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Physician Co-editor Y. Ralph Chu, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of HMS or RMS. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: bauerfamily@earthlink.net.

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Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Doreen Hines at (612) 362-3705.

MetroDoctors

CONTENTS VOLUME 8, NO. 2

2

www.metrodoctors.com: Introducing Our New Enhanced Web Site

4

FEATURE

MARCH/APRIL 2006

Interpreting: Who Should Pay?

6

Meeting Your State Legislator

7

COLLEAGUE INTERVIEW

Lee H. Beecher, M.D.

10

St. Paul City Council Votes for Smoke Free Ordinance Classified Ads

11

Tobacco Use Among Twin Cities Area College Students

14

Is Disease Management the New Face of Managed Care?

16

Index to Advertisers

17

Prior Authorization Needed for Many Health Care Services

19

AMA—Participation at the National Level

21

Minnesota at the Forefront for Recognizing and Rewarding Quality Care

23

PHYSICIAN’S SOAP BOX

U.S. Health Care—Market Failure or Failure to be a Market?

RAMSEY MEDICAL SOCIETY

25 26 27 28

President’s Message RMS Election Results/Call for Resolutions RMS Annual Meeting New Members/In Memoriam

HENNEPIN MEDICAL SOCIETY

29 30 31 32

Chair’s Report HMS in Action/Call for Resolutions Awards Presented/In Memoriam New Members

The Journal of the Hennepin and Ramsey Medical Societies

On the cover: Who should bear the added cost of providing interpreter services, and how can quality be assured?

Article begins on page 4.

March/April 2006

1

www.metrodoctors.com Introducing Our New Enhanced Web Site

T

TODAY IT SEEMS LIKE EVERYBODY has a Web site, doesn’t it? If

you want to find out more about an organization or an issue, it’s common practice to go out on the Internet and search. We all do it—it’s just become part of how we conduct business.

Hennepin and Ramsey Medical Societies realized a few months ago that we had a real opportunity to do a more effective job communicating with our members through our Web site, so we decided to enhance the functionality and usability of www.metrodoctors.com.

We are unveiling our new and improved Web site this month, which has much needed improvements now in place. We will routinely communicate with you using our Web site as a place where you can go to download information.

The legislative tab will provide you with a summary of the legislative or political issues that we are working on. Click on any of the topics and you will find a position paper that will highlight what the issue is, and what stance HMS and RMS and others are taking on it. We realize that our legislative advocacy work is an ever-growing need and therefore we want to make sure that we’re communicating with you about these types of issues.

Come take a tour with us . . .

The home page is the portal for getting into our Web site.

The publications tab will hold just that — our publications. We have current and past issues of our journal, MetroDoctors for you to view or download.

Visit us at: http://www.metrodoctors.com

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The Journal of the Hennepin and Ramsey Medical Societies

The Hennepin Medical Society tab will contain information specific to Hennepin Medical Society. We’ll have information about upcoming meetings, special projects and news and events.

The Ramsey Medical Society tab will contain much of the same information as what is included in HMS’ tab, but will be RMS specific.

The News and Events tab is the place to go to find out about upcoming events that are being sponsored by the medical societies. We will also use this page as a place to tell you about issues that are in the news.

The Medical Student tab was designed specifically for medical students because we offer a number of opportunities specific to them. Medical students can learn about ways to get involved with our Shadow a Physician program, or our mentorship program with the University of Minnesota.

We hope you will find this Web site a useful tool to communicate with us, and to learn about the various activities that we are working on in support of you, our members.

We want to hear your comments, too — click on the Contact Us tab at the bottom of each page and let us know what you think.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2006

3

FEATURE STORY

Who

Interpreting Should Pay?

M

MINNESOTA HAS BECOME more diverse in recent years and the waves of inmigration are likely to continue. The number of immigrants residing in Minnesota increased by more than 200,000 from 1990 to 2004, and the new arrivals are not just locating in the urban areas of Minneapolis and St. Paul; many are now recruited for jobs in greater Minnesota in communities such as Worthington, Glencoe, Willmar, Rochester and St. Cloud.

The 2000 Census collected data on the percent of persons 5 years and over that speak a language other than English at home. This data can be sorted by county. The greatest concentration was in rural Watonwan County (15.9 percent), closely followed by urban Ramsey County (15.8 percent). Many new immigrants have moved to communities south of the Twin Cities, but there are growing numbers in central and northwestern Minnesota. The percentage of recent immigrants in Kandiyohi County is now estimated to exceed 17 percent. More than 50 percent of this year’s kindergarten class in Willmar are the children of recent immigrants. Fortunately, the legislature has recognized the added challenges and costs associated with educating immigrant children and provides special revenue to districts for English-as-a-second-language and bi-lingual programs.

Health Care Implications

What does the growth and distribution of new immigrants mean for health care? Good communication is at the heart of quality patient care; in fact it is essential. For patients with LEP, or limited English proficiency, it is not only important, but Title VI of the Civil Rights Act requires providers to ensure that LEP patients have access to language assistance services when needed.

The debate is not whether LEP patients should have interpreters available when they need to access health care; the question is who should bear the added cost and how quality can be assured.

Even though, as noted above, recent immigration is not just an urban phenomenon, it does not affect all hospitals, clinics and health care professionals equally. Providers in heavily settled areas have had to gear up to meet the special needs of new residents by hiring interpreters or contracting with interpreter firms. Hennepin County Medical Center reported that their un-reimbursed costs for interpreter services in 2005 exceeded $2.6 million. Affiliated Community Medical Centers, (ACMC) headquartered in Willmar has hired four full-time interpreters with an annual un-reimbursed cost exceeding $100,000. In a recent survey conducted by the Minnesota Medical Group Management

BY PHIL RIVNESS ASSOCIATE ADMINISTRATOR, NORAN NEUROLOGICAL CLINIC

4

March/April 2006

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Association (MMGMA), some respondents reported that their un-reimbursed costs for interpreter services had grown by as much as 500 percent over the previous year; 84 percent expected their costs to increase in 2006. Some clinics reported that more than 30 percent of their patients require language interpreter services.

Economics 101

Interpreter costs can best be understood by considering the economics of a single patient visit. When a patient is seen for the first time in a primary care clinic, the clinic’s reimbursement for a typical office visit ranges from about $36 if the patient is covered

by Medical Assistance (MA) or MinnesotaCare (MC) to about $120 if covered by a health plan. For a typical follow-up visit, the clinic would be paid approximately $25

by MA or MC and about $66 by a health plan.

The average charge for contracted language interpreter services is $50 per hour, often with a two-hour minimum. The MA and MC program reimburses providers up to $25 per patient visit for language interpreter services. Health plans provide no reimbursement for these services. Assuming a two-hour minimum of contracted interpretation, the clinic would lose $39 dollars each time they see a new MA or MC patient and lose $50 for each follow-up patient. The clinic would net $20 for each new health plan patient but lose $35 on each follow-up.

Health plans, in concert with the Minnesota Chamber of Commerce, have argued that health care providers Percent of Persons 5 Years and Over Who Speak should just absorb the added costs for interpreter services a Language Other Than English at Home as the “cost of doing business” and that requiring health (based on the 2000 census) plans to cover these costs would constitute a new “manBase Potential LEP* County Percent date.” It is more reasonable, however, in an employerPopulation Patients based health care system, to include these variable costs in Hennepin 12.8% 1,043,809 133,607 the premiums employers pay. This is precisely what occurs Dakota 7.6% 328,482 24,964 in the workers’ compensation system. Interpreter services Carver 6.2% 64,052 3,971 are covered, the cost becomes a part of the employer’s Nobles 15.4% 19,410 2,911 experience rating and are factored into the premiums the Stearns 6.3% 124,571 7,847 employer pays.

Kandiyohi 9.9% 38,620 3,823 Legislation will be introduced in the 2006 Session to Swift 6.6% 11,311 746 require health plans to either provide interpreters for LEP patients they insure or reimburse providers for the costs of Ottertail 5.3% 53,980 2,860 contracting for these important services. The legislation Ramsey 15.8% 476,014 75,210 will also include a provision adjusting reimbursement for Sibley 9.2% 14,281 1,313 MA and MC patients to a level reflecting actual costs.

Watonwan 15.9% 11,081 1,761 These changes will place responsibility for payment Olmstead 9.8% 115,459 11,314 for language interpreter services where it rightfully belongs Polk 8.1% 29,256 2,385 and help to ensure access to quality services to our recent * LEP (limited language proficiency) immigrants.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2006

5

Meeting Your State Legislator

A

A FACE-TO-FACE MEETING with your legislator can be a powerful opportunity to advance your agenda. The meeting can also position you as a reliable expert on your issue and an important ally for your legislator… if it’s done right. Follow these steps for a successful visit:

1. Plan your meeting.

Decide whether you are going alone, or with a group of constituents. If you go as a group, decide who is going to lead the meeting, and what each person is going to contribute to the discussion. This will help eliminate awkward silences or repetitive messages, and will ensure that you hit all the key points you want to cover. You will likely have only 15 or 20 minutes for your meeting, so plan accordingly.

2. Know your audience.

Do a little research about your legislator if you don’t know much about him or her. Find out his or her positions on the issues you’re focusing on.

3. If there are multiple issues that are important to you, select one that you will discuss for that meeting.

Attempting to persuade a legislator on multiple issues not only weakens your position as a reliable, focused constituent, but it also dilutes your impact on each issue.

5. Make an appointment…

But don’t be surprised if it changes. Legislators often have last-minute hearings or committee meetings. Be flexible.

6. Meet in your home district.

Meetings in the home district are often less hurried than meetings at the capitol, and they provide the “home turf” advantage. Find out when your legislator is in his or her home district, and schedule your appointment then, or if your workplace illustrates your position, invite them to visit you. If this is not possible, travel to the capitol as an alternative.

7. Once you’re in the door, begin by finding something personal that you have in common with the legislator.

Do they live on the street where your mother grew up? Are their kids in your child’s class at school? Does something in their office suggest an interest that you share, such as fishing, sports, or art? Engage in a little “small talk” to break the ice — but keep it brief.

8. State the reason for your visit.

Be clear about why you are there, why they should be interested (remember to mention again that you’re a constituent, and use local examples), and what you want them to do.

9. State your case.

Again, keep it concise, focused and personalized.

4. Define your message.

Focus your comments on one issue. Then, rather than trying to say everything you know or think about that issue, plan two or three observations or arguments that get at the heart of your position.

10. Invite comments and questions.

Engage your legislator in dialogue. Don’t worry if they ask you something you don’t know the answer to — simply tell them you don’t know, but that you’ll find out for them.

BY KATHY JOHNSON,CAE, PRESIDENT MSAE

11. State only what you know.

Don’t overstate your case, fudge facts, or guess.

6

March/April 2006

MetroDoctors

12. Ask for a commitment.

If you don’t ask your legislator for action, you won’t see any. If they decline, encourage them to think about it, and let them know you’ll keep in touch.

13. Have a leave-behind.

Provide your legislator with brief, written information for further reflection. Make sure it contains the local angle for your district.

14. Report on your visit.

As soon as possible after your visit (in the hallway is ideal), jot down notes that record the tone, what was said, and what questions were asked in the meeting. Not only will this help in reporting on your visit, but also it will help you build a record of your relationship with your legislator that can inform future dialogue. Let your group know that you made the visit, and report what you covered and what the legislator said. If possible, provide them with a copy of your leave-behind materials as well.

15. Follow up.

Send a handwritten thank-you note to your legislator. Let them know that you appreciate their time. If you promised to get them additional information, provide it or let them know how and when they can expect to receive it.

16. Visit more than once.

Over time, visit with your legislator to continue to discuss the issue and make requests as you have them. Be sure to be a reliable source of information for them on your issue by delivering what you promise, avoiding overstatement and communicating clearly.

This article is reprinted with permission from the Midwest Society of Association Executives (MSAE).

The Journal of the Hennepin and Ramsey Medical Societies

COLLEAGUE INTERVIEW

Lee H. Beecher, M.D.

Lee H. Beecher, M.D. is a board certified (ABPN) adult psychiatrist with special qualifications in addiction psychiatry. His practice includes outpatient medical psychotherapy, pharmacotherapy, and couples psychotherapy.

He graduated from the University of Minnesota Medical School, completed his residency at the University of Chicago, and completed a fellowship with the U.S. Navy in Pearl Harbor.

Questions were provided by Drs. Beth A. Baker, Peter H. Dehnel, Laurie Drill-Mellum, Edward P. Ehlinger, Donald M. Jacobs, James Jordan, Roger Kathol, Deane C. Manolis, Robert Nesheim, and James A. Rohde.

Q A

As it pertains to psychiatry and mental health, how would you recommend we proceed to give the public access to information on the cost and quality of their care?

The public is well aware that health care insurance premiums are on the rise faster than other costs. When mental health or substance abuse services are sought, one rapidly learns that outpatient psychiatric services are often restricted by insurance management carveout arrangements, high patient deductibles and copayments, and provider networks that queue patients. This results in long wait times to see psychiatrists for brief visits, poor care planning and case coordination between mental health providers and with treating (PCP) physicians, and little respect for the value of doctor-patient care continuity. Moreover, insurance payments favor medication prescribing by psychiatrists and other physicians, and a “split therapy” paradigm of medication checks by physicians with psychotherapy by psychologists and social workers. There is simply no evidence that this paradigm as current insurance industry standard provides optimal clinical results or cost-effective psychiatric/mental health care. To remedy this, we must implement strategies to make a provider’s psychiatric services accountable to their patients, and that patients must direct the flow of payment dollars for their care. Strategies to accomplish this include: 1. Terminating restrictive insurance company provider agreements. Most are onerous. 2. Strict policies on privacy and confidentiality of medical records and patient information. 3. Promoting individual provider and clinic practice Web sites to advertise mental health provider accessibility, qualifications and fees. This will encourage provider competition and visibility.

Please comment on the collaborative role of the mental health disciplines (psychiatry, psychology, clinical social work, mental health nursing) in providing comprehensive evaluations and patient specific treatment. Do we need working models for this approach to care and measures of effectiveness and cost that is provided to patients?

