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Doctors MetroDoctors tHe JournaL of tHe Hennepin and ramsey medicaL societies
Physician Co-editor Lee H. Beecher, 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 Sue A. Schettle 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: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (952) 903-0505 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com. MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Doreen Hines at (612) 362-3705.
MetroDoctors
contents VOLUME 9, NO. 6
2
NOVEMBER/DECEMBER 2007
Letters
Index to Advertisers
3
Reflections on the Minnesota Freedom to Breathe Act
5
feature
Does Minnesota Need an Amendment to the Minnesota Constitution Guaranteeing the Right to Health Care?
12
Amending the Minnesota Constitution — How Do You Do It?
Health Care Legislative Panel
13
Redesigning Our Health Care System: Proposed Medical School Must Help Create New Models of Care
16
Medicine and Public Health — It’s Time to Renew Our Vows
18
Physician Perspective of the 35W Bridge Collapse
20
Minnesota Responds Medical Reserve Corps: Physician Volunteers During Disasters
23
2007 Minnesota Medical Association Annual Meeting
24
Members in the News
Ramsey Medical Society
25 26
President’s Message
27
28
29 30 31 32
11th Annual Winter Medical Update 2008 in San Diego/ 2007 RMS Annual Community Service Award/New Members Physicians Host “Meet and Greet” for Rep. Murphy/ Stillwater Physicians Meet with Representatives/ RMS’ For-Profit Subsidiary Expands to Reach All Minnesota Physicians/ RMS Winter Gala and Annual Meeting Smoke-Free Dakota Celebrates the Implementation of Freedom to Breathe/Smoke-Free Washington County Celebrates a Smoke-Free Minnesota Hennepin Medical Society
Chair’s Report Senior Physicians Association/In Memoriam Celebrating Freedom to Breathe/New Members HMS Alliance News
The Journal of the Hennepin and Ramsey Medical Societies
On the cover: Should the Minnesota Constitution be amended to ensure health care as a right for all citizens? Article begins on page 5.
November/December 2007
1
Letters
T
he annual meeting of the Minnesota Medical Association recently concluded a productive session addressing issues related to the health of Minnesota residents and its health care system. During this meeting, we heard testimony regarding a proposed Minnesota Constitutional Amendment that would give every Minnesota resident the “right to health care.” (H.F. 683 proposes an amendment to read: “Every Minnesota resident has the right to health care. It is the responsibility of the governor and the legislature to implement all necessary legislation to ensure affordable health care.”) On its surface, this sounds like a wonderful plan. Everyone should have appropriate and affordable health care. However, as with most things that sound too good, there may be a catch.
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November/December 2007
Given the state of our current health care system, with many patients uninsured and the costs of health care rising, one can see the need for a change. “Don’t just stand there, do something,” someone in the Minnesota Legislature can be heard shouting, and a (proposed) Minnesota Constitutional Amendment was born in an attempt to fix our health care system. However, the “right to health care” is so poorly defined that nobody knows how this will be handled logistically, financially or ethically. Providing health care (which is also undefined) requires action on the part of health care professionals (doctors, nurses, medical assistants, therapists, administrators, etc.) and facilities (hospitals, clinics, surgery centers, imaging centers, laboratories, etc.). As doctors, we all want to provide the best care to our patients. Providing that care, however, comes at a cost. This cost would be borne by the government or the health care providers and facilities. To mandate the “right to health care” without defining how the government is going to provide that health care, or what constitutes “health care” is putting the cart before the horse. To create a Constitutional Amendment guaranteeing the right to health care is not the way to bring this about. Our Declaration of Independence calls out our “...right to life, liberty and the pursuit of happiness.” Similarly, the Bill of Rights, ratified as amendments to the U.S. Constitution, provides the right for the freedoms of speech, press, religion, to keep and bear arms, to assemble, petition, and the right to be free of unreasonable search and seizure. These are all passive rights and help to define our wonderful country. No action is required to fulfill these rights. They are a given, as long as no one (such as the government) attempts to limit those rights. Providing health care takes resources, time and action. Upon receiving our medical degrees, many medical doctors (M.D.) and doctors of osteopathy (D.O.) took the Hippocratic
