. 'RADUATE 3CHOOL OF -EDICINE !NDREA -ALCHIODI 4ATRO - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE -ICHAEL * 4HRALL - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE -ATTHEW #OLIN 4URNER - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE %UN +YUNG 7ON - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE $EMETRIS 9ANNOPOULOS - $ 5 OF -. 'RADUATE 3CHOOL OF -EDICINE

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TIATIVE BE PROACTIVE IN EDUCATING MY PATIENTS AND MYSELF ABOUT THESE PRODUCTS OR JUST WATCH THE MARKET AND MY PRACTICE TO SEE HOW THIS RELATIVELY NEW APPROACH TO HEALTH CARE UNFOLDS OVER THE NEXT FEW YEARS ) RECOMMEND TO MY COLLEAGUES AND FELLOW PHYSICIANS THAT WE SHOULD NOT TAKE THE PASSIVE APPROACH ) WILL PLAN TO MAKE AVAILABLE MORE INFORMATION ON THESE CONSUMER DRIVEN HEALTH PLANS BASED ON REQUESTS WHETHER IN THE FORM OF SEMINARS PRESENTATIONS OR RESOURCES ! lNAL NOTE NOT RELATED TO INSURANCE PROD UCTS 4HROUGH INSIGHTFUL THINKING HARD WORK AND DEDICATION TO THEIR PROFESSIONAL RESPON SIBILITIES THE STAFF OF 2-3 WAS SUCCESSFUL IN SECURING A ONE YEAR GRANT FROM THE -INNESOTA 0ARTNERSHIP FOR !CTION AGAINST 4OBACCO 4HE GRANT IS AWARDED TO A PHYSICIAN DRIVEN CITIZEN PARTICIPATION EFFORT TO SUPPORT SMOKE FREE POLICIES IN $AKOTA #OUNTY ) ANTICIPATE THAT ) SPEAK FOR ALL WHEN ) CONGRATULATE THE STAFF FOR THEIR EFFORTS AND SUCCESS !S ALWAYS ) WELCOME YOUR QUESTIONS

CONCERNS AND CRITICISMS ) APPRECIATE YOUR CONTINUED SUPPORT OF THE 2AMSEY -EDICAL 3OCIETY AND WANT TO ENSURE THE VALUE YOU RECEIVE FROM YOUR MEMBERSHIP

#HARLES 4ERZIAN - $ -OBILE C TERZIAN WORLDNET ATT NET -ETRO$OCTORSÊÊ/ iÊ ÕÀ > Ê vÊÌ iÊ i i« Ê> `Ê,> ÃiÞÊ i` V> Ê- V iÌ iÃ

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&%7 /& 53 !2% !&&),)!4%$ WITH ORGANIZA TIONS THAT GO BACK YEARS TO THE MID S )T IS MY PLEASURE TO BE THE #HAIR OF THE (EN NEPIN -EDICAL 3OCIETY THAT CELEBRATED ITS TH ANNIVERSARY *UNE 7HAT FOLLOWS IS A MODEST HISTORY THAT ) HOPE WILL GIVE YOU AN IDEA OF THE IMPORTANT ROLE THAT THE (ENNEPIN -EDICAL 3OCIETY HAS PLAYED AND CONTINUES TO PLAY IN HISTORY 4HE FOUNDING OF THE (ENNEPIN -EDICAL 3OCIETY YEARS AGO ON *UNE