The real problem is not the professional training of psychiatrists, primary care physicians, ER docs, nurses, psychotherapists, and alcohol/drug counselors. We are fully able to use the telephone, FAX machine, and mail to communicate, and regularly do whether we are paid to do so or not. This is simply good medicine and good health care practice.

However, most of us are now tied into multiple and rigid reimbursement systems which actively discourage our collaborative efforts on behalf of patients. Over the years I have evaluated models of nurse and/or social worker case management, crisis intervention, primary care integration, and urgent care evaluation in the hospital ER. All of these initiatives work when there is financial support and provider buy in — until the grant runs out. So, I don’t think we will find system models of collaborative care that will solve the current crisis in mental health care access and delivery. Moreover, most case-management and disease management activity at the health plan or insurance company level actually distances the patient and provider from ongoing, individualized, care planning and mutual accountability. We need a paradigm shift to empowering individual clinicians and clinics to do what works and is right for patients.

This will happen when patients and their families direct the money, and when providers compete on price and quality.

(Continued on page 8)

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2006

7

Colleague Interview (Continued from page 7)

What is the best format/venue for informing patients about the quality and cost of medical services? Many are disinterested or believe the issue is too complex to understand, and physicians are very sensitive about widespread release of quality data.

First, it is simply untrue that patients and their families cannot understand information about the costs and quality of medical care. Certainly there is a time and place to evaluate medical care cost and quality, and this is not when one is on the way to the ER in the ambulance. Second, regarding physicians being concerned about the widespread release of “quality” data from the government or insurance companies, the general public and the physician community have every reason to be concerned!

Population-based data comparing clinics or health care systems in Minnesota are not adjusted for illness severity or other patient characteristics.

In addition, there is a misplaced hope that electronic medical records coupled with evidence-based treatment guidelines will differentiate quality clinics and physicians. Add to this imperfect storm pay-for-performance financial incentives based on flawed assumptions and data. Every physician in Minnesota should have a Web site that describes his or her experience, training, practice scope and fees. There are many formats and venues for conveying quality information to patients: A collaborative relationship with one’s doctors (the “Medical Home” concept), actual experiences of relatives and others with the provider or clinic, advocacy organizations (for psychiatric services, the Minnesota Alliance for the Mentally Ill and Mental Health Association of Minnesota), peer reviewed literature and Internet sites such as those of the Mayo Clinic and Johns Hopkins, and national professional association treatment guidelines.

Regarding cost information, one should via the Internet have access to and compare provider fees and allowable insurance payments for medical services. Also, one should have access to detail on insurance contracts coverage and costs online.

Do you see overuse of psychiatric services as a bigger issue than underuse or vice versa? How do you see the move to consumer-driven health care influencing overuse/ underuse?

The notion of over-utilization of psychiatric services is simply false.

This has been a rationalization for cutting mental health and chemical dependency services over the past two decades. Managed care has reduced mental health outlays from about 7 percent of health care expenditures in 1985 to 2-3 percent now. Moreover, 20-40 percent of insurance dollars go to managing the care, i.e. administrative costs for external or internal behavioral carveout organizations working for the parent insurance entity to control mental health spending.

8

March/April 2006

How do we improve access to adequate psychiatric care for patients in the Twin Cities — particularly those who need chronic care?

Improve the pay to those who provide it. Use as the quality-measuring tool the actual experiences of patients as reported to advocacy organizations such as Minnesota Alliance for the Mentally Ill (NAMI-MN) and the Mental Health Association of Minnesota (MHAM). Publicize, critique and analyze problems and innovative approaches to psychiatric services care access and quality. Advocate reform of the present discriminatory payments system for mental health. For example, for the disabled and elderly patient, Medicare pays 50 percent of $113.17 allowable for 50 minutes with a psychiatrist. Our private insurance systems and Medicaid mental health carveouts follow suit with Medicare.

How have you modified your release of psychiatric information based on HIPAA requirements?

I am more stringent in protecting privacy than is required by the current HIPAA regulations. Specifically, I do not release information about my patients to any third party without their explicit, case-specific consent for the release. I will submit insurance forms for them if they request me to do this, but I will offer only information needed to process the claim — usually diagnosis and treatment code.

Recognizing that there is a shortage of behavioral health resources in the community, how can primary care get more “up to speed” in the management of behavioral health issues?

I am very impressed with the interest and mounting skills of many primary care colleagues. But more needs to be done to help improve the primary care of patients with mental and substance-related disorders.

Seek out a psychiatrist at any time to discuss questions you may have about psychiatric care.

What can we do to encourage more medical students to consider psychiatry as a career choice?

Support the able efforts of the University of Minnesota Department of Psychiatry, Mayo Clinic, and create clinical teaching mentorships for students and residents with practicing community psychiatrists. The Minnesota Psychiatric Society has a strong and nurturing Women’s Psychiatry Committee, for example.

What can we do to help re-establish behavioral health as an essential component of good, overall patient care, especially for patients with chronic or complex medical needs?

Actually, I do not like the term “behavioral health” because it overlooks the presence of motivation, emotion, and cognition in almost all as-

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

pects of medical care. Also, psychiatrists are physicians and often detect problems that require the attention of other physicians. We know what to do to practice good psychiatric medicine. This includes the valuable contributions of psychologists and others. Are doctors willing to step up to the plate and help their patients get quality psychiatric services?

I think so.

You have long been a pillar of quality psychiatric care.

For over 30 years you have maintained an independent practice, which among many specialties has become rare.

How do you see the future for psychiatry, family medicine, and other primary care specialties?

I hope to contribute to these discussions in the future. We, as professionals, are valuable to our patients. Just ask them.

for psychiatric evaluation services under your control. Certainly mental health nurses are a part of the solution. ER doctors and their staff want access to psychiatrists. You are successfully approaching hospital administrators and government payors about the ER and short-term psychiatric bed crisis in the Twin Cities and in greater Minnesota. The MMA and Minnesota Psychiatric Society strongly support these efforts.

We clearly need to encourage more psychiatrists to take on new patients and negotiate collaborations, for example, with mental health centers and hospital triage.

How should practicing physicians respond when health plan or disease management sponsored case or disease managers (with informed consent — psychiatry or otherwise) contact them about helping to facilitate improved clinical outcomes for one of their patients?

Collaboratively and also with skepticism. The patient should first be informed of insurance case management activities and give his consent.

Patient inquiries about cost and accountability to all parties, including the insurance company, are always appropriate. The doctor, clinic, or mental health center is the real venue of care rather than a health plan or insurance company.

You have a long and distinguished history of critiquing insurance companies and mental health carveouts. Do you feel that a single-payor (public) system would obviate all carveouts, and what are the advantages/disadvantages to the mental health consumer/provider of such a system?

No, I do not see a single payor as a panacea at all. We do in fact have single payor for most severely mentally ill patients now — Medicare and Medical Assistance. I favor allowing patients more control of where these dollars go in our public and private systems. I am very concerned that we, as a society, have shirked our responsibility to this vulnerable population, and I strongly urge professional and public advocacy for mentally ill patients — to include “Remarkable their housing in the community.

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What might you see as appropriate responses/ plans from organized medicine to address what I see in my practice of emergency medicine as a crisis in the provision of psychiatric services for both inpatients and outpatients?

Not only finding beds for those with unstable psychiatric emergencies, but also arranging care for those who need outpatient evaluation and care has become harder and harder over the years. Yet, patients and/or their families expect that these services will be available (and reasonably so) and often they’re not, at least in a timely fashion. How desperate does it have to get before it gets better?

Emergency medicine physicians are faced with daunting challenges concerning the evaluation and disposition of mentally ill and substance using patients. ER docs are doing the right thing by insisting on more support in the ER MetroDoctors

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St. Paul City Council Votes 4 to 3 for the Smoke Free Ordinance

O

ON WEDNESDAY, January 11, 2006 the

Saint Paul City Council approved an ordinance drafted by smoke free supporter Councilman Dave Thune by a vote of four to three. Mayor Chris Coleman wasted no time upholding his campaign pledge when he signed the ordinance that same afternoon. Former Mayor Randy Kelly twice vetoed Thune’s ordinances during his tenure.

Council members Kathy Lantry, Lee Helgen, and Jay Benanav continued to support Dave Thune in his effort to enact a smoke free ordinance in Saint Paul. Council members Dan

Bostrom, Pat Harris, and Debbie Montgomery voted no.

The ordinance goes into effect on March 31, 2006 and will ban smoking in Saint Paul bars, restaurants, pool halls, bingo parlors, and bowling centers. Smoking will be allowed in outdoor patios. Smokers who do not comply can be arrested for trespassing and business owners who do not comply will risk losing their liquor license.

The Ramsey Medical Society supported Council member Thune’s ordinance and organized important medical testimony

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Dave Thune, Councilman

supporting the need to eliminate the health risks of tobacco use and from second hand smoke. Other key organizations supporting the ordinance included the Ramsey Tobacco Coalition, the Association for Non-Smokers Rights, the Minnesota Partnership for Action Against Tobacco, and the Minnesota afďŹ liates of the American Cancer Society, the American Lung Association, and the American Heart Association.

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The Journal of the Hennepin and Ramsey Medical Societies

Tobacco Use Among Twin Cities Area College Students Background Following the 1998 Minnesota Tobacco Settlement and the multi-state Master Settlement Agreement with the tobacco industry, the 18–24 year old population became the youngest legal target in the United States for tobacco advertising, marketing and promotion.

The tobacco industry quickly responded to this change by developing promotional campaigns specifically geared to this population. Tobacco company sponsorship of young adult-focused concerts, bands, bar nights, trips, clothing and other promotional materials burgeoned. The success of these efforts was seen in the rise of tobacco use by young adults to the point where they became the group with the highest tobacco use rate in the country.

Despite that major shift in strategy by the tobacco industry, tobacco control advocates were still focusing most of their attention on tobacco use prevention among children and adolescents and smoking cessation among older adults. This was due to the fact that there was a paucity of data about the status of tobacco use by young adults.

To correct that deficiency, Boynton Health Service at the University of Minnesota (U of MN) began to systematically collect, analyze and report on data about tobacco use among college and university students.

These data were used to modify tobacco use prevention efforts on campus, to stimulate the development of young adult-oriented smoking cessation programs, and to encourage policy changes on and off-campus. On the U of MN campus, these data were influential in the development of policies that led to smoke-free residence halls, smoke-free building entrances,

BY EDWARD P. EHLINGER, M.D., MSPH KATHERINE LUST, PH.D., MPH, RD, AND DAVID GOLDEN

MetroDoctors

and the elimination of tobacco sales in the student union.

In two 2004 studies of U of MN undergraduates and nursing students from the U of MN and the College of St. Catherine, it was discovered that prolonged exposure to second hand smoke tripled on weekends (Figure 1) and that over 70 percent of that exposure occurred in bars and restaurants (Figure 2).

These data were presented to the Minneapolis City Council and the Hennepin County Board as they deliberated smoke-free ordinances in their respective jurisdictions. It was during this debate that the importance of these data for smoke-free ordinances became evident and that more information on tobacco use by college students was needed. Subsequently, Boynton Health Service was funded by the Hennepin Medical Society, through a (Continued on page 12)

Figure 1

Exposure to Environmental Tobacco Smoke 18-24 year old undergraduates Average Weekday

60

Average Weekend day

54.8

50 40

39 34.3

30

30.7 29.6

20 10.9

10 0

O hours

<30 min to 1 hour

2+hours

Level of Exposure Data Source: 2004 U of M Student-Health Assessment Survey

Figure 2

Exposure to Environmental Tobacco Smoke 18-24 year old nursing students 80 70 Tobacco users Non-tobacco users

60 50 40 30 20 10 0

Campus Event

Res Hall

Bar/Rest. House/apt.

Parties

Worksite

Auto

Other

NA

2004 Nursing Student Tobacco Survey

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2006

11

Tobacco Use (Continued from page 11)

Table 1

2-year public schools: • Anoka Technical College • Century Community and Technical College • Dakota County Technical College • Hennepin Technical College • Inver Hills Community College • Normandale Community College • South Central Technical College • St. Cloud Technical College 4-year private schools: • Augsburg College • Bethany Lutheran College • Bethel University • Concordia University • College of St. Catherine • Carlton College • Hamline University 4-year public schools: • St. Cloud State University • University of Minnesota–Twin Cities

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March/April 2006

Frequency of Tobacco Use

Demographics

Among current tobacco users, the frequency of use varied greatly depending on age. Younger students tended to use tobacco less frequently than students age 25 or older. Daily tobacco use was 9.7 percent for all students, 8.3 percent for 18-24 year-old students, and 17.6 percent for students age 25 and older. Daily use rate was 6.3 percent among students in 4-year schools and 18.4 percent in 2-year schools (Figure 4).

Mean Age: 22.4 years (range 18-65) 18-24 year olds 67.3% 2-year schools 90.3% 4-year public 93.5% 4-year private Gender: 34.2% male 60.2% female 5.6% not designated Race/ethnicity: Non-white 13.9% 2-year schools 15% 4-year public 12.8% 4-year private

Minnesota Department of Health grant, to gather that information.

Survey of Twin Cities Area College Students: Participation, Methodology and Demographics In January, 2005, all 2-year and 4-year public and private post-secondary education institutions within 80 miles were invited to participate in a survey of tobacco and alcohol use among their students. Seventeen schools agreed to participate. Participating schools included eight public 2-year schools, seven private 4-year schools, and two public 4-year schools. The combined enrollment in these schools is over 87,000 students. Participating institutions are listed in Table 1.

Depending on the size of school enrollment, a random sample of 25–50 percent of undergraduate students was surveyed at each institution from February through April, 2005, using the “CORE Tobacco, Alcohol, and Other Drug Survey.” This standardized survey has been used since 1992 at the U of MN and is used at numerous post-secondary education institutions throughout the country. Through U. S. or Campus Mail, 15,407 surveys were delivered. The overall response rate was 43.8

Table 2

percent with a range from 32.2 percent to 60.5 percent among the participating schools.

Selected demographics of the respondents from all schools are outlined in Table 2.