Oath. To paraphrase the main and most familiar tenet of this oath, it assures that we will “first, do no harm.” In this regard, as doctors we must often decide if action or inaction is best for the health of our patients. First we have to come to a diagnosis, which requires listening to the patient, examining the patient, and often reviewing tests. Once we establish a diagnosis, treatment options are considered. As we all know, on occasion, complications arise and our attempt to help a patient may turn into an event of harm through post-operative infection, misdiagnosis, medication reactions or similar unforeseen consequences. Thus, we always weigh the risks and benefits of intervention to determine the most appropriate treatment. The MMA as a group is hesitant to actively oppose the proposed Minnesota Constitutional Amendment for fear of appearing to oppose patient’s rights and needs for health care. Nothing could be further from the truth. We want what is best for our patients and the state of Minnesota. In this case, the government is considering taking a sick health care system and prescribing a remedy (the “right to health care”) without fully understanding the risks. Someone in the Minnesota legislature should be shouting, “Don’t just do something, stand there.” The government and the MMA need to step back and take a better look at our health care system and determine what needs fixing. Passing the proposed Constitutional Amendment would create a currently unattainable goal and only further complicate our health care system and confuse the residents of Minnesota — our patients. Before such an Amendment can be passed, we need to better research and understand the means by which we can provide the “right to health care.” The proposed Minnesota Constitutional Amendment (H.F. 683) should not be passed by our legislators.
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
Nick Meyers, M.D.
Reflections on the Minnesota Freedom to Breathe Act: Tobacco, Public Policy and Public Health
A
sonal. We perceive the course of events through the filter of our own eyes and ears, and our personal experience affects our memory. Even though history cannot truly be objective, recalling and interpreting events is a common and valuable exercise. The 2007 Minnesota Freedom to Breathe Act is a capstone on a 27-year process that began with the first in the nation Minnesota Clean Indoor Air Act in 1975. It took almost three decades to satisfactorily implement the initial legislation’s intent. Smoking at work and other public places was the norm in the 1970s. Resistance to change came in many forms especially from smokers, business leaders, politicians and some physicians. “Legislating behavior” was the cry from opponents. Does that still sound familiar? The legislative success this year brings to completion a long effort and deserves to be celebrated. We have made major public health strides in cleaning the air Minnesotans breathe. Physicians and their professional organizations are to be congratulated for the major role they played in keeping the issue alive and collaborating with health plans and other professional groups to effect a major social change. Why should professional organizations like county, state and national medical societies get so involved in a public health issue? Why should physicians spend their volunteer time trying to move city councils, county boards and state legislatures? I think it is because our patients expect us to do it. We are their advocates one-to-one in the office and as a group in public forums. We are charged by our patients to act in their best interest and they expect us to take a lead when it affects their health. BY
a . stu a rt h a nson , m . d .