MARKS THE BEGINNING OF THE OLDEST MEDICAL ORGANIZA TION IN CONTINUOUS EXISTENCE IN THE 3TATE OF -INNESOTA /N THAT DATE NINE PHYSICIANS ORGA NIZED THE 3T !NTHONY AND -INNEAPOLIS 5NION -EDICAL 3OCIETY WITH THE PURPOSE OF COLLABORAT ING AND ORGANIZING TO BEST MEET THE NEEDS OF THE GROWING COMMUNITY ,ATER AS EPIDEMICS MADE THEIR WAY ACROSS THE COUNTRY THE 3OCIETY S FOCUS BECAME MORE AND MORE INVOLVED WITH PUBLIC HEALTH INITIATIVES 4HE 3OCIETY LED CAMPAIGNS TO PROMOTE THE EARLY DIAGNOSIS AND TREATMENT OF COMMUNICABLE DISEASES AND INTRODUCED VACCINATION AND IMMUNIZATION PROGRAMS IN THE PUBLIC SCHOOLS AND IN SPECIAL CLINICS $URING THE MID S THE 3OCIETY SET IN MOTION A NATIONALLY RECOGNIZED PROGRAM TO ASSIST LOW INCOME FAMILIES IN OBTAINING NEEDED MEDICAL SERVICES AT A COST THAT THEY WERE ABLE TO AFFORD 4EN YEARS LATER AREA PHYSICIANS WERE IN STRUMENTAL IN SETTING UP THE lRST PREPAID HEALTH PLAN THE FORERUNNER OF "LUE #ROSS "LUE 3HIELD )T WAS HOPED THAT THESE EFFORTS WOULD DAMPEN ANY THOUGHTS OF SOCIALIZED MEDICINE )N THE S (EALTH -AINTENANCE /R GANIZATIONS (-/S BEGAN TO EMERGE WITH SOME OF THE EARLY PROGRAMS INCLUDING 'ROUP (EALTH -ED#ENTERS (EALTH 0LAN .ICOLLET %ITEL (EALTH 0LAN AND "LUE 0LUS (ENNEPIN -EDICAL 3OCIETY FORMED 0HYSICIANS (EALTH 0LAN 0(0 A PREDECESSOR TO -EDICA $URING THIS TIME (ENNEPIN -EDICAL 3OCIETY ALSO HELPED TO FORM THE &OUNDATION FOR (EALTH #ARE %VALU ATION WHICH LATER BECAME KNOWN AS 3TRATIS (EALTH

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!LSO IN THE S THE (ENNEPIN -EDI CAL 3OCIETY FORMED THE lRST CENTRALIZED CREDEN TIALING SERVICE IN THE NATION WHICH HELPED TO REDUCE THE ADMINISTRATIVE PAPERWORK BURDEN THAT PHYSICIANS EXPERIENCED AS PART OF THEIR APPOINTMENTS TO HOSPITALS MEDICAL STAFFS (ENNEPIN -EDICAL 3OCIETY WAS A FOUND ING PARTNER IN THE MALPRACTICE INSURANCE CARRIER -IDWEST -EDICAL )NSURANCE #OM PANY --)# THAT HELPS TO MAINTAIN ACCESS TO MEDICAL LIABILITY COVERAGE FOR PHYSICIANS -EMBERS OF THE (ENNEPIN -EDICAL 3OCIETY CONTRIBUTED THOUSANDS OF HOURS AND TALENTS TO IMPROVE THE HEALTH OF THE COMMUNITY THROUGH $OCTORS (OUSE#ALLS 3UCCESS BY 3IX 5NITED 7AY 0HYSICIAN 2EFERRAL 3ERVICE ACCESS TO SER VICES DURING THE NURSING STRIKE GUN BUY BACK PROGRAM IN (ENNEPIN #OUNTY AND THE !BUSE 0REVENTION AND #ONmICT 2ESOLUTION PROJECT )N THE PAST DECADE (-3 HAS CONTINUED TO ADVOCATE FOR ITS MEMBERS AND THEIR PATIENTS AND TO SUPPORT THE PUBLIC HEALTH WITH SECOND HAND SMOKE INITIATIVES THE FOUNDING OF THE #ENTER FOR #ROSS #ULTURAL (EALTH AND SIGNIlCANT CHARITABLE CONTRIBUTIONS THROUGH THE (ENNEPIN -EDICAL &OUNDATION 5SEFULNESS IS THE BEST MEANS BY WHICH TO MEASURE SUCCESS AND HISTORY SHOWS THAT THE (ENNEPIN -EDICAL 3OCIETY HAS EXERTED GREAT INmUENCE IN IMPROVING BOTH THE COMPETENCE OF THE LOCAL PHYSICIAN AND THE HEALTH OF THE LOCAL PEOPLE 4HE THRUST OF ACTIVITIES OF THE 3OCIETY HAS CHANGED OVER TIME REmECTING ADVANCES IN CLINICAL MEDICINE AND NEWER SOCIOECONOMIC AND POLITICAL ISSUES AFFECTING PATIENT CARE (OWEVER THE 3OCIETY HAS NEVER FORGOTTEN ITS MISSION TO PROMOTE THE HONOR OF THE PROFESSION AND THE USEFULNESS OF ITS MEMBERS 4HANKS FOR YOUR CONTINUED MEMBERSHIP IN THE (ENNEPIN -EDICAL 3OCIETY