Findings Current Tobacco Use

Of all students surveyed, 29.7 percent reported that they had used tobacco within the last 30 days (current tobacco use). The current use rate by males was 32.6 percent and by females was 27.9 percent. The current tobacco use rate for 18-24 year-old students was 29.4 percent compared with 32.3 percent for students 25 years of age or older. Students in 2-year schools had a current tobacco use rate of 36 percent compared to 27.2 percent for students in 4-year schools (Figure 3).

Age at First Use

While the majority of initiation of tobacco use continues to occur prior to going to college, over 20 percent of current users started smoking after the age of 18 (Figure 5).

Quit Attempts

Among 18-24 year old current tobacco users, 57.8 percent don’t consider themselves smokers. Of the 42.2 percent who defined themselves as a smoker, 56.4 percent have tried to quit within the past 12 months. The average number of quit attempts was 3.5 among students who consider themselves smokers.

Among students 25 years and older who reported being current smokers, 70.2 percent considered themselves smokers and 55.5 percent have tried to quit in the past 12 months.

They averaged 4.6 quit attempts during that time.

Figure 3

Current Tobacco Use Figure 4 Users

80 70

Non Users

70.6

70.3

Daily Tobacco Use

By Type of School

72.8

67.7

20

64

60

18.4

50

15

40 36

30

10

32.3 29.7

29.4

27.2

20

9.7

5

6.3

10 0

0 All Students

18-24 years

25+

2 year

4 year

MetroDoctors

All schools

2-year schools

4-year schools

The Journal of the Hennepin and Ramsey Medical Societies

Figure 5

Age of First Use of Tobacco % of all Students–Current Users <18 18-20 21+

on ways to help students quit smoking. The fact that nearly 25 percent of all tobacco users on-campus began to use tobacco after the age Figure 6

Average Number of Drinks/ Week by Smoking Status 78 Non tobacco users Used tobacco past 30 days

9 19.9 2.1

8.7 8.1

8 7 6

5.1

5

Smoking Status Related to Alcohol and Other Drug Use One of the most surprising findings of the survey was the strong association between tobacco use and alcohol and other drug use. The average number of alcoholic drinks consumed per week was significantly higher for current tobacco users than for non-smokers. This association was true at all ages but particularly dramatic for 18-24 year-olds where the average number of drinks per week for smokers was over three times as high as that of non-smokers (Figure 6).

A similar relationship was noted between current tobacco use and marijuana and other illegal drug use (Figures 7 and 8).

The data also demonstrated that current smokers most frequently smoke where alcohol is being served. When asked where they smoked, 80.8 percent of smokers stated they smoked at private parties and 75.1 percent stated they smoked in bars.

Discussion Tobacco use continues to be a significant problem on college campuses. The intensity of tobacco use is less on 4-year campuses which indicates a continued need for efforts to keep intermittent tobacco use from progressing to daily use, while on 2-year campuses there is a greater need for cessation services. The number of students trying to quit smoking is encouraging and argues for expanded research

MetroDoctors

4 3

2.6

2.6 2.2

2 1 0

All Students

18-24 year olds

of 18 argues that college students need to be a priority group for both tobacco use prevention and cessation efforts.

The strong relationship between tobacco and alcohol use suggests that the contextual aspects of tobacco use must also be addressed in tobacco control programs. It also raises hopes that smoke-free bar and restaurant ordinances may have an impact on smoking rates among college students.

This survey was unique in many ways.

It was the first of its kind to include multiple schools (public and private) in a distinct geographic area. The inclusion of 2-year schools has generated data on a distinct population that exist nowhere else. The fact that this survey was funded by Hennepin Medical Society and was part of that group’s efforts to address a significant public health issue is also unprecedented.

This survey and subsequent dissemination of the data could not have occurred without their involvement. The process of doing the survey and the data generated from it should be helpful in guiding prevention, cessation, and policy initiatives, not only in Minnesota, but also throughout the country.

25+ year olds

Figure 7

Figure 8

Other Illegal Drug Use

Past 30 Day Marijuana Use Rate

By Smoking Status

(excluding marijuana)

Past 12 Months

By Smoking Status

Non tobacco users Used tobacco past 30 days

Non tobacco users

40

Used tobacco past 30 days

37.2 34.2

35

25

30

23.2

22.2

20 25 16.7

20

18.8

15 10

15 10

7

7.4 5

5 0

5

5.1

6.5

4.9

0 All Students

The Journal of the Hennepin and Ramsey Medical Societies

18-24 year olds

25+ year olds

All Students

18-24 year olds

25+ year olds

March/April 2006

13

Is Disease Management the New Face of Managed Care?

D

DISEASE MANAGEMENT programs are

gaining traction with many of the nation’s employers as employers struggle to control rising health care costs. In the current health care system medical providers are compensated for treating acute illnesses in the short term.

Disease management programs focus on chronically ill patients in an attempt to both improve the quality of care enrollees receive and to control the growth of health care costs.

Disease management incorporates a combination of tools including enhanced screening, patient education, symptoms monitoring, provider coordination and evidence based medical treatment guidelines.(9) Disease management program theory, however, runs counter to the current economics of health care delivery: in other words, U.S. medical providers are not paid for preventing disease.

When managed care arrived on the scene in the early 80s as a replacement to the fee-forservice “sickness care” system, it was advertised by the insurance industry as a new wellness and prevention model for health care.(1) With hindsight, it can be demonstrated that at least two popular managed care myths have heavily influenced the development of disease management model assumptions.

Myth #1: Managed Care Delivers Wellness and Prevention

Although the health insurance industry has touted wellness and prevention as its main goal for decades, its main accomplishment has been in the area of employer marketing

BY THOMAS SPENCER, CORINNE ABDOU, R.N., KATHY KING, R.N. AND DAVID SPENCER, M.D.

14

March/April 2006

with 69 percent of all United States employers offering this benefit by 2000.(2)(3) This has resulted in an employer-sponsored health insurance system so rich in benefits that nearly every predictable human condition from the common cold to sore muscles is covered by the employer paid premium. Since nearly all routine and predictable conditions are lumped together with major diseases for coverage under an employer contract, modern health care insurance is no longer insurance against the unforeseen catastrophic disease but rather pre-paid medical care.

Disease Management programs are gaining

group (DRG), are rewarded because they are the easiest to measure and, in theory, to control. Disease management tools like enhanced screenings and patient education, which may result in positive health and economic outcomes, are not rewarded because they are harder to measure and their impact in terms of better health and lower costs may not be known for many years.

The economic bias toward health care processes in the U.S. system of health care delivery has resulted in a structural misalignment of incentives between the two most critical parties in the health care equation, the doctor and his patient. This misalignment became permanent because of the second popular myth of the managed care era.

traction with many of the

Myth #2: Insurance Companies are More Efficient Case Managers

nation’s employers as

Case management was described as one of the four essential functions of managed care in a 1992 publication by United HealthCare titled “The Managed Care Resource.” Before 2000, case management was directed toward patients with diagnosed, complex medical conditions usually triggered by acute episodes of illness. Disease management, in contrast was specifically concerned with the management of chronic illnesses like diabetes, emphysema and osteoporosis.(3) Increasingly the distinctions between the two approaches have diminished, yet two characteristics of each have remained the same: first, the involvement of an insurance company employed nurse case manager to coordinate the provision of care services; and second, the emphasis on patient education.

Curiously, a search of the medical literature generates almost no peer reviewed evidence to support the notion that insurance

employers struggle to control rising health care costs.

Employer-sponsored health insurance works against disease management model theory in two important ways. First, pre-paid health care makes medical services so accessible to employees that there is no immediate incentive for the employee to participate in preventing his own illness.

Second, physicians and other health care providers are contracted with insurance companies to provide medical treatments or the “processes of care.” Health care processes, as captured by codes like current procedural technology (CPT) and diagnostic related

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The Journal of the Hennepin and Ramsey Medical Societies

company nurse case managers do better in terms of health outcomes than family physicians who directly supervise the care of their patients. According to a Congressional Budget Office report “there is insufficient evidence to conclude that disease management programs can generally reduce overall health spending.”

Although patient education is cited in all disease management models as an essential disease management component, it generates almost no reimbursement for the primary care physician. By contrast, case management at the insurance company level employs about 16,000 nurse case managers according to the Case Management Society of America.(4)(7) How Does Disease Management Work?

Disease management starts by identifying subpopulations of employees who also have a diagnosed or undiagnosed chronic disease.

In the case of diabetes, for example, patients need to monitor and to control their blood sugar levels. They may use diet, exercise, insulin and other medications to help them control blood sugar. Patients are largely responsible for their own care and monitoring, especially in the home.

Next, patients are enrolled in a disease management program that offers a standardized set of evidence-based medical processes.

In diabetic patients these interactions include blood pressure screenings, annual foot and eye exams, annual lab tests for kidney function and cholesterol and twice yearly checks for hemoglobin.

If the interactions result in the prevention of complications like elevated blood pressure, high cholesterol and low hemoglobin levels they are judged to be successful. The longterm benefits of positive diabetes management such as the prevention of blindness, strokes, renal failure and amputations are not typically captured because they may not be known for years. See Figure 1.

Disease management programs are not free to implement. Typically they are offered to employers for an up-front investment.

Thereafter they are continued through a permember-per-month charge to the employer.

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Does Disease Management Lower Costs?

In 2004 Blue Cross and Blue Shield of Minnesota began collaborating with American Healthways — a Nashville based HMO — to provide 144,000 participating Blue Cross members with a program that targets 17 chronic health problems. Under the program, nurses coordinate care for each of the targeted diseases according to the American Healthways formula. Early results from the program, according to Dr. Bill Gold, Blue Cross’ Chief Medical Officer and Vice President, show that the insurer saved $4.23 for every $1 invested in the program.(5) If an employer were to accept the Blue Cross-American Healthways report at face value, then the future success of disease management is not in doubt. According to the

Congressional Budget Office, however, there are a number of important methodological issues in assessing the cost effectiveness claims of these companies. These issues stem from the following cost considerations: • Administrative costs — enrollment, education, intervention, etc.; • Disease cost capture — all physician, medication, clinic, emergency room, hospital, etc.; • Unintended costs — false positives, invasive testing, new diagnosis, etc.; • Selection bias — volunteer costs are lower than the reference group; and • Regression to the mean — participants volunteer or are selected on the basis of high cost.

(Continued on page 16)

Figure 1.

The Path by Which a Disease Managment Program for Diabetes Could Lead to Better Health Outcomes and Lower Health Costs • Selection of patients • Education • Communication • Monitoring • Feedback • Coordination of Care

Disease Management Intervention

‚ Process Outcomes

Adherence to evidence-based guidelines, such as: • Annual foot and eye exam • Annual tests for kidney function and cholesterol • Biannual test for hemoglobin A1c, or control of blood sugar

‚

Changes in intermediate measures, including: • Hemoglobin A1c • Blood Pressure • Cholesterol

Intermediate Outcomes

‚ Health Outcomes

‚

Ê

Changes in the incidence of outcomes, including: • Blindness • Leg amputation • Heart attack • End-stage renal disease • Death

Quality of Life

Health Care Utilization

• Related to cost-effectiveness

Changes in the utilization of services, including: • Hospitalization • Doctor visits • Emergency dept. visits • Dialysis

Source: Congressional Budget Office

The Journal of the Hennepin and Ramsey Medical Societies

‡

Economic Outcomes

• Cost of the intervention minus any savings from health improvements

March/April 2006

15

March/April Index to Advertisers Childrenâ&#x20AC;&#x2122;s Physician Network ........................

Outside Back Cover ClassiďŹ ed Ads ............................................ 10 Coldwell Banker Burnetâ&#x20AC;&#x201D; Bruce Birkeland............ Inside Back Cover CrutchďŹ eld Dermatology ............................ 9 Mankato Clinic ......................................... 10 MMIC ...................................................... 18 Minnesota Oncology Hematology, P.A. ............

Inside Front Cover RCMS, Inc. ....................... Inside Back Cover Minnesota Healthcare Network and Triium .......................................... 20 Weber Law OfďŹ ce ..................................... 16 Whitesell Medical Locums, Ltd. ................ 20

Disease Management (Continued from page 15)

Given the economic clout of the health insurance industry, there is a widespread assumption that physicians and providers will embrace disease management program protocols. While there is some evidence in recent studies in the ďŹ eld of rheumatology that suggest that better health and economic outcomes are attainable when physicians implement the formula as designed, important weight was given in these same studies to patient education that led to timely patient access to the rheumatologist.(6)(7) Peer reviewed studies, however, do not support this assumption. In fact, in an October 13, 2004 cover letter introducing the CBOâ&#x20AC;&#x2122; disease management report Senator Don Nicklesâ&#x20AC;&#x2122; concluded that â&#x20AC;&#x153;The few studies that report cost savings do so for controlled settings and generally fail to account for all health care costs, including the cost of the intervention itself.â&#x20AC;? (2) Is There a Prescription for Disease Management Success?

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16

March/April 2006

In a 2004 study conducted by the non-partisan Employee BeneďŹ t Research Institute, workers rated health insurance as the most important beneďŹ t they receive by a margin of ďŹ ve to one (60 percent to 17 percent). The same study concluded, â&#x20AC;&#x153;employers that do not offer health insurance may have difďŹ culty in attracting and retaining skilled workers.â&#x20AC;? (7) New health insurance products such as health savings accounts may be used by employers as a foundation from which to build a disease management program.

After the employee, the employer has the most to gain from taking an active role in the design of a disease management program.

A cursory review of health care insurance industry pronouncements from 2003 until now would seem to indicate that the future of disease management is now.(5) In important ways its arrival echoes many of the assumptions and the truth claims of the early managed care era 25 years ago. What hasnâ&#x20AC;&#x2122;t changed is that there is little more evidence today than there was in 1980 to prove that sophisticated management of health care processes, or insurance company led case management or patient education as currently practiced will

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deliver better employee health and lower health care services costs. The lack of contemporary evidence for disease management programs is evidence itself that employers should ask the following questions before embarking on a disease management program: 1) Does the program reward employees for compliance and better health outcomes?

2) Does the program support the physician/ patient relationship and plan of care?

3) Are savings in health care resources utilization shared with the employer?