MetroDoctors
Photo by Scott Smith
All history is in part fictional and per-
I became involved with tobacco control in the mid 1970s after four or five years in practice and regularly lecturing on pulmonary rehabilitation and cardiopulmonary resuscitation. I saw myself teaching physicians and patients recovery procedures for diseases that were preventable. Eighty to 90 percent of the patients I saw had diseases that were preventable, and tobacco was the cause. Looking around my practice environment, I saw ashtrays in our waiting rooms, staff and patients smoked in our cafeteria and we asked patients whether they wanted a smoking or non-smoking room when we admitted them to the hospital. It all didn’t seem right! If we are going to leave this world a better place when we are through, tobacco control seemed like a good place to start. In discussing the issue with my pulmonary colleagues, it was obvious that we needed to clean up our own house before we could ask others to limit indoor smoking. Park Nicollet Clinic (formerly the St. Louis Park Medical Center and the Nicollet Clinic) set about to become smoke-free in all our buildings and grounds. Our primary hospital, Methodist in St. Louis Park, wished to defer their participation. A task force representing all interested parties came up with a plan that was implemented between 1980 and 1982. As far as I know, Park Nicollet was the first
The Journal of the Hennepin and Ramsey Medical Societies
multi-office medical practice to go smoke-free in the country except for some Indian Health Service facilities in Arizona and Alaska. When the Hennepin Medical Society (HMS) Auxiliary in 1983 passed a resolution charging the medical society to work for a smoke-free society by the year 2000, they were not talking about our county society. They meant our country. The American Medical Association (AMA) was their target. When the resolution was to come before the AMA House of Delegates, the Minnesota Delegation needed a spokesperson to present the case and to defend the resolution. Since I was new to the delegation, had some experience in tobacco policy and did not smoke, as did several others in the delegation, I was designated to carry the resolution. It passed by agreeing to request a study and for the staff to make a report at the next meeting. Thus began a fight over the next several meetings to define what was meant by a smoke-free society and what were the elements that needed advocacy. The Minnesota Medical Association (MMA) implemented a smoke-free workplace in 1984, and the Minnesota Department of Health (MDH) formed a task force to develop its Minnesota Plan for Non-Smoking and Health to bring to the legislature in 1985. The task force recommended the community form a coalition of interested organizations to give credence and support for moving state legislation and it was chartered January 1, 1985. Then the Surgeon General, C. Everett Koop, championed the Smoke-free Society 2000 concept at the spring meeting of the American Lung Association. The auxiliary’s resolution had developed “legs.” I had a three-month sabbatical in 1984 visiting South and Southeast Asia, China and Japan. My project was to study different (Continued on page 4)
November/December 2007
3
Freedom to Breathe Act (Continued from page 3)
countries’ approaches to tobacco control by interviewing health professionals and government officials. I found the less developed countries were hooked on tax revenues and the finance ministers were winning out over health ministers in any attempt to reduce tobacco consumption. Economics were winning over health. Pakistan, India, Malaysia, Indonesia and China were actually promoting tobacco use. Only Singapore and Japan, the most economically developed, had begun any elements of public policy to curb smoking. Europe had some good examples in Scandinavia to follow, but Asia was not to be emulated. I found the obvious, public policy had a major influence on how a culture approached a public health problem like tobacco and I could see the parallels in the history of the United States as we had progressed economically. The Minnesota Smoke-free Coalition 2000 (MSFC 2000) began operating in 1985 as the legislative session began and was instrumental in getting the tobacco excise tax increased and funds designated to tobacco
control. Also, a Swedish group approached the MMA about starting an initiative to prevent youth from smoking. Thus another new organization, A Smoke-Free Generation, was born. In conjunction with MDH, a t-shirt give away by A Smoke-Free Generation was the largest public health intervention (in raw numbers) up to 1987. A rally at the Metrodome brought 4,000 kids from all over the state to hear the Smoke-Free Generation message from rock bands including one led by a wrestler, Jesse Ventura. The MDH had grants to give to communities, schools and to state-wide initiatives. The MSFC 2000 started a Clean Air Healthcare program to promote smoke-free medical facilities. The MMA, RMS and HMS led the way. Gradually, by the late 1980s about 30 percent of the hospitals and clinics were, or were in the process of, eliminating smoking in their facilities. That was the time to ask the legislature for supporting legislation. By now the Minnesota Hospital Association was on board asking that we establish “a level playing field” for all hospitals. Competition has its benefits sometimes. After a two-year phase-in period, all medical