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#HAIR -ICHAEL " "ELZER - $ 0RESIDENT *AMES ! 2OHDE - $ 0RESIDENT ELECT 0AUL ! +ETTLER - $ 3ECRETARY %DWARD 0 %HLINGER - $ 4REASURER !NNE - -URRAY - $ )MMEDIATE 0AST #HAIR -ICHAEL " !INSLIE - $

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.ANCY + #OOLEY - $ /BSTETRICS 'YNECOLOGY 7ESTERN /" '9. ,TD

3 ! 0ARASHOS - $ 0H $ .EUROLOGY 4HE -INNEAPOLIS #LINIC OF .EUROLOGY ,TD

*AMES 7 %RDAHL - $ #ARDIOVASCULAR $ISEASES -INNESOTA (EART #LINIC

+AREN %LIZABETH 0ORTH - $ .EUROLOGY 4HE -INNEAPOLIS #LINIC OF .EUROLOGY ,TD

%RIC 2 %RNST - $ #ARDIOVASCULAR $ISEASES -INNESOTA (EART #LINIC

3TEVEN $ 3TEIN - $ .EUROLOGY %DINA 3OUTHDALE 0HYSICIAL 4HERAPY

'AIL * &RANCIS - $ .EUROLOGY 4HE -INNEAPOLIS #LINIC OF .EUROLOGY ,TD

-ATTHEW !ARON 7EINRICH - $ /BSTETRICS 'YNECOLOGY 7ESTERN /" '9. ,TD

3ARAH ! &REITAS - $ /BSTETRICS 'YNECOLOGY 7ESTERN /" '9. ,TD

-ARY - 7INNETT - $ &AMILY -EDICINE #EDAR 2IVERSIDE 0EOPLE S #ENTER

#HERYL ! (ANSEN - $ /BSTETRICS 'YNECOLOGY 7ESTERN /" '9. ,TD

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!LLAN 0 )NGENITO - $ #HILD .EUROLOGY 4HE -INNEAPOLIS #LINIC OF .EUROLOGY ,TD

)NGRID !BOLS -ANTYH - $ .EUROLOGY 4HE -INNEAPOLIS #LINIC OF .EUROLOGY ,TD 'EORGE !DAM - $ .EUROLOGY 4HE -INNEAPOLIS #LINIC OF .EUROLOGY ,TD 2AJIV +UMAR !GGARWAL - $ .EUROLOGY 4HE -INNEAPOLIS #LINIC OF .EUROLOGY ,TD *ACQUELINE 4 "ERNARD - $ .EUROLOGY 4HE -INNEAPOLIS #LINIC OF .EUROLOGY ,TD #URTIS ! "OEHM - $ )NTERNAL -EDICINE 0ARK .ICOLLET (EALTH 3ERVICES $ONALD * #HADWICK )) - $ #HILD .EUROLOGY 4HE -INNEAPOLIS #LINIC OF .EUROLOGY ,TD .ORMAN 0 #HAPEL - $ & ! # # #ARDIOVASCULAR $ISEASES -INNESOTA (EART #LINIC 4HOMAS &RANCIS #HENG - $