Footnotes: 1. Harris, JM Jr., â&#x20AC;&#x153;Disease management: new wine in new bottles?â&#x20AC;? [editorial] Ann Intern Med 1996; 124: 838-842. 7.

2. Conrad, Kent, U.S. Senate, â&#x20AC;&#x153;An Analysis of the Literature on Disease Management Programsâ&#x20AC;? Committee on the Budget, Congressional Budget OfďŹ ce, (October 13, 2004) 3. Krasner, Jeffrey, et al. â&#x20AC;&#x153;Fewer Companies Offering Health BeneďŹ ts as Costs Riseâ&#x20AC;? The Boston Globe (September 15, 2005) 4. Epstein, RS, Sherwood, LM. â&#x20AC;&#x153;From outcomes research to disease management: a guide for the perplexed.â&#x20AC;?

Ann Intern Med 1996; 124:832-837 5. Pallarito, Karen et al., â&#x20AC;&#x153;Disease Management: The New Face of Managed Careâ&#x20AC;? HealthDay, (January 5, 2004) 6. Carias K, Kramer N, Paolino J, et al. â&#x20AC;&#x153;Expert care is better than inexpert care: rheumatologists patients hospitalized with acute arthritis have better outcomes than non-rheumatologists: preliminary observations.â&#x20AC;? [abstract]. Arthritis Rheum 1994; 37(9 suppl):1169 7. Clough, John D, â&#x20AC;&#x153;Chronic Disease Management and Managed Care: Specialists Have an Important Role,â&#x20AC;?

Cleveland Clinic Journal of Medicine [editorial] 8. Fronstin, Paul, et al., â&#x20AC;&#x153;Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2005 Population Surveyâ&#x20AC;? IB.287 (November 2005) 9. McAlister, Finlay A, and others â&#x20AC;&#x153;A Systematic Review of Randomized Trials of Disease Management Programs in Heart Failure.â&#x20AC;? American Journal of Medicine, vol.110, no.5 (April 1, 2001), pp.378-384.

Thomas D. Spencer is President of Advanced Healing Systems, LLC, a distributor of a new medical technology that heals chronic wounds.

Before joining Advanced, Spencer spent 17 years in the health insurance and medical device industries. Corinne Abdou, R.N., is a principal in Kaleidoscope Health Systems, Inc. Kathy King, R.N., is Director of Nursing at Minnesota Masonic Homes in Bloomington. David Spencer, M.D., is a retired professor of medicine from the University of Illinois Medical School.

The Journal of the Hennepin and Ramsey Medical Societies

Prior Authorization Needed for Many Health Care Services

T

THE 2005 MINNESOTA Legislature modified

coverage for a variety of the health care services provided to patients covered by Medical Assistance (M.A.), General Assistance Medical Care (GAMC), and MinnesotaCare.

The following summarizes some of the more significant changes: Effective September 1, 2005, for services provided on or after that date, new prior authorization requirements were added for nonemergency cesarean section, hysterectomy, spinal fusion and tympanostomy tubes.

Non-Emergency Cesarean Sections Criteria established by the Minnesota Department of Human Services (DHS) provide that coverage for non-emergency cesarean sections will be made for the following conditions: • Previous cesarean deliveries (no trial labor or VBAC attempt is required) • Abnormal fetal presentations • Suspected cephalopelvic disproportion • Multiple gestation • Placenta previa • Preeclampsia • Fetal anomalies that contraindicate labor and vaginal delivery • Maternal health conditions that contraindicate labor and vaginal delivery No prior authorization is necessary for emergency cesarean deliveries, which DHS defines as, “a condition including labor and delivery that if not immediately diagnosed and treated could cause a person serious physical or mental disability, continuation of severe pain, or death.”

BY JANET SILVERSMITH

MetroDoctors

Hysterectomy Criteria established by the Minnesota Department of Human Services (DHS) provide that coverage for hysterectomies will be made for the following conditions: • Malignant disease of the cervix, uterus, ovaries, or fallopian tubes; • Symptomatic uterine fibroids (leiomyomas) that are either: – causing bladder pressure, pain, fullness, functional disturbance, – bleeding unresponsive to conservative therapy, or – showing rapid and progressive enlargement.

• Recurrent or persistent uterine bleeding or discharge with failure to respond to conservative management; • Confirmed diagnosis of endometriosis with documented failure of non surgical management, e.g. use of hormonal therapy (if not contraindicated) and/or low dose contraceptives; • Endometritis that is unresponsive to conservative management; • Chronic pelvic inflammatory disease unresponsive to conservative management; • Adenomatous endometrial hyperplasia with moderate or severe atypia recurring despite conservative management; • Obstetrical catastrophes, such as uncontrollable postpartum bleeding, uterine rupture, uncontrolled uterine sepsis developing from septic abortion, placenta accretion, etc.

• Septic abortion not responsive to conservative management; • Removal of the uterus in non-gynecologic pelvic surgery where necessary to encompass disease originating elsewhere, as in uterine involvement in colon cancer or in abscesses secondary to diverticulitis;

The Journal of the Hennepin and Ramsey Medical Societies

• Symptomatic uterine prolapse or descent resulting in general pelvic relaxation; • Other conditions determined to be medically necessary.

It is important to note that the prior authorization requirements do not replace the requirement for a hysterectomy acknowledgement statement (HAS), which still must be submitted with the claim.

Spinal Fusion Criteria established by the Minnesota Department of Human Services (DHS) provide that coverage for spinal fusion will be made for the following conditions with radiographic documentation: • Degenerative, traumatic, infectious or other pathology causing spinal instability; • Neural/epidural compression resulting from vertebral fractures or vertebral destruction from tumor; • Pseudoarthrosis; • Spinal tuberculosis; • Chronic discogenic back pain without instability following extensive diagnostic evaluation, failure of conservative measures and an absence of other sources of pain and underlying psychosocial issues.

Tympanostomy Tubes Criteria established by the Minnesota Department of Human Services (DHS) provide that coverage for tympanostomy tubes will be made for the following conditions: • Recurrent acute otitis media which is unresponsive to medical management; • Complications of otitis media; • Development of advanced middle ear disease; • Treatment failure secondary to drug allergy or intolerance.

(Continued on page 18)

March/April 2006

17

Prior Authorization (Continued from page 17)

Imaging Services New prior authorization requirements for outpatient CT scans, MRIs and nuclear cardiology diagnostic services were also passed by the Legislature, but the Minnesota Department of Human Services has postponed the implementation of this provision pending review of “new ways to manage the authorization process.”

Circumcisions The legislative change that has received considerable attention, and drawn the ire of numerous groups, including physicians, is the prohibition on coverage for circumcision unless the procedure is deemed (through the prior authorization process) medically necessary or required because of a well-established religious practice.

According to criteria established by DHS, if, in the opinion of the attending physician, a pathologic condition exists that requires

circumcision, prior authorization can be requested, but it is noted that medical necessity for newborn circumcision is rare. Per DHS, phimosis alone is not considered a pathologic condition and does not support medical necessity for circumcision in infants and children.

The Department of Human Services (DHS) defines a well-established religious practice as: “1) being a member of a recognized religious sect or division of the sect; and 2) adhering to the tenets or teachings of the sect or division of the sect that requires newborn male circumcision. Note: The known and established religions that have a religious practice of infant male circumcision are Judaism, Islam and Coptic Egyptian Christianity.”

For those enrolled in a prepaid program (e.g., PMAP), circumcision remained a covered service until January 1, 2006.

Other In addition to the various prior authorization changes, a number of services are no longer covered under Minnesota’s health care safety

net programs. They include circumcision, drugs for erectile dysfunction, sex reassignment surgery, and services provided at the emergency room that are not for emergency, emergency stabilization or urgent care.

Recent guidance from DHS regarding payment for non-emergency services indicates that for dates of services on and after October 1, 2005 (claims will be reprocessed), hospitals will be reimbursed for the facility component of a non-emergency emergency department visit at the office payment level, which is a reduction from charges associated with emergency department services.

The non-emergency payment changes do not apply to physician and other professional services or to Critical Access Hospitals.

Finally, new authority was granted to DHS to allow them to prior authorize new drugs approved by the FDA after July 1, 2005 for 180 days post market introduction.

Janet Silversmith, M.A., is Director of Health Policy for the Minnesota Medical Association.

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18

March/April 2006

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The Journal of the Hennepin and Ramsey Medical Societies

AMA — Participation at the National Level

F

FOR MANY PHYSICIANS in the county and

state societies, there is a disconnect with the American Medical Association. This is even truer for physicians who are not even members of organized medicine. Many feel that they do not know anyone who is active in the AMA, or what the AMA does.

Minnesota actually has many physicians involved at the AMA level. Our Minnesota Medical Association has 12 members who are the delegates/alternate delegates to the national meetings, which occur twice a year, June and November/December. The current chair of the MMA delegation is Dr. Frank Indihar, of RMS. HMS members Drs. David Estrin and Ben Whitten are alternate delegates; RMS member Dr. Ken Crabb is a delegate and I am an alternate delegate. Dr. Michael Gonzalez-Campoy, RMS member, is a delegate for the AMA Minority Affairs Consortium. Dr. Joe Keenan, HMS member, is a delegate for the American Geriatrics Society. Many other MMA members from Rochester, Duluth and throughout the state are active either on the state’s delegation or for other organizations.

The AMA governance is similar to our county and state governance structure. The Board of Trustees is the governing body; trustees are elected by the AMA House of Delegates (HOD). The president-elect, speaker and vicespeaker of the HOD are elected by the HOD and serve, with the president and past president, on the board. RMS member Dr. William Jacott was a trustee from 1989 to 1998.

The next layer of governance consists of various councils and sections. There are Councils on Medical Education, Medical Service, Ethical and Judicial Affairs, Long Range Planning and Development, Science

BY BLANTON BESSINGER, M.D., M.B.A.

MetroDoctors

and Public Health, and Specialty Sections (29).

The Council on Legislation is a very active group that follows closely the national and state legislative initiatives and recommends to the board the appropriate action to take. Its members are appointed by the AMA Board of Trustees (BOT). Dr. John Van Etta of Duluth currently serves on the Council on Legislation.

Another council is the Council on Constitution and Bylaws; this council serves as a fact-finding and advisory committee on matters pertaining to constitution and bylaws, and recommends changes that it deems appropriate for action by the HOD. The members are nominated by the BOT and are elected by the HOD. The term is four years, and a member may serve two terms if re-elected. I have applied to the BOT to be nominated this year to run for this council at the AMA Annual Meeting in June, 2006.

This opportunity arose at the AMA Interim Meeting in December of 2005, when we learned that three of the six active member slots were up for election in 2006 and that only one incumbent was planning to run again. I made known my interest to the Minnesota Delegation, who discussed this and supported the

The Journal of the Hennepin and Ramsey Medical Societies

decision to explore it with the North Central Medical Conference (Minnesota, Wisconsin, Iowa, Nebraska, North Dakota and South Dakota) Candidate Selection Committee.

This committee also supported my candidacy and recommended it to all the North Central delegates and who unanimously approved. In spite of the 11th hour decision, with the great help of Dr. Bob Meiches and the staff at MMA, and other MMA delegates, we were able to leave a flyer on the last day announcing my candidacy.

Three other people have announced, and the BOT will probably nominate at least two candidates for each of the three positions. The election is on the next to last day of the 2006 AMA Annual Meeting. The voting members will be the 500 plus delegates at the meeting.

There will be many caucus committee interviews and a reception is planned. However, the biggest part of the campaign will be the contact with all the delegates and alternates that will be at the meeting. The contacts will include several mailings over the months before the meeting, and most importantly, personal contacts by physicians to physicians in other states and specialties who will be at the meeting or can speak to those who will be at the meeting.

A campaign committee has already met twice to plan the strategy and logistics of this effort. HMS member Dr. Ben Whitten and RMS member Dr. Michael Gonzalez-Campoy are co-chairs of the campaign committee, along with Dr. Paul Matson, past president of MMA from Mankato, and Dr. Kevin Flaherty, Wisconsin delegate. The MMA staff is already active with the committee, and the lead person is Lorrie Holmgren, director of communications.

Several friends (including my wife) have asked why, at my stage of life, I have any interest in getting involved at the AMA (Continued on page 20)

March/April 2006

19

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March/April 2006

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MetroDoctors

AMA Participation (Continued from page 19)

level, and why the Council on Constitution and Bylaws. I have been going to AMA meetings since 1999 when I was president-elect of the MMA. I have always had an interest in constitution and bylaws issues. I have been to the Reference Committee on Constitution and Bylaws at both meetings the past six years.

I have been involved in writing constitutions and bylaws for my county and state societies, medical staffs, and hospitals. In my officer positions with MMA, as medical director for the Children’s Hospital, and as president of non-profit boards, I have acquired knowledge and experience with governance issues.

Organizations, small and large, have many and variable ideas to achieve their purposes.

However, no matter how well intended and good the ideas may be, they will be of no value if the members are not able to come to agreement on which ones to implement and how to implement them successfully. How a group does this is its Organizational Behavior.

Organizational Behavior (an actual academic discipline) has both informal and formal structure. The formal part is constitution and bylaws. They are the framework by which several to many people can deal with each other fairly and work together effectively.

The AMA is a large and complex organization with many different constituents.

It has many strong individuals, the informal structure. But it is now thriving and having success in many areas because of strong efforts to be inclusive and have everyone participate.

This is based to a great extent on its formal structure.

I note that I still have not answered the question of why I seek to serve on this council.

There is no succinct answer, but rather the feeling that I want to continue my involvement at the AMA level, and try to get more involved with its activities. I know it is a cliché, but I do believe that what one gets out of something is proportionate to what effort is put into the activity. I also believe that physicians in Minnesota have much to offer at the county, state and national levels of organized medicine, in associations and specialty societies. This type of campaign, win or lose, will benefit Minnesota physicians now and in the future, by letting the rest of the country know who we are and what we can bring to the table.