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November/December 2007
MetroDoctors
facilities and licensed daycare facilities were to be smoke-free January 1, 1992. The rest of the decade was a holding pattern with some gains and some losses. MDH lost its tobacco tax funding, which was diverted to the general fund, and the Office of NonSmoking and Health was eliminated. Then, the Attorney General, Skip Humphrey, and Blue Cross filed a lawsuit against the big tobacco companies alleging fraudulent sales practices causing harm. In 1998 the case in Minnesota was settled for $6.2 billion over 25 years. That led to a huge national Master Settlement for other states of over $200 billion. Some of the Minnesota money was set aside to fund smoking cessation and secondhand smoke reduction in an organization now called ClearWay Minnesota. The state received an upfront sum that was set aside to fund youth tobacco education. Unfortunately, when budget shortfalls presented, the endowment for youth was consumed by the general fund and the wonderful award winning target market program by MDH was eliminated. The state will receive about $200 million per year for another 15 years, which currently goes into the general fund. Health in Minnesota is on the upswing as 2007 comes to an end. Last year we passed a major increase in the tobacco excise tax, and this year we completed the long road to breathe clean indoor air. Still, we have nearly 20 percent of adults over 18 who continue to smoke and new recruits are starting every day. Fire safe, self-extinguishing cigarettes required after January 1, 2009, will reduce secondhand smoke in homes and reduce childhood exposures. Yet tobacco products are still lethal when used as directed. The glass is half full but getting fuller. We can’t let down yet and we certainly don’t want to break the glass. A graduate of Dartmouth College and the University of Minnesota School of Medicine, A. Stuart Hanson, M.D. is a renowned clinical pulmonologist at Park Nicollet Clinic, St. Louis Park. Dr. Hanson has served in several leadership positions including Chair of the Hennepin Medical Society, President of the Minnesota Medical Association and a delegate to the American Medical Association. It is through his vision, leadership, testimony and enduring drive for a smoke-free Minnesota that the State Legislature passed the Freedom to Breathe Act. Dr. Hanson was recently honored as a recipient of the University of Minnesota’s Harold S. Diehl Award. The Journal of the Hennepin and Ramsey Medical Societies
feature story
Does Minnesota Need an
Amendment to the Minnesota Constitution Guaranteeing the Right to Health Care?
W
When you talk to Minnesota legislators today it is easy to see that health care legislation is high on their list of priorities for the 2008 Session. Members of the Legislative Commission on Health Care Access (the “Commission”) are now meeting weekly at the Capitol in Subcommittee Working Groups. The Commission is co-chaired by Senator Linda Berglin, Minneapolis, and Representative Tom Huntley, Duluth. Senator Berglin chairs the Health and Human Services Budget Division of the Senate Finance Committee, and Representative Huntley chairs the Health Care and Human Services Division of the House Finance Committee. The Working Groups include: Cost Containment: Identify Health Care Costs/Savings; Cost Containment: Restructure the Health Care System Through Identified Savings; Development of New Cost Containment Strategies; Public Health; Insurance Market Reform; Health Care for Long Term Care Workers; Single-Payer Health Care; and, Bridging the Health Care Continuum. The Working Groups consist of over 30 legislators, over 40 interested citizens, five physicians representing health care organizations, and three physicians representing the MMA. The three physicians representing MMA are: Dr. George Schoephoerster of St. Cloud on the Cost Containment: Identify Health Care Cost Savings Working Group; Dr. Don Jacobs of Minneapolis on the Cost Containment: Restructure the Health Care System Through Identified Savings Working Group; and Dr. Richard Geier of Rochester on the Insurance Market Reform Working Group. The Commission’s final report is due in time to be considered during the 2008 Session. Many legislative observers predict that the Commission’s final report will include recommendations that will, at a minimum, move the health care system strongly in the direction of universal health care. They predict, even more strongly, that the Commission report will create the foundation for a universal health care system to be implemented after a proposed Constitutional Amendment is approved by voters in the 2008 general election. In order to provide background for the upcoming debate, physicians should become familiar with the legislation introduced during the 2007 Session as Senate File 204: Section 1. Constitutional Amendment Proposed. An amendment to the Minnesota Constitution is proposed to the people. If the amendment is adopted, a section will be added to article XIII, to read: Sec. 13. Every Minnesota resident has the right to health care. It by ro g er k . johnson , c a e