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,ià `i ÌÊ* Þà V > à 4OR # !ASHEIM - $ *AMES -ATHAI !BRAHAM - $ /MOBOSOLA /BASOLA !KINSETE - $ *ESSICA ,YNN !LEXANDER - $ 4ADASHI , !LLEN - $ #HRIS 2 !LLIMAN - $ *OHN 7 !LLRED - $ 'EORGES 3ALIBA !L -ACARI - $ ,EROY !MELINE - $ #HRISTINA % !NDERSON - $ %RIC * !NDERSON - $ %LENA 6 !PASOVA - $ 3HACHIE 6 !RANKE - $ *OSEPH , !RMS - $ !NDREW & !RTHUR - $ $ENIZ ,EVENT !SLAN - $ *ARED 0ETER !USTIN - $ -ICHAEL * !YLWARD - $ 6ERONIKA "ACHANOVA - $ %LIZABETH *OAN "AKER - $ *ASON 6ANCE "AKER - $ !MY , "ANKS - $ *ENNIFER 3UZANNE "ANTZ - $ *ANE % "ARTHELL - $ 3AGAR "EDI - " " 3 -ELENA $ "ELLIN - $ #YNTHIA - "ELT - $ *AMES &RANK "ENCIVENGA - $ *AMES 2 "ENZIE - $ #HRISTINE 'OVE "ERG - $ 0ETER # "ERG - $ -ICHAEL *OSEPH "ERGER - $ 3TEFAN #HRISTIAN "ERTOG - $ "RIAN # "ETTS - $ 3ACHIN 3HANKAR "HARDWAJ - $ -ANEESH "HARGAVA - $ *AYASHRI "HASKAR - $ ,ISA !NN "ISHOP - $

3YLVESTER - "LACK - $ !NNE ( "LAES - $ $ONNEVAN "LAKE - $ %MILY #RAY "ORMAN 3HOAP - $ #HRISTOPHER 3 "OWRON - $ *EFFREY 2EX "RACE - $ !NNE ( "RACEY - $ *ENNI , "RADLEY - $ .EIL !LEXANDER "RATNEY - $ *OHANNES "RECHTKEN - $ +EVIN .ATHANIEL "ROWN - $ *AMES 2OBERT "RUNS - $ 2OBERT % "ULANDER - $ 2ICHARD 7 % "URG - $ 2ACHEL 3 "URTON - $ %MIRO % #AICEDO 'RANADOS - $ .EAL &REDERICK #AMPBELL - $ "ENJAMIN + #ANALES - $ -UNA 4 #ANALES - $ -ARIA ,UIZA #ARAMORI - $ +ELSEY . #ARIGNAN - $ !NNELISA -AY #ARLSON - $ 6ERA " #ARLSON - $ !LLISON , #ASHMAN - $ 'EORGE . #AUCUTT - $ 4EREZA - #ERVENKA - $ *ACLYN &AULKNER #HAFFEE - $ -ARYDEE # #HAMBERLAIN - $ ,AURA #HAMBERS +ERSH - $ *ULIE !NNE #HAMPAGNE - $ #LAYTON 7 #HEN - $ 0OLO #HEN - $ 3HARON &EI (SIEN #HEN - $ 6ICTOR #HIU - $ -OLLY - #HRISTIANSON - $ $AVID 9UNG #HUNG - $ *USTIN #HRISTOPHER #HURA - $ *OHN 7 #OLFORD - $ *OHN 2ICHARD #OLLINGHAM - $ +RISTEN ,YNN #OULTER - $ !MY "ETH #RIEGO - $ *OHN % #ROUCH - $ 3HERI 3 #ROW - $ 3COTT # #ROWE - $ +ATHRYN 2 #ULLEN - $ !MY 2ENAE #UNNINGHAM $ / !NGELA - $AHLE - $ 4HOM ' ! $AHLE - $ *ANELLE ,A"INE $AILEY - $ #ARI 'IBBS $AKIN - $ *OHN ! $AMERGIS *R - $ *ASON ! $ANIELS - $ %MILLIE $ $EDON - $ 4ARA *EAN $ENKE - $ 3UPREET $ESHPANDE - $ (ELLINA $ESSIE - $ !ARON 3HAWN $E6RIES - $ *ASON -ATTHEW $E6RIES - $ *ENNIFER % $ICK - $ %MILY % $ICKMAN - $ $EANNA * $IEBOLD - $ 4IMOTHY ' $IRKS - $