The Journal of the Hennepin and Ramsey Medical Societies

Minnesota at the Forefront for Recognizing and Rewarding Quality Care

A

AT HEALTHPARTNERS Outcomes Recog-

nition (ORP) awards dinner last November, Northwest Family Physicians (NWFP) took top honors for delivering top-notch care for its patients. NWFP, which serves suburbs northwest of Minneapolis, received the highest award for meeting all quality targets in HealthPartners pay-for-performance bonus program. Northwest Family Physicians and 29 other medical groups received a total of $1.4 million in bonus payment. In accepting the award, Dr. Dawn Blomgren, medical director of NWFP said, “This award is for everyone at NWFP. It takes a team to achieve this.” The pay-for-performance (P4P) program recognizes providers for delivering evidence-based care for diabetes, coronary artery disease, preventive care, tobacco addiction, generic prescribing and for providing excellent patient access.

Following the modern Hippocratic Oath to “apply, for the benefit of the sick, all measures which are required and to prevent disease whenever they can,” most physicians work to provide the right care for their patients. The current payment system, however, doesn’t reward best care. That’s why the Institute of Medicine (IOM), in its 2001 report Crossing the Quality Chasm urged payers to align their payment policies with quality improvement.

The IOM’s recommendation is fast gaining momentum after one of the biggest payers in the nation, the federal government, announced steps to implement P4P initiatives.

The Centers for Medicare and Medicaid Services reported in May that an early demonstration project at more than 270 hospitals showed a significant improvement in quality of care including care for heart failure, hip and knee replacement and pneumonia.

Team Effort Even before the IOM recommendation,

HealthPartners was one of the first health plans in the nation to implement a P4P program in 1997. The program recognized primary care physicians who are on the front lines of patient care.

Today, there are over 100 private P4P programs in the nation according to a survey by the Institute for Health Policy Studies at the University of California, San Francisco.

One key reason for their popularity is increasing evidence that aligning financial rewards to medical groups is an effective strategy for improving patient care.

One dramatic success story is Family Health Services of Minnesota (FHSM). FHSM received a HealthPartners award for helping patients with diabetes reduce their risk of heart attack, stroke and other complications by reaching all treatment targets and for keeping patients up-to-date on preventive care. FHSM’s formula for achievement includes steps that any medical group can implement: • Set concrete goals such as increasing percent of patients at their treatment goals for blood pressure, glucose, cholesterol, aspirin and nonuse of tobacco.

• Evaluate and address barriers among patients, clinic staff and physicians such as patient resistance and access to affordable medication.

• Take a team approach and develop systems. FHSM put A1c machines in each clinic, has standing orders for nurses to test patients’ glucose if necessary and counsels patients during visits.

• Provide tools and training like patient education packets and foot exam standards and tools in every exam room.

• Make results transparent, by sharing clinic results and having physicians review their partners.

• Establish friendly competition between clinics and between providers.

• Align incentives such as awarding a physician pool for meeting targets.

• Don’t accept close enough.

The results are truly award winning. Five years ago, 88 percent of FHSM’s patients had a glucose test, 79 percent had LDL tested and very few reached all of their target goals. By 2004, those numbers increased to 97 percent for glucose test, 95 percent for LDL test and more than one of three patients reached all their treatment goals for glucose, cholesterol, blood pressure, aspirin use and non-tobacco use. In addition, FHSM achieved a benchmark of 35 percent for optimal diabetes care meeting all five treatment targets to decrease patient risk of developing cardiovascular complications.

FHSM’s experience shows that it takes the whole team. Physicians report that for the first time, clinic administrators are asking how they can help improve care. One clinic system, for example, developed performance standards for receptionists to assure that patients with diabetes had at least two visits with their personal physician annually and that lab work was done and available for each visit.

Why We Need to Measure A strong case can be made for the need to improve the quality of care in the U.S. In 2003 McGlynn, et al reported in the New England Journal of Medicine that Americans received only 55 percent of recommended care. The Institute of Medicine’s 2000 report, To Err is Human, estimated that 44,000 to 98,000 Americans die each year from preventable medical errors. In November 2005, Wennberg, et al reported in the journal Health Affairs, that Medicare pays some California hospitals four times more than others to care for similar patients and the more expensive care resulted in lower, not higher, quality and patient satisfaction.

BY GAIL AMUNDSON, M.D. FACP

(Continued on page 22)

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The Journal of the Hennepin and Ramsey Medical Societies

21

Minnesota at the Forefront (Continued from page 21)

Engaging Physicians A key lesson learned in Leapfrog’s national study of P4P is that physicians are more likely to participate and embrace P4P if they view measures as valid and scientifically sound. Physicians are involved in defining HealthPartners performance measures. Clinical measures are based on physician-developed Institute for Clinical Systems Improvement (ICSI) guidelines. ICSI members number over 75 percent of physicians practicing in Minnesota.

Supporting Physicians HealthPartners supports physicians by routinely providing access to electronic registries and by providing members with health improvement, disease management and medical and behavioral health case management services support.

What Gets Measured Gets Improved In 1997 no group met HealthPartners tobacco target of 80 percent of patients who were asked about tobacco use at every visit. Two years later, 10 groups reached that goal, and last year 18 of 30 groups met today’s target of 95 percent.

Plus, 75 percent of smokers repored they got help quitting. And it makes a difference. Today, over 90 percent of patients are asked about tobacco and 70 percent of smokers receive help quitting. Over the past seven years as to-

bacco quality measures have risen dramatically, tobacco use among HealthPartners members fell from 26 percent to 15 percent. Over that same time children’s exposure to second hand smoke plummeted by two thirds, falling from 23 percent to 8.6 percent.

All Recommended Care Diabetes and heart disease are properly managed by controlling all risk factors not just one or two. HealthPartners P4P program recognizes and rewards providers for addressing all risk factors. The goal is to provide optimal care for each individual patient. For example, to be considered optimal, diabetes patients must have blood glucose, LDL (bad) cholesterol and blood pressure well controlled. They must not smoke and they must also take daily aspirin if they are over 40. Meeting all targets is a high quality standard and medical groups are rising to the challenge.

The number of members who received all of the recommended care for diabetes has quadrupled in the past five years steadily climbing from 5 percent to 22 percent. In 1999 only one in five HealthPartners members with coronary artery disease received optimal care.

By 2003 the number had more than doubled.

Now over one half have minimized their risk of future heart problems.

Another way to evaluate quality is to look at average levels for glucose, cholesterol and blood pressure control across all patients.

Each is steadily decreasing for HealthPartners

Excellent Diabetes Care 30%

2004 ORP Target 30%

20%

10%

0%

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Optimal Diabetes Care

New Optimal Diabetes Care

1999

2000

2001

2002

2003

2004

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Clinics: • Family HealthServices of Minnesota • Northwest Family Physicians • Camden Family Physicians • Ridgeview Care System • Crossroads Medical Centers, PA • North Suburban Family Physicians • Quello Clinics, Ltd. • Allina Medical Clinic • Fairview Clinics • Minnesota Healthcare Network • North Clinic, PA • Western WI Medical Associates • RiverWay Clinics • WINONAChoice

MetroDoctors

members with diabetes or heart disease.

Average A1c now surpasses treatment recommendations, falling in the last 10 years from 8.7 percent to 6.8 percent. Similarly average LDL cholesterol in members with heart disease decreased from 109 mg/dl in 1999 to 86 mg/dl in 2004 also surpassing current treatment recommendations. Average systolic blood pressure in members with diabetes dropped from 134 mmHg to 122 mmHg over the past five years too. A remarkable achievement!

Making a Difference As a direct result, HealthPartners members with diabetes are healthier. Rates of preventable complications are down. In 2004, compared to 1994, 80 patients were spared a heart attack, 120 avoided an amputation and 320 fewer patients developed the eye complication that can lead to blindness.

Demonstrating this link between rewarding quality and improving patient outcomes is why the Institute of Medicine’s report Performance Measurement: Accelerating Improvement highlights HealthPartners as a “pioneer” and calls for national measurement standards that include composite measures like HealthPartners diabetes, heart disease and preventive care measures.

Generic Drug Use In addition to rewarding improved care, HealthPartners also rewards physicians for improving efficiency. Mesaba Clinics, for example, received an award for increasing its use of generics from 47 percent to 60 percent in one year. Using more tried and true generic medicines has increased 13 percent overall among HealthPartners members in the past three years and has reduced drug costs by $62 million helping to mitigate rapidly escalating health care costs that threaten all of us in Minnesota and across the country.

Hospitals Specialty Care This year, HealthPartners expanded its P4P program offering bonus incentives to cardiology, physical therapy, behavioral health and OB/GYN. It’s another step in building a payment structure that supports and rewards physicians for reliably delivering the care that improves health and saves lives.

Gail Amundson, M.D., serves as Associate Medical Director for Quality Improvement at HealthPartners.

The Journal of the Hennepin and Ramsey Medical Societies

PHYSICIAN'S SOAP BOX

U.S. Health Care— Market Failure or Failure to be a Market?

W

hen was the last time that you went to the mall and purchased some clothing, books, jewelry, saw a movie, had lunch and then went home with only paying a minimal co-pay? The different vendors would simply submit a bill to your home insurance company. The goods would seem cheap but your home insurance costs would be astronomical! With no accountability for costs on the consumer’s part, each store would bill the insurance company as much as possible. Suppose the insurance company could arbitrarily decide to not pay for some of the purchases. The stores would try to bill as much as possible. The insurance company would try to pay as little as possible. The established prices would have nothing to do with what the consumer would have been prepared to pay.

Worse yet, people with modest consumption habits would be charged the same for insurance as those that go on daily shopping sprees. Suppose laws were written that disallow discriminating against the shopaholics by either raising their premiums or refusing to sell them insurance. Costs generated by shopaholics would have to be borne by everyone. Premiums would be driven up for all. As premiums rose, those with lower incomes would have to opt out of purchasing insurance and yet when they did need something from the mall, they would be charged the inflated prices generated by this wacky insurance scheme. Such a situation would be a gross distortion of free market capitalism.

The described scenario is preposterous but it is the equivalent of modern U.S. health care. Who is to blame for this bizarre scenario? It was an act of Congress, not the free market that started medical services being billed to the third party rather than directly to the patient.

In free markets, prices are set at the meeting point between the most that the consumer is willing to pay and the least that the vendor is willing to receive in return for the product. The consumer is free to go elsewhere to seek a lower price and the vendor is pressured to reduce prices to attract business. This pressure tends to reduce the profit margin per item sold. To maintain a viable business, the vendor must sell as much product as possible to as many people as possible.

The vendor must continuously strive to make a better product at a low price. If unsuccessful, they will go out of business and someone will step up to the plate and do it better. The business world is in a

BY LEE KURISKO, M.D.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

continuous state of reordering while getting better and better at delivering what people want at lower prices. As a result, since the industrial revolution, living standards have been rising. According to Michael Rothschild, author of Bionomics; Economy as Ecosystem, virtually every consumer product ever studied has dropped in price when measured in non-inflationary dollars if free markets are allowed to work.

Because the U.S. health care market is not a free market, double-digit inflation in annual insurance costs is common.

The key ingredient in an efficient market is the consumer-vendor interaction. The consumer must be able to decide if he is getting sufficient value for his dollar and the vendor must be pushed to provide that value. In American health care, this interaction is negated. With a third party payer system, the patient does not function as a consumer.

The inflated prices seen in U.S. health care are not an example of “market failure” but the result of failing to make health care a market.

With a minimum of 43 percent of all health care costs borne by government, the potential market for health care is further undermined.1 Arguably, Americans don’t get much for their tax-derived public dollars. Prior to the advent of Medicare, the elderly were paying 20 percent of their income on health care expenditures. They now pay 19 percent.2 This huge entitlement program hardly saves the elderly any money. This is especially true when you consider that they had to pay taxes into Medicare throughout their productive years. They would be better off to have not paid for Medicare, skipped the entitlement and pay for their own health care instead. This does not even weigh into account the benefit of a less-taxed society producing a more vibrant economy that would elevate everyone’s standard of living thereby increasing the affordability of health care.

Capitalism is not about haves and have-nots. It is really about “haves and have-laters.” Markets have produced automobiles, televisions, microwave ovens and stereo systems that used to only be for the wealthy. Now most of us enjoy these things at reasonable cost. If given the opportunity, the same dynamic could unfold in health care. Why did it only cost $550 for my human sized dog to have a hysterectomy and a bilateral salpingo-oophorectomy whereas the same operation would cost tens of thousands of dollars for a human female? The reason is that veterinarians work in a free market and physicians don’t.

(Continued on page 24)

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Soapbox (Continued from page 23)

The elderly have grown accustomed to the entitlement of Medicare. Despite being the wealthiest cohort of retirees of all time, they have demanded a prescription drug benefit to “control the costs.” A rudimentary understanding of economics will prove that such an entitlement will not control costs, but actually escalate them. As pointed out previously, price is the meeting point between what the purchaser is willing to pay and what the provider is willing to receive. If Medicare kicks in a subsidy for a drug, the amount the consumer is willing to pay for the commodity remains the same. If he was originally willing to part with $50 to obtain a prescription, the outside contribution by a third party will not change this threshold. The amount that the vendor wants is obviously as much as possible and, therefore, if a third party is footing part of the bill, the price will tend to rise. After all, the consumer is still willing to part with $50 to get the product. The prescription drug benefit will elevate the true costs of drugs.

Drug costs are also escalated by federal involvement in the drug approval process. The Food and Drug Administration has a monopoly on certifying the safety of prescription medications. The current process is so inefficient and costly that it costs drug manufacturers about 800 million dollars to bring a single drug to market. Such a cumbersome and costly process is only feasible for the largest companies. Smaller players are effectively excluded from competing. Limited competition leads to higher prices and fewer choices for consumers.

Being a government monopoly, the FDA has no meaningful accountability for performing its function cheaply and in a timely manner. Competing independent consumer organizations would. The independent consumer organization that can certify the safety and efficacy of a new medication expeditiously while keeping costs down will attract business and push other organizations to do the same.

Independent consumer organizations are already at work in other fields. Underwriters laboratory certifies electrical equipment. If UL began giving its stamp of approval to items that electrocuted people, they would immediately lose credibility and some other organization would step up to the plate and do it better. Likewise any independent drug approval agency that gave its stamp of approval to an unsafe drug would quickly suffer from public censure. With the FDA being a government monopoly, it will suffer no consequences for having approved drugs such as Vioxx that are now generally recognized as unsafe.