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
is the responsibility of the governor and the legislature to implement all necessary legislation to ensure affordable health care. Section 2. Submission to Voters. The proposed amendment shall be submitted to the people at the 2008 general election. The question submitted shall be: “Shall the Minnesota Constitution be amended to state that every resident of Minnesota has the right to health care and that it is the responsibility of the governor and the legislature to implement all necessary legislation to ensure affordable health care?” Yes………. No……….. Section 3. Action by Legislature and Governor. If the Constitutional Amendment proposed in Section 1 is approved by the people at the 2008 general election, the legislature and the governor must enact legislation to implement the Constitutional Amendment by July 1, 2011. To provide you with insight into the thinking of physicians and legislators on both sides of the Universal Health Care Constitutional Amendment issue, 10 personal interviews were conducted. The interviews include three legislators, four physicians, one clinic management consultant, and one health care attorney. Senator John Marty represents District 54 (St. Paul suburbs) and chairs the Senate Health, Housing, and Family Security Committee. Representative Tom Huntley represents District 7A (Duluth) and he chairs the Health Care and Human Services House Finance Division. Representative Matt Dean represents District 52B (a suburban district in Washington County) and he serves on the Health Care and Human Services House Finance Division. (Spouse of Dr. Laura Dean.) Dr. Michael Belzer is the medical director of the Hennepin County Medical Center in Minneapolis and a former chair of the Hennepin Medical Society Board of Directors. Dr. V. Stuart Cox is an otolaryngologist with Midwest ENT of St. Paul and serves as current president of the Ramsey Medical Society. Dr. Peter J. Dehnel is a pediatrician with All About Children Pediatrics in suburban Minneapolis and is the current chief of the Children’s Hospitals and Clinics professional staff. Dr. Laura Dean is an obstetrician/gynecologist with Stillwater Medical Group and is a member of the Ramsey Medical Society Board of Directors. (Spouse of Representative Matt Dean.) (Continued on page 6)
November/December 2007
5
Feature (Continued from page 5)
Jim Reimann is a consultant to medical practices with Physician Advocates of Minnesota and chairs the Payer Relations Committee of the Minnesota Medical Group Management Association (MMGMA). Henri Minette, J.D., M.P.H., is an attorney practicing health care law with Lockridge Grindal Nauen P.L.L.P. in Minneapolis and he provides counsel to the Hennepin and Ramsey Medical Societies and to the MMGMA. Why do you believe Minnesota needs a Constitutional Amendment to provide health care to its citizens? Senator Marty: Many do not receive health care today. Fifty to 60 years ago we adopted
the Universal Declaration of Human Rights and we have not lived up to that declaration. Prisoners in Minnesota already have the constitutional right to health care. I believe the rest of my constituents deserve the same right. Representative Huntley: We have between seven and eight percent uninsured in Minnesota. We need to take action to get universal coverage for all Minnesotans. Representative Dean: I don’t believe we need the Constitutional Amendment. We need to look at access, quality and cost. A mandate will have to define health care and I question how it will be affordable. A Constitutional Amendment is a bridge to a single payer health care system. Dr. Belzer: I don’t believe we need a Constitutional Amendment but it is a clever idea. I
INTRODUCED BY: SUBJECT:
Right to Health Care
REFERRED TO:
Reference Committee C
WHEREAS,
RESOLUTION No. 316 2007 Ramsey Medical Society Hennepin Medical Society
the Minnesota House of Representatives and the Minnesota Senate will likely address a Constitutional Amendment in the 2008 Legislative Session that states that “Every Minnesota resident has the right to health care,” and
WHEREAS,
“the right to health care” is poorly defined by the Constitutional Amendment, and
WHEREAS,
because the “right to health care” is poorly defined the likelihood of individuals filing lawsuits for what they perceive to be their “right” to particular medical procedures afforded to them under this Constitutional Amendment has the possibility of occurring, and
WHEREAS,
“the right to health care” in any form will require sufficient facilities and personnel in a sustainable form over a long period of time to provide this poorly defined health care, therefore be it
RESOLVED,
that the Minnesota Medical Association support the development of a workgroup that will develop legislation that will define accessible, affordable, financially viable health care that will benefit all Minnesotans, and be it further
RESOLVED,
that the Minnesota Medical Association will develop the workgroup by the end of 2007 and hold at least one meeting by then, and be it further
RESOLVED,
that the Minnesota Medical Association actively oppose the Constitutional Amendment until the workgroup makes its recommendation.