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#HAD ! (AROLDSON - $ 3TEPHANIE (ART 'OULEAU - $ *AMES # (ARVANKO - $ +EVIN 3TUART (ATCHER 2OSS - $ %RIC * (AZEN - $ !DAM / (EBB - $ #HRISTIE 3 (EIKES - $ "RETT (ENDEL 0ATERSON - $ $ONAVON * (ESS *R - $ #HUONG $INH (OANG - $ 6IET (OA (OANG - $ 4ARA , (OLM - $ !ARON # (OLTEBECK - $ )RENE (ONG -C!TEE - $ -ICHAEL 4ODD (OPFENSPIRGER - $ #ARA !NN (OULE - $ !NGELA + (OUSE - $ "ART !LONZO (OVEY $ / -ICHAEL * (OWELL - $ !NDRAYA * (ULDEEN 4IBBETTS - $ 0AUL & (UNT - $ 2ACHEL )RENE (UOT - $ +EBEDE (USSEIN - $ ,EANN ' (UTCHISON - $ #HI "AO (UYNH - $ 4ODD % *ACKMAN - $ .ICOLE *ACOBI - $ 3HANNA -ICHELLE *AGUSCH - $ $EKA ! *AMA - $ 3ETH #HALMERS *ANUS - $ 4UN *IE - $ 0AUL ,EWIS *OERN - $ *AMES %RIK *OHANSON - $ #ASEY ( *OHNSON - $ #YBELE $IANE *OHNSON - $ *ASON 3 *OHNSON - $ 0ATRICK + *OHNSON - $ -ARKLYN * *ONES - $ *ONATHAN *AMES *ULIANO - $ $EBORAH 3 +ACMARYNSKI - $ +ELLY $ +ADLEC - $ 0ATRICIA - +ALLEMEIER - $ 0ETER )SAAK +ARACHUNSKI - $ $ARSHAK ( +ARIA - $ 2AJEEV +AUL - $ 3UJATA +AUSHAL - $ 3COTT 0ERRY +EELEY - $ +IM - +ELLY - $ *AVAD +EYHANI - $ !MIT +HANNA - $ *ONG $ +IM - $ -ARK ! +LEIN - $ +ENNETH $ +LEIST - $ !MY * +NOPKE -OONEY - $ 0AUL 3EUNG *OON +OH - $ 'ALINA +OLDOBA - $ +AMBIZ +OSARI - $ $ANIEL 7ILLIAM +RAFT - $ .ATHANIEL 3 +REYKES - $ 3ARAVANAN + +RISHNAMOORTHY - $ +RISTOPHER $ANIEL +RUEGER - $ *ESSICA %LLEN +UEHN(AJDER - $

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-OUSUMI +UNDU - $ +EN -ORIYAMA +UNISAKI - $ ,AURA 4 ,A&AVE - $ !LEXANDER # ,AI - $ $AVID 0 ,AMBERT - $ !NDREA ,YNN ,AMPLAND - $ *EFFREY + ,ANDER - $ 0H $ 2OBERT ,ARBI /DAM - $ 6INCENT ,AROCHE - $ +ATHLEEN -ARY ,ARSON - $ 0ETER +UAN TEH ,EE - $ 3ANG 5N ,EE - $ 3ANGJIN ,EE - $ +ATHERINE ,IETZ - $ 0AUL +EUN ,IM - $ "RADLEY # ,INDEN - $ 4IMOTHY % ,INDSAY - $ ,USHA ,IU - $ !NTOINETTE ,ILLIAN ,OPEZ - $ %VA -ARIE ,UHMAN - $ 3TEPHEN * ,UKASEWYCZ - $ 4ROY # ,UND - $ 4HUAN 6INH ,Y - $

#ORRECTION )N THE -AY *UNE ISSUE OF -ETRO$OCTORS LISTING OF .EW -EMBERS FOR THE 5NIVERSITY OF -IN NESOTA 0HYSICIANS !CTIVE THERE WERE SEVERAL SPECIALTY ERRORS 7E APOLOGIZE FOR THE MISTAKE

4HE FOLLOWING PHYSICIANS WERE LISTED AS PRACTICING h0EDIATRIC -EDICAL 4OXICOLOGY v 4HE CORRECT SPECIALTY IS h0EDIATRIC "LOOD AND -ARROW 4RANSPLANTv OR h0EDIATRIC "-4 v s + 3COTT "AKER - $ - 3 s "RUCE 2 "LAZAR - $ s 3ATKIRAN 3INGH 'REWAL - " " 3 s -ARGARET ,OUISE -AC-ILLAN - $ s 0AUL *OHN /RCHARD - $ s *AKUB 4OLAR - $ 0H $ s -ICHAEL 2 6ERNERIS - $ s *OHN % 7AGNER - $