Consumer’s Union does a great job reviewing and rating sundry consumer items. My certification as a radiologist is through a private non-governmental organization, the American Board of Radiology.

Independent certification organizations work and they could work for the pharmaceutical industry also.

To keep costs low, in the insurance industry, individual risk needs to be stratified. Life insurance mandates an assessment of one’s risk of dying. Auto insurance mandates an assessment of the likelihood of a motor vehicle accident. With health insurance purchased in 24

March/April 2006

large blocks by employers the 20-year-old fitness fanatic is effectively paying the same as the 60-year-old obese smoker. If the young person loses his job, he may opt to skip insurance rather than pay inflated prices. By denying basic actuarial facts, the number of uninsured increases. With government-enforced laws that increase the number of uninsured, the knee jerk response of the masses is to further increase government involvement with nationalized health insurance.

The norm of insurance being obtained from the employer is not a free market manifestation. The precedent was set during World War II with government imposed wage and price controls. In order to compete for employees, employers began to offer health insurance.

Health insurance is purchased in large blocks rather than by individuals thereby limiting the competition to keep prices down and the flexibility to tailor the product to the individual.

Under the current system of American health care, the patientconsumer has no meaningful accountability for the costs incurred. A trip to the emergency department for a simple headache may prompt both a CAT scan and an MRI scan. The charges for both tests will be vastly inflated by the third party payer system. The tests may be performed when a simple history and physical exam may have sufficed.

Compounding the problems further is an army of predatory attorneys ready to pounce at even the hint of a medical mistake. Physicians feel obligated to leave no stone unturned in the assessment of patients.

Every possible test and intervention is undertaken even when reasonable medical judgment would dictate that they are not necessary.

Hence, the sky is the limit and all physicians live on eggshells waiting for their next lawsuit. Even the perception of a medical mistake must be avoided and therefore all stops are pulled on the assessment of even the simplest of health problems. The parasitism of attorneys is sapping the life out of the medical profession. With every physician seeing each patient as a potential litigant, a natural consumer-provider relationship is further warped.

The landscape of American health care is a gross distortion of a free market. Rather than having doctor-patient relationships we have doctor-patient-government-third-party-payer-attorney-doctor relationships that have mangled that which an effective market could and should be.

Lee Kurisko, M.D., is with Consulting Radiologists Ltd. in Minneapolis.

(Footnotes) 1 Bailey, R., “Democratic Health Care,” Reasononline, February 19, 2004 www.reason.com/links/links021904.shtml 2

Citizen’s Council on Healthcare Website, cchconline.org, “17 Medicare Facts”

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

PRESIDENT’S MESSAGE JAMES J. JORDAN, M.D.

Physicians’ Well-Being: Can We Be Devoted Without Being Devoured?

A

AS I BEGIN MY TERM as Ramsey Medical Soci-

President James J. Jordan, M.D. President-Elect V. Stuart Cox, M.D. Past President Charles G. Terzian, M.D. Treasurer Peter B. Wilton, M.D.

ety’s 136th President, I am particularly cognizant of the fact that I am one of a few psychiatrists ever to hold this position. What will it mean to have a psychiatrist serve as president of Ramsey Medical Society in 2006? No, I will not be urging you to make couches a standard fixture in every exam room. But, yes, I do have another agenda. I am encouraging the members of this organization to use the year 2006 to focus on our own mental health and well-being as physicians, in order to better serve the community.

Paying attention to our own well-being is not mere self-indulgence. It is a serious issue that merits public attention, as well as our own. The well-being of its physicians has a direct impact on the quality of care a medical system can deliver.

Yes, we all know it anecdotally. And the statistics support the stories we hear: the rate of doctors choosing primary care practice has faced a steady decline over recent years. A Meritt Hawkins survey just three years ago found that 80 percent of all surveyed physicians, aged 50 and over, planned to quit full-time practice in the next one to three years. (Physicians Weekly Vol. XXI, No. 1. January, 2004) And what about those of us who remain in the trenches? According to a study in the Journal of the American Medical Association, a level ranging up to 80 percent of practicing physicians report feeling some combination of emotional exhaustion, depersonalization, and low levels of personal achievement. (Chopra, Sotile, and Sotile. “Physician Burnout” in the Journal of the American Medical Association February 4, 2004) One hundred and fifty years ago, the German philosopher and scholar, Frederick Nietzsche wisely advised, “physician, help yourself; thus help your patient, too. Let this be his best help; that he may behold with his eyes the man who heals himself.”

But, is this trend simply a reflection of overwork? I contend that it is not. Certainly physicians work hard and long hours. Doctors tend to be hard workers who thrive on challenge; we expected hard work and long hours when we entered this profession. I believe that the problem is rooted in a serious imbalance between the demands of our profession and the rewards from

RMS-Board Members

Todd D. Brandt, M.D., At-Large Director Charles E. Crutchfield, III, M.D., At-Large Director Laura A. Dean, M.D., Specialty Director Jeremy T. Carlson, Medical Student Andrew S. Fink, M.D., At-Large Director Ronnell A. Hansen, M.D., Specialty Director Thomas J. Losasso, M.D., At-Large Director Robert C. Moravec, M.D., At-Large Director Jane C. Pederson, M.D., M.S., Specialty Director Lon B. Peterson, M.D., At-Large Director Thomas D. Siefferman, M.D., Specialty Director Stephanie D. Stanton, M.D., Resident Physician Jacques P. Stassart, M.D., At-Large Director Christina J. Templeton, M.D., Specialty Director David C. Thorson, M.D., Specialty Director RMS-Ex-Officio Board Members & Council Chairs

Blanton Bessinger, M.D., AMA Alternate Delegate V. Stuart Cox, M.D., Communications Council Chair Kenneth W. Crabb, M.D., AMA Delegate Robert W. Geist, M.D., Ethics & Professionalism Council Chair J. Michael Gonzalez-Campoy, M.D., Ph.D., MMA Immediate Past President Frank J. Indihar, M.D., AMA Delegate Neal R. Holtan, M.D., Community Health Council Chair Mark J. Kleinschmidt, Clinic Administrator Anthony C. Orecchia, M.D. Education Resource Council Chair Lyle J. Swenson, M.D., Public Policy Council Chair Richard W. Anderson, M.D., Sr. Physicians Association President RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive Officer Katie R. Anderson, Executive Assistant Doreen M. Hines, Manager, Member Services

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The Journal of the Hennepin and Ramsey Medical Societies

it. We live in a difficult world; the demands are growing. The rewards, and I speak of rewards beyond financial, must offset the demands. For, while we are by nature devoted to our work and our patients, without adequate reward, we are vulnerable to becoming devoured by the demands.

Can we remain devoted to our profession without being devoured? I believe we can. And so do Drs. Karyn D. Baum, Henry C. Emmons, Jon S. Hallberg, and Irving J. Lerner, who helped initiate a dialog on the topic at the RMS Annual Meeting on January 27. They spoke to their own experiences, opening a dialogue that I hope will continue throughout this year. For each of us must find a way to nurture that which will allow us to practice according to our own passions and values.

Practicing according to our own passions and values is the first reward that we need to maintain in order to balance the demands. At Hamm Clinic, we have found our ways. Our clinicians report high career satisfaction. We have outcome research to document that our patients’ lives improve. It is due, in great measure, to being an independent clinic where we are rewarded by being able to practice as we believe we should.

The second reward I would like to address is the doctor-patient relationship. New practitioners are drawn to medicine because they want to make a difference in their patients’ lives. We all want to make a difference in our patients’ lives.

But here, perhaps, is where the system has gone most askew. The practice of medicine has undergone a radical depersonalization. We doctors are pressured to be merely “health care providers” and see our patients as merely “health care consumers.” And we must not yield to this pressure.

As the director of a mental health clinic, I am constantly evaluating and defending our patient care policies — policies that include refusing to pre-set limits on the number and frequency of patient care sessions. When it is necessary to jus(Continued on page 26)

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25

Ramsey Medical Society

RMS-Officers

RMS President’s Message (Continued from page 25)

tify these policies, I am aided enormously by our outcome research data, collected and analyzed internally for more than a decade. Certainly our clinicians benefit from practicing according to strong professional values and passions. But it is our patients who are the real winners.

There is a third professional reward of which I must speak and it is also based on relationships. We must keep our practices and ourselves fresh and dynamic through our collegial and consultative relationships. In a Texas Medical Association paper on strategies for preventing physician burnout, Dr. Judy Googins recommends that physicians cultivate relationships outside their specialties and outside the medical profession. (Googins, et.al. Coping with Stress in the Practice of Medicine The Texas Medical Association’s CME Online Course) As the president of Ramsey Medical Society, I want to be a leader in cultivating these relationships with each other, whether we are oncologists, family practitioners, pediatricians or psychiatrists. It is important not to become a “lone ranger” in practice. The support and stimulation from colleagues, including colleagues from other specialties and disciplines, improves both our practice and our well-being.

Of course, there is nothing better to stimulate fresh thinking than learning and teaching.

We are all committed to continuing our own education in order to stay licensed. But I encourage all my colleagues to also consider the rewards that come from the various teaching opportunities

available. Each fall, we are gifted with a bright group of residents, interns and fellows who bring to us as much as we give to them. They have new ideas and they question old ones. They haven’t yet found their own niche in the system, so they see it with much more clarity. They are excited and they are scared. They help rekindle the passion I first felt going into medicine, and it’s that passion which keeps me here.

Although Nietzsche addressed the problem 150 years ago, physicians’ well-being has become more difficult to maintain in today’s competitive health care environment. But, I believe it is possible to remain devoted without being devoured.

I even believe that health care organizations can act to nurture the dedication and enthusiasm of their providers without draining them. And, I believe that such actions will result both in superior quality of patient care and long-term cost effectiveness.

Like Dr. Terzian and others who precede me as RMS President, my goal is to continue work toward ensuring a healthy environment for medical practice. In order to address this issue from both individual and organizational standpoints, we need a forum that encourages creative thinking, communication and collegial support. My hope is that the Ramsey Medical Society will serve as that forum over the next year. My contact information follows — please let me hear from you. And let us continue the discourse.

2006 RMS Election Results Congratulations to the newly elected RMS leaders

PRESIDENT James J. Jordan, M.D. Psychiatry Hamm Memorial Psychiatric Clinic

PRESIDENT-ELECT V. Stuart Cox, M.D. Otolaryngology Midwest Ear, Nose & Throat Specialists

TREASURER Peter B. Wilton, M.D. General Surgery St. Paul Surgeons, Ltd.

AT-LARGE-DIRECTOR Charles E. Crutchfield III, M.D. Dermatology Crutchfield Dermatology

AT-LARGE-DIRECTOR Robert C. Moravec, M.D. Emergency Medicine St. Joseph’s Hospital Medical Director

OBSTETRICS & GYNECOLOGY SPECIALTY DIRECTOR Laura A. Dean, M.D. Obstetrics & Gynecology Stillwater Medical Group, P.A.

James J. Jordan, M.D. (651) 224-0614 jjordan@hammclinic.org

CALL FOR RESOLUTIONS Please help us to assure that your interests are accurately conveyed by contacting RMS staff to submit resolutions: phone (612) 362-3704; fax (612) 623-2888; or e-mail: rjohnson@metrodoctors.com Deadline: Resolutions due by May 11, 2006 RMS Caucus Thursday, May 25, 2006 United Hospital Wednesday, June 7, 2006 United Hospital

PEDIATRICS PSYCHIATRY SPECIALTY TRUSTEE SPECIALTY TRUSTEE Thomas D. Siefferman, M.D. Christina J. Templeton, M.D. Pediatrics Psychiatry Pediatric & Young Adult Hamm Memorial Medicine, P.A. Psychiatric Clinic

MMA Annual Meeting September 14-15, 2006 – Minneapolis Convention Center Minneapolis, MN

MMA HOUSE OF DELEGATES Blanton Bessinger, M.D. J. Michael Gonzalez-Campoy, M.D., Ph.D. Frank J. Indihar, M.D.

If you are interested in serving as an Alternate Delegate, please contact RMS.

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The Journal of the Hennepin and Ramsey Medical Societies

2006 RMS Annual Meeting

Award for his volunteer work with seniors and the underinsured.

Dr. Lyle J. Swenson, past president of RMS, presented a plaque to outgoing president Dr. Terzian. RMS Bylaws revisions were approved and will be effective January 1, 2007.

Attendees were invited to participate in a panel discussion with Karyn D. Baum, M.D., internal medicine, U of M, Primary Care Center; Henry C. Emmons, M.D., Center for Spirituality and Healing, U of M; Jon S. Hallberg, M.D., Dept. of Family Medicine and Community Health, U of M and Medical Commentator, “All Things Considered,” MN Public Radio; and Irving J. Lerner, M.D., oncologist at Allina. The theme of the discussion was “Doctors: Can We Be Devoted Without Being Devoured?” Hamm Clinic psychologist Xan K. Banker, Psy.D., L.P. served as the moderator. The panelists shared suggestions and thoughts on ways to recharge the internal batteries and continue enjoying the day-to-day practice of being a physician.

The evening began and ended with old jazz music performed by the “Mouldy Figs.”

Dr. Charles G. Terzian (right), outgoing RMS president, presents the presidential medallion and the gavel to incoming RMS president James J. Jordan, M.D.

RMS president-elect Stuart Cox, M.D., Kelli Cox and Gwen Crabb.

Dr. Vernon Sommerdorf (center), RMS Community Service Award recipient, was joined by his family (from left) Lori Corey, Norma, Philip and his guest Linda Schultz.

Robert Nesheim, M.D., Peter Daly, M.D., LuLu Daly and Pat Crutchfield.

Dr. James J. Jordan, his wife Mary Ellen, were joined by two of their five children.

Far right is son Jim and left is son-in-law David Kett with daughter Beth Jordan, M.D.

MetroDoctors

RMS past presidents standing with incoming president James J. Jordan, M.D. From left: Robert Geist, M.D., James Jordan, M.D., Ken Crabb, M.D., Tom Dunkel, M.D. and Vernon Sommerdorf, M.D.

The Journal of the Hennepin and Ramsey Medical Societies

Panelists (from left): Irving J. Lerner, M.D., Jon S. Hallberg, M.D., Henry C. Emmons, M.D. and Karyn D. Baum, M.D.

March/April 2006

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Ramsey Medical Society

O

ver 100 physicians, resident physicians and medical student members, spouses, and guests enjoyed an evening devoted to installing the 136th president of RMS, the Community Service Award, mental health issues, and physician collegiality. The Midland Hills Country Club in St. Paul was the scene of the enjoyable and informative evening on Friday, January 27, 2006.

Dr. James J. Jordan became the 136th president of RMS with the passing of the presidential medallion and the gavel from outgoing president, Dr. Charles G. Terzian. Dr. Jordan is a psychiatrist and Director of the Hamm Clinic. Dr. Vernon Sommerdorf, retired family physician who practiced with Payne Avenue Clinic, received the RMS Community Service

RMS UPDATE David B. Hale, M.D., Ph.D. University of Hawaii School of Medicine Emergency Medicine Woodwinds Health Campus

Todd A. Smith, M.D. Mayo Medical School Family Medicine HealthEast Cottage Grove Clinic

New Members

Robert O. Hildebrandt, M.D. University of Minnesota Medical School Obstetrics & Gynecology Stillwater Medical Group, P.A.

Laurie C. Wright, M.D. University of Minnesota Medical School Anesthesiology Associated Anesthesiologists, P.A.

RMS welcomes these new members to the Society. Schools listed indicate the institution where the medical degree was received.

Ronald N. Hochman, M.D. Harvard Medical School Medical Oncology/Geriatric Medicine Parker Hughes Cancer Center

1st Year Active Practice

Active Julia A. Beckman, M.D. University of Iowa College of Medicine Pediatrics Pediatric & Adolescent Care of Minnesota, P.A. Joan L. Benner, M.D. Michigan State University College of Human Medicine Emergency Medicine Stillwater Medical Group, P.A. Matthew P. Boente, M.D. Rush Medical College Obstetrics & Gynecology Minnesota Oncology Hematology, P.A. Ronald J. Bryant, M.D. Central Regional Pathology Laboratories David Casement, M.D. Loyola Stritch School of Medicine Internal Medicine/Pediatric Medicine Allina Medical Clinic Shoreview Janel A. Cox, M.D. Washington University School of Medicine Radiation Oncology Minnesota Oncology Hematology, P.A. Diana R. Danilenko, M.D. Mayo Medical School Obstetrics & Gynecology/Maternal & Fetal Medicine Minnesota Perinatal Physicians Kathleen M. DeManivel, M.D. University of Minnesota Medical School Dermatology Stillwater Medical Group, P.A. Sharon L. Dykes, M.D. Brown University Medical School Colon & Rectal Surgery Colon & Rectal Surgery Assoc., Ltd.

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March/April 2006

Phillip M. Kibort, M.D., MBA University of Minnesota Medical School Pediatrics/Gastroenterology Children’s Hospitals & Clinics Subhashini J. Ladella, MB, BS Christian Medical College, Madras University, Vellore, Tamil Nadu Maternal & Fetal Medicine Minnesota Perinatal Physicians Matthew K. Malmberg, M.D. Associated Anesthesiologists, P.A. Averial E. Nelson Jr., M.D. University of Minnesota Medical School Internal Medicine Aspen Medical Group–Highland Thomas P. Nobrega, M.D. University of Minnesota Medical School Internal Medicine/Cardiovascular Diseases St. Paul Heart Clinic, P.A. Peter M. Parten, M.D. Loyola Stritch School of Medicine Orthopaedic Surgery Summit Orthopedics, Ltd. Andrzej Petryk, M.D. Medical School of Wroclaw, Poland Medical Oncology & Hematology Minnesota Oncology Hematology, P.A. Mark A. Scheible, M.D. University of Minnesota Medical School Family Medicine East Metro Family Practice–Woodlane John F. Schwerkoske, M.D. Ohio State University College of Medicine Hematology/Medical Oncology Minnesota Oncology Hematology, P.A. Byron H. Simmons, M.D. Central Regional Pathology Laboratories

Robert C. Anderson, M.D. University of Minnesota Dermatology Dermatology Consultants, P.A. H. Parry Dilworth IV, M.D. University of Minnesota Medical School Anatomic/Clinical Pathology, Surgical, Gastrointestinal Hospital Pathology Assoc., P.A. Jane M. Hermann, M.D. University of Minnesota Family Medicine Allina Medical Clinic Woodbury David A. Krason, M.D. Medical College of Wisconcin, Milwaukee Infectious Disease/Internal Medicine St. Paul Infectious Disease Associates, Ltd. Ann E. Lavers, M.D. University of Minnesota Urology/Urologic Surgery Metro Urology, P.A. Richard D. Levine, M.D. Tulane University School of Medicine Family Medicine/Psychiatry University of Minnesota Medical Center Namrata A. Magar, MB BS Lokmanyua Tilak Mun Medical College, Bombay University Family Medicine Bethesda Clinic

Lina Missova, M.D. Higher Medical Institute Bulgaria Family Medicine MinnHealth Family Physicians, P.A. –Woodbury Stian R. Mjanger, M.D. University of Minnesota Anesthesiology Associated Anesthesiologists, P.A. Matthew C. Monteiro, M.D. University of Minnesota Family Medicine MinnHealth Family Physicians, P.A. –White Bear Surekha Pagidipala, M.D. Ghandi Medical College Family Medicine Park Nicollet Clinic–Bloomington Anne M. Rosenberg, M.D. University of Iowa College of Medicine Endocrinology HealthEast Maplewood Clinic Pediatricians for Health Jack B. Shelton Jr., M.D. Uniformed Services University of Health Services Pathology-Anatomic/Clinical/Cytology Hospital Pathology Associates, P.A. Umeng D. Thao, M.D. University of Minnesota Plastic Surgery/General Surgery HealthEast Oakdale Clinic Maria V. Vu, M.D. University of Minnesota Family Medicine MinnHealth Family Physicians, P.A. –Larpenteur

In Memoriam DELMAR R. GILLESPIE, M.D. died peacefully on December 16, 2005 at the age of 97. Dr. Gillespie was a graduate of the University of Minnesota Medical School and completed an internship at Ancker Hospital. He practiced general medicine in North Dakota for a few years and returned to Minnesota to complete a fellowship at the Mayo Graduate School in internal medicine. Dr. Gillespie served in the Army Medical Corps during WWII. He practiced at the Earl Clinic/Physicians Clinic in St. Paul until his retirement in 1981. Dr. Gillespie was a past president of the Ramsey Medical Society, the Minnesota Medical Association, and the Minnesota Society of Internal Medicine. He received the WCCO Goodneighbor Award in 1969. Dr. Gillespie joined RMS in 1946.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

CHAIR’S REPORT JAMES A. ROHDE, M.D.

Don’t Retire— Keep the Job You Have

I

I AM NOW IN MY 32nd year of practice (if

Chair James A. Rohde, M.D. President Paul A. Kettler, M.D. President-elect Anne M. Murray, M.D. Secretary Edward P. Ehlinger, M.D. Treasurer Eric G. Christianson, M.D. Immediate Past Chair Michael B. Belzer, M.D.

you count the year running mission hospitals in Africa). By this fall I could start drawing a Social Security check and taking advantage of the 401k funds. My wife Sharon and I could buy a home on a lake up north and watch the seasons change. Having grown up on a lake in Michigan and having enjoyed many wonderful vacation weeks on Minnesota lakes, this has always seemed to be the ideal place to relax.

Or, I could do like Dr. Kevin Strathy described in last month’s MetroDoctors and retire to a practice in Florida where my father lives and my former partner Ed Lomatta practices.

Ed and Dr. Mario Patrini enjoy sharing an office in Ft. Myers. I have often thought a “Minnesota Physicians” clinic would immediately do well with all the northerners in that area.

Does any practice opportunity ever turn out to be as wonderful as it seems from the outside?

Though I have started to note the retirement of docs who entered practice after I did, I have also seen many practice through their 60s and even 70s. Particularly in the primary care field of family medicine where 20-30 year relationships are an asset, leaving the practice one has built up over the years is an irreplaceable loss. One’s patients are very supportive of continuing practice a few more years. Finding a new doctor is not what they want to do. And with no longer delivering babies or making hospital rounds, life is a bit more sane.

A few months ago Sharon and I had a discussion and decided to see if we could find that “up north lake home” within driving distance of my office and do a pre-retirement move to defer the need to think of retiring.

We waited until after son Ben’s wedding in October to start the search, which we expected to take one-two years. We did not count on the number of homes languishing on the market for months, waiting for us to make an offer.

The first serious day of looking we found a house in Shakopee that was perfect. Two days before Christmas we were moved in.

HMS-Board Members

Alan L. Beal, M.D. Carl E. Burkland, M.D. Peter J. Dehnel, M.D. Sundeep Dev, M.D. Laurie Drill-Mellum, M.D. Raymond A. Gensinger, Jr., M.D. Frank S. Rhame, M.D. Richard D. Schmidt, M.D. Janette H. Strathy, M.D. Thomas C. Tunberg, M.D. David J. Walcher, M.D. HMS-Ex-Officio Board Members

Michael B. Ainslie, M.D., MMA-Trustee Mary Anderson, Co-Presiding Chair, HMS Alliance Martha Arneson, Co-Presiding Chair, HMS Alliance Beth A. Baker, M.D., MMA-Trustee Kelly Cawcutt, Medical Student Representative Karen K. Dickson, M.D., MMA-Trustee David L. Estrin, M.D., AMA Alternate Delegate Donald M. Jacobs, M.D., MMA-Trustee Dawn Lunde, MMGMA Representative Richard K. Simmons, M.D., Sr. Physicians Association Representative Karin M. Tansek, M.D., MMA-Trustee Benjamin H. Whitten, M.D., AMA Alternate Delegate HMS-Executive Staff

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

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Most of you wouldn’t expect one to find a beautiful lake in Shakopee but after looking at Victoria, Prior Lake and Waconia, we are glad we didn’t pass up looking at this rambler on Lake O’Dowd. The view is just about perfect “up north” except for the 8th tee of Stonebrooke Golf Course to our left and the green across the lake to our right. This hole has been voted one of the top 10 holes in Minnesota and includes a ferryboat that takes the golfers and carts across the lake to the fairway.

The fact that we are six-seven minutes from our grandchildren in Prior Lake and our son Corey is a police officer in Shakopee are bonuses.

The move has increased my drive time from 10 minutes to 22-25, and leaving a beautiful friendly neighborhood in Bloomington was not without some pain. But this should add years to my career and fun to our years.

The Hennepin Medical Society includes Scott, Carver, Anoka and part of Dakota Counties.

So I can now understand the many members in these more rural communities better.

It is not always necessary to find that retirement place in Florida dodging hurricanes, or up north too far from office or grandchildren. One retired orthopedist I ran into at the airport years ago said the first thing you had to do when you retired was go out and find another job. So why not keep the one you have a little longer. Anyone that wants to help me learn the Stonebrooke course, or go for a relaxing boat ride can e-mail me this spring at jrohde@edinafp.com or call me at the office, (952) 925-2200.

March/April 2006

29

Hennepin Medical Society

HMS-Officers

HMS IN ACTION JACK G. DAVIS, CEO

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

The Metropolitan Hospital Physician Leadership Committee is in the process of standardizing and streamlining the process of documenting medical staff member’s immune status. This spring several hospitals will be piloting a collaborative system to record and share immune status. The ultimate goal would be to standardize the data collection component and lessen the redundancy of completing the form for physicians.

The Hennepin and Ramsey Medical Societies are supporting the efforts of the Minnesota Medical Group Management Association to pass legislation that would require payment from third party payers

Call For Resolutions –

Due Date: Friday, May 12, 2006 A resolution identifies and directs a specific issue for the Minnesota Medical Association to focus their attention on. When appropriate, resolutions are forwarded to the AMA for national consideration.

Save These Dates: Wednesday, May 24, 2006 Hennepin Medical Society’s Caucus 7:00–8:30 a.m.

Thursday-Friday, Sept. 14-15, 2006 Minnesota Medical Association Annual Meeting Minneapolis Convention Center Visit our Web site at www.metrodoctors.com.

Search under Hennepin Medical Society to find additional information about being a delegate, resolutions, HMS Caucus, and a link to the MMA Annual Meeting.

Contact Kathy Dittmer at (612) 623-2885 or kdittmer@mnmed.org.

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March/April 2006

to financially support the cost of translator services. This issue is becoming very critical to practices throughout the state and is also a high priority for the Minnesota Medical Association.

The Hennepin Medical Society was awarded a continuation grant from the Minnesota Department of Health to continue its efforts in 2006 in support of local policy changes restricting exposure to second hand smoke in the work place.

HMS is also looking forward to conducting a second public opinion poll in Hennepin County and Minneapolis related to the smoking ordinances. This effort is being funded by a grant from the Minnesota Partnership for Action Against Tobacco (MPAAT). HMS continues to work

with the University of Minnesota, Boynton Health Services, on a project related to tobacco use for 18-24 year olds. (See article on page 11). HMS will help to support a survey in 2006 that will go out to 18 college campuses in Minnesota related to this issue. The funding from this project is included as part of the Minnesota Department of Health grant.

Many HMS members participated in hearings before the Hennepin County Board of Commissioners as they were considering weakening their ordinance prohibiting exposure to second hand smoke in the work place. Testifiers or letter writers included: Brian Anderson, M.D., Brian Rank, M.D., Ben Whitten, M.D., Ed Ehlinger, M.D., Mark Manley, M.D., Peter Dehnel, M.D., James Young, M.D., Christy Boraas (medical student), Travis Olives (medical student), Jim Rohde, M.D., Cesar Ercole (medical student), Rich Lussky, M.D., Stuart Hanson, M.D., Meg Lelonek (medical student), Heather Nelson (medical student), Christine Ziebold, M.D., Gail Brottman, M.D., Benjamin Ho (medical student), Randy Croeschl (medical student), and Alex Luger (medical student). Unfortunately, Commissioner MetroDoctors

Peter McLaughlin changed his position and a weakened ordinance became effective on January 1, 2006. The weakening of the ordinance does not affect bars in Minneapolis, Golden Valley or Bloomington.