4HESE PHYSICIANS WERE ALSO LISTED INCORRECTLY AS PRACTICING h0EDIATRIC -EDICAL 4OXICOLOGY v AND SHOULD HAVE BEEN LISTED AS h(EMATOLOGY /NCOLOGY v s 2AJARAM .AGARAJAN - $ s *OSEPH 0 .EGLIA - $ - 0 ( s -ARIE % 3TEINER - $ s "RENDA 7EIGEL - $

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33 3 neighborhoods neighborhoods neighborhoods ofofKenwood Kenwood of Kenwood roof roofroof top topterrace top terrace terrace and andand more. more. more. bedrooms, 5 bedrooms, 55baths. baths.

5 baths. bedrooms, kitchen kitchen kitchen and andand more. more. more.

33 3 55bedrooms, bedrooms, bedrooms, 33baths. baths.

3 baths. and andand Lowry Lowry Lowry Hill.

Hill.Hill.

33bedrooms, bedrooms, 3 bedrooms, 2+bedrooms, 2+bedrooms, 2+bedrooms, 33baths. baths.

3 baths. 44baths. bedrooms, bedrooms, bedrooms, 33baths. baths.

3 baths. baths.

4 baths.

The The The Ultimate Ultimate Ultimate in in Perfection! in Perfection!

Perfection!

Recently Recently Recently completed, completed, completed, this thisWilliam this William William Beson Beson Beson mastermastermasterpiece piece piece isistruly truly is truly unbelievable. unbelievable. unbelievable.

Exquisite Exquisite Exquisite finishes finishes finishes and andand quality quality quality craftsmanship craftsmanship craftsmanship ininevery every in every detail. detail. detail.

Boasting Boasting Boasting aa a graceful graceful graceful ambiance ambiance ambiance and andand utilitarian utilitarian utilitarian spaces spaces spaces and andand every every every amenity amenity amenity you youyou can cancan imagine! imagine! imagine!

44bedrooms, bedrooms, 4 bedrooms, 55baths. baths.

5 baths.

Go West Young Family We saved the best for last! Build the home of your dreams on a choice cut of the last piece of Prime Edina Real Estate. This is no East Edina, this is the West. These are the homes where the open spaces roam, and the lofty and soaring vaults tray. Don’t tell us about the Old World Charm. Heck, we built that, too. “Your investment will be significant in your next home, it may as well be on a home that you custom design!” There are 23 lots now available to turn your dreams into reality.

Call Scott Card John Shaw

612.209.6455

or visit us on the web at

612.720.4678

www.ParkwoodKnolls.com

Call Call Call

Bruce Bruce BruceBirkeland Birkeland Birkeland 612-925-8405 612-925-8405 612-925-8405 www.brucebirkeland.com www.brucebirkeland.com www.brucebirkeland.com

Continuing Medical Education FALL 2005

PRIMARY CARE FOCUS

SURGERY FOCUS

Vascular Diseases: A Primary Care Perspective September 16-17, 2005

Endorectal Ultrasonography Workshop September 7, 2005

Annual Psychiatry Review: An Eclectic Presentation of Psychiatric Erudition September 19-20, 2005

Colon & Rectal Surgery: Conundrums and Controversies September 8-10, 2005

Twin Cities Marathon Sports Medicine Conference September 30 - October 1, 2005

Transplant Immunosuppression 2005: Improving Recipient Outcomes September 28 - October 1, 2005

Preventing Cardiovascular Events: Early Detection and Treatment October 6, 2005 Annual Autumn Seminar: Obstetrics, Gynecology and Womenâ&#x20AC;&#x2122;s Health October 10-11, 2005 Internal Medicine Review: Update 2005 October 19-21, 2005

ALSO OFFERED E. T. Bell Fall Pathology Symposium November 4, 2005 Emerging Infections in Clinical Practice and Emerging Health Threats (11th Annual) November 10-11, 2005

Screening for Cystic Fibrosis November 4, 2005 Thoracic Oncology and Primary Care November 11, 2005

All courses listed take place in the twin cities metro area.

This reflects our current listing.

For more information contact: Continuing Medical Education 612.626.7600 or 1.800.776.8636 cmereg@umn.edu Register Online! www.cme.umn.edu