The following graduate students have been awarded Hoban Scholarships for the 2005-2006 school year: Kara J. Conway, Jennifer Dobratz, Anna Henry, Kara Mitterholzer, Sue Schettle, Debra Thingstad Boe, Vinh Vuong and Azza A. Zarroug.

The Hennepin Medical Society Executive Committee voted to support financially the following projects or organizations: (1) Smoke Free Coalition for their continued efforts to pass the Freedom to Breathe legislation; (2) Sotile Event “Medical Marriages” seminar; (3) Orleans Parish Medical Society of New Orleans as they deal with the challenges brought on by hurricane Katrina; and (4) Hamm Clinic in St. Paul in recognition of their work in providing charitable psychiatric services.

The Hennepin Medical Society Alliance, in cooperation with the University of Minnesota Medical School and HMS, presented a series of three seminars on January 27 to medical students, residents and practicing physicians. The events were well attended and were funded by many of the metro area hospitals and systems. The speakers at the seminars were Wayne and Mary Sotile, relationship psychologists.

Pictured above from left: Sue Schettle, HMS Director of Marketing and Member Services; Dianne Fenyk, HMSA; Mary and Wayne Sotile; and Diane Gayes, HMSA.

The Journal of the Hennepin and Ramsey Medical Societies

HMS NEWS

Medical Society for 30 years, serving as its chair in 1995. Dr. Schwartz practices at Minnesota Oncology Hematology, PA.

HMS Makes Award Presentations

MetroDoctors

Mick Belzer, M.D., (right) immediate past-chairman of HMS presents Dr. Ronald Cranford with the Shotwell Award.

Dr. Burton Schwartz (right) is awarded the 2005 Charles Bolles Bolles-Rogers award by HMS immediate past chair Mick Belzer, M.D.

In Memoriam J.A. “TONY” ABULLARADE, M.D., died December 31, 2005 at the age of 84. He graduated from the University of San Salvador Medical School. Dr. Abullarade co-founded Southwest Clinic in Edina and practiced family medicine for over 50 years. He joined HMS in 1955.

WALEED N. AMRA, M.D., died on November 18, 2005 at Mayo Clinic in Rochester. He was 72.

He was born in Al-Bira, Palestine. He graduated from Vanderbilt University School of Medicine in Nashville. Dr. Waleed began his career in surgery as a Lt. Commander in the U.S. Navy in 1965.

He went on to practice medicine and surgery for over 30 years in Chaska, Shakopee and Edina. Dr. Amra joined HMS in 1969.

LEO C.T. FUNG, M.D., age 42, died December 10, 2005 after a battle with cancer. Dr. Fung was Chief of Pediatric Urology at the University of Minnesota. He worked tirelessly on behalf of his patients as both a surgeon and a researcher. He joined HMS in 2005.

The Journal of the Hennepin and Ramsey Medical Societies

WILLIAM KRIVIT, M.D., Ph.D., age 80, passed away on December 8, 2005. He graduated from Tulane University School of Medicine in New Orleans. Dr. Krivit was Professor of Pediatrics, active emeritus, at the University of Minnesota, and co-founder of the Minnesota Blood and Marrow Pediatric Transplant program. He was a teacher, researcher, and world lecturer in fields related to bone marrow transplant.

THEODORE H. LESTER, M.D., age 76, died November 8, 2005 in Naples, Florida. He graduated from Washington Medical School in St. Louis. He served as a Captain in the U.S. Army Medical Corp stationed at Nuremberg, Germany for four years before returning to practice family medicine in Brown’s Valley, Minnesota for three years as the town’s only physician. In 1963 he moved to Fridley and became a partner at the Fridley Medical Center where he practiced for the next 17 years. Dr. Lester joined HMS in 1961.

SIDNEY NERENBERG, M.D., an ophthalmologist, died on November 20, 2005. He was 78.

He graduated from the University of Minnesota Medical School. Dr. Nerenberg was an associate professor at the University of Minnesota. He joined HMS in 1985.

ABE M. “MIKE” SBOROV, M.D., died November 17, 2005, at the age of 87. He graduated from the University of Minnesota Medical School and completed his internship at Anker Hospital.

He practiced in Edina for nearly 50 years.

AUREL SULCINER, M.D., a Romanian Holocaust survivor, died December 6, 2005 at the age of 84. He escaped Romania and eventually arrived in Israel, where he worked as a nursing assistant. He graduated from the Universite de Paris VI, Paris, France in 1958. After finishing a medical internship and working as a physician in Israel, he immigrated to Canada in 1962 and completed another medical internship. In 1964, he obtained an immigration visa for the United States. He completed an internship at Methodist Hospital and then started a solo practice. His career eventually centered on two practices: he was medical director of the Glen Lake Sanitorium and a psychiatrist at the Minneapolis VA Medical Center. Dr. Sulciner joined HMS in 1967.

March/April 2006

31

Hennepin Medical Society

On Tuesday, January 10, Mick Belzer, M.D., immediate past chair of the Hennepin Medical Society, had the honor of presenting awards to two outstanding Hennepin Medical Society member physicians at the Abbott Northwestern Medical Staff meeting.

Ronald E. Cranford, M.D., neurology, received the Shotwell Award. Dr. Cranford has specialized in the field of clinical ethics and more specifically neuroethics over the past three decades. He has served as an advisor and a consultant to several national commissions on right-to-die issues, including defining death and persistent vegetative state, as well as ethical issues regarding the terminally ill. As a medical-ethical consultant and neuroethicist, Dr. Cranford has been involved with numerous landmark right-to-die cases in the United States. His career positions have included: Professor of Neurology, University of Minnesota Medical School; Senior Physician and Assistant Chief of Neurology, Hennepin County Medical Center; and Faculty Associate, Center for Bioethics, University of Minnesota. He has been an academic neurologist at HCMC since 1971.

The Shotwell Award is presented annually to a person within the State of Minnesota who has displayed dedicated service to mankind; made a significant break-through in some form of research or a significant contribution to the field of medicine; and/or has been instrumental in innovations and/or improvements in health care delivery.

Burton S. Schwartz, M.D., oncology/ hematology, was the recipient of the Charles Bolles Bolles-Rogers Award, which is given to a physician who, by reason of his/her professional contribution on the basis of medical research, achievement or leadership, has become the outstanding physician of this and other years. Dr. Schwartz is a clinical professor in medicine at the University of Minnesota Medical School. He is also a consultant in Hematology and Oncology at Hennepin County Medical Center, where he received the Outstanding Teacher Award in 1982 and 1987. Dr. Schwartz is the immediate past president of the Minnesota Board of Medical Practice, having served on the Board since 1998, and has been a member of the Hennepin

MARSHALL IRVING “MARK” HEWITT, M.D., died recently at the age of 92. He graduated from Indiana University School of Medicine in Indianapolis. Dr. Hewitt practiced internal medicine until retiring and moving to Florida.

He joined HMS in 1968.

Steven Bentz, M.D. Multicare Associates of Twin Cities–Fridley Family Medicine

New Members HMS welcomes these new members to the Society.

First Year in Practice Scott Anseth, M.D. Orthopedic Medicine & Surgery, Ltd. Orthopaedic Surgery Brijesh Kapoor, M.D. Kidney Specialists of MN, P.A. Nephrology Robin Kunze, M.D. Northwest Anesthesia, P.A. Anesthesiology Jeffrey Peterson, M.D. Consulting Radiologists, Ltd. Radiology Gavin Pittman, M.D. Orthopedic Partners, P.A. Orthopedics

Active Faruk Abuzzahab, M.D. Clinical Psychopharmacology Consultants, P.A. Psychiatry Sureshbabu Ahanya, M.D. Minnesota Perinatal Physicians Karl Anderson, M.D. Suburban Emergency Associates, P.A. Emergency Medicine Shabnam Barnhart, M.D. Partners in Pediatrics, Ltd. Pediatrics Gavin Bart, M.D. HFA Internal Medicine Clinic Internal Medicine Scott Benson, M.D. Apple Valley Medical Center Family Medicine 32

March/April 2006

Jennifer Biglow, M.D. Skin Specialists, Ltd. Dermatology William Block, M.D. Minnesota Perinatal Physicians Obstetrics & Gynecology Craig Bowron, M.D. Allina Medical Clinic Abbott Northwestern Hospitalist Srvc Hospitalist David Burrus, M.D. Minnesota Perinatal Physicians Maternal & Fetal Medicine Paul Cammack, M.D. Northwest Orthopedic Surgeons Orthopaedic Surgery Mimi Cho-Rohlfsen, M.D. Dermatology Specialists, P.A. Dermatology Paul Fadden, M.D. Metropolitan Urology Clinic, P.A. Urology/Urological Surgery Sheila Flynn, M.D. Multicare Associates of Twin Cities–Fridley Family Medicine Jeffrey Freed, M.D. Associated Skin Care Specialists, P.A. Matthew Gall, M.D. Minnesota Oncology Hematology P.A. Hematology/Oncology Timothy Gavin, M.D. Surgical Consultants, P.A. Kathy Gromer, M.D. Minnesota Lung Center– Pulmonary Disease Shawn Gross, M.D. Edina Eye Clinic, P.A. Ophthalmology

Timothy Hestness, M.D. Metropolitan Anesthesia Network Anesthesiology Michelle Johnson, M.D. Valley Family Practice P.A. Family Medicine J. Jones, M.D. Minnesota Perinatal Physicians David Ketroser, M.D. Physicians Spine Care Neurology Jacqueline Luong, M.D. Midwest Plastic Surgery Plastic Surgery S. Manjula, M.D. Hennepin County Medical Center Anesthesiology Christopher Ott, M.D. Fairview Oxboro Clinic Family Medicine Grace Peterson, M.D. North Memorial Clinic–Golden Valley Family Physicians Family Medicine Kathleen Pfelghaar, M.D. Minnesota Perinatal Physicians Maternal & Fetal Medicine Bradley Pierce, M.D. Surgical Consultants, P.A. General Surgery Natarajan Raman, M.D. HFA Oncology Clinic Hematology/Oncology David Sandell, M.D. Northwest Family Physicians, P.A.–Crystal Family Medicine

Suzanne Teragawa, M.D. Multicare Associates of Twin Cities–Blaine Family Medicine Ezgi Tiryaki, M.D. Hennepin Faculty Associates Joel Thompson, M.D. Bloomington Lake Clinic, Ltd. Minneapolis Family Medicine Amy Thorsen, M.D. Colon & Rectal Surgery Clinic Colon & Rectal Surgery Julie Topping, M.D. HCMC General Medicine Internal Medicine Carole Vincent, M.D. Multicare Associates of Twin Cities–Blaine General Surgery William Wagner, M.D. North Memorial Perinatal Center Maternal & Fetal Medicine Ian Weber, M.D. Hennepin County Medical Center Orthopaedic Surgery Cynthia Weisz, M.D. North Clinic, P.A.– Internal Medicine

Resident Physicians Liliana Bordeianou, M.D. U of MN Graduate School of Medicine Colon & Rectal Surgery John Bruun, M.D. U of MN Graduate School of Medicine Colon & Rectal Surgery

Lisa Saul, M.D. Abbott Northwestern Hospital Obstetrics & Gynecology Leslie Smith, M.D. Hennepin County Medical Center General Surgery

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

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Beautiful East Isles residence. Every imaginable amenity is found in this state of the art, 3 level condo just 1 ½ block from Isles.

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A private 625 square feet riverfront terrace surrounds this one bedroom plus den corner loft in a premier downtown building. Panoramic views of the Stone Arch Bridge, Falls and Mill Ruins Park. Granite kitchen, hdwd flrs, & warm details. A rare opportunity to own significant outdoor space directly on the river.

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Features superb attention to detail, abundant updates, in-ground pool, commercial grade kitchen and much more. 5 bedrooms, 6 baths.

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

Membership Advantages for Physicians and their Practices NEW I.C. System

is a Minnesota (St. Paul) based company specializing in full-service revenue cycle management solutions for the health care industry. They are now offering RMS members effective, ethical, and cost effective solutions to collecting debts, improving cash flow and reducing costs. For more information and a no-obligation price estimate, please contact I.C. System directly at 1-800279-3511 and let them know you are a RMS member.

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

Schwarz Williams Companies, Inc. offers RMS members

individual and group benefits (medical, dental, life, disability) as well as human resource support services, executive benefits, retirement programs, COBRA/HIPAA/ ERISA compliance, and benefit administration. To find out more information, contact Jim Fries at (763) 591-5822 or visit their website at www.schwarzwilliams.com.

SafeAssure Consultants recently partnered with RMS to offer the required OSHA compliance training for our members and their staffs. Our members receive a 50-60% discount on services and training.

To meet or exceed the Minnesota OSHA and Federal OSHA requirements talk with SafeAssure at 1-800-920-SAFE or visit their website www.safeassuremedical.com for more information.

Call RMS at 612-362-3704 for details.

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because child mettion thebecause criteria childfor metstanding the criteria for standing orders for Bacteria orders for Bacterial Conjunctivitis.

Conjunctivitis. has acalled rash.” Parent called to “Son has a rash.”“Son Parent to thank the

Dr. Barton Schmitt, Denver Children’s Hospital Dr. David A. Thompson, MacNeal Hospital, Chicago, and University of Chicago • Over 500 guidelines to support nurse triage callers • Experienced, specially-trained nurse and medical representatives located in a modern, technically advanced call center in Minneapolis/St. Paul • Enjoy peace of mind and relief from common after-hours medical calls For more information contact us at:

(612) 813-7435 or cpn@childrensmn.org

thank the nurse who told her to have

nurse who told her to have her child seen. her child seen. The child was diagnosed with a streptococcal infection the next The child was diagnosed with a streptococcal day.“I would never have taken him in if it wasn’t for the nurse.”

infection the next day. “I would never have taken him in if it wasn’t for the nurse.”

CPN is a servicemark of Children’s Physician Network, an affiliate of Children’s Hospitals and Clinics of Minnesota.