HOUSE ACTION: Resolution 316 was REFERRED TO THE MMA BOARD OF TRUSTEES.
6
November/December 2007
MetroDoctors
am fully supportive of it as a springboard to policy development. The Amendment does tee up the issue. We could provide universal care without the amendment. Dr. Cox: I believe everyone in Minnesota has the right to be covered by a basic benefit set. I am not certain that a Constitutional Amendment is the best way to achieve that goal. Dr. Dehnel: I do not believe we need an Amendment to achieve universal health care coverage. Dr. Dean: I do not believe we need a Constitutional Amendment because Minnesota has close to the lowest rate of uninsured persons in the country. Steps can be taken to provide care short of a Constitutional Amendment. Mr. Reimann: Ninety some percent of Minnesotans have some type of health care coverage and I do not believe we need a Constitutional Amendment. I think there are enough current options for patients to access health care in Minnesota. Mr. Minette: The debate ultimately centers on the question of whether access to health care is a right or not a right. If the Minnesota Legislature decides that it should be a right, one way to do that is to amend the Constitution of the State of Minnesota to make it a right. Do you support legislation providing for an amendment to the Minnesota Constitution that establishes the right to health care for Minnesotans? Senator Marty: I am not as interested in guaranteeing coverage as I am in guaranteeing health care to Minnesotans. We have done a poor job in public health. For example, we had a shortage of flu vaccine a couple years ago and we had to take steps for certain people to receive the vaccine and we were unable to vaccinate everyone. We are all better off if everyone is protected. I am more interested in providing health care to everyone than how the health care is delivered. Representative Huntley: Yes, I was a chief author in the House. We have the votes to pass the legislation. Representative Dean: Physicians have a mandate to care for people without regard for the ability to pay for the care. Everyone has the The Journal of the Hennepin and Ramsey Medical Societies
right to access to care. How do we provide for an affordable health care system with a Constitutional Amendment? Dr. Belzer: Yes, as I am enough of a Pollyanna to believe in the end we will not let the providers’ ship sink. People do have the right to health care. Dr. Cox: No, as I previously stated, I am not sure an amendment is the correct way to provide basic benefits. Dr. Dehnel: No, unless the state decides to get into actually providing the care, the only thing the state can do is guarantee universal coverage. There is a distinction between providing the care and providing coverage for the care. Dr. Dean: I do not support the legislation. A Constitutional Amendment is not the most effective or appropriate means to achieve quality health care for the citizens of Minnesota. The language establishing health care as a right creates challenges and the courts would end up defining health care. Legal challenges could end up bogging the health care system down and raise costs. Mr. Reimann: Without knowing all the details involved in implementation it would be impossible to support legislation establishing a Constitutional Amendment. Mr. Minette: As legal counsel Mr. Minette elected not to state his personal opinion. If such a Constitutional Amendment is adopted, will everyone residing in the state be covered or will it apply only to legal Minnesota residents? Senator Marty: I was a chief author on the 2007 bill and we determined that universal coverage would be less expensive than our current system of health care. We are concerned about people moving into the state for health care. However, we know that Minnesota is not the kind of place where people are turned away. We need to deal with the immigration issues, which are complicated by illegal immigrants and by federal statutes. Representative Huntley: That question has not been decided. Our intent is to cover legal residents but federal law affects the residency requirement due to the definitions of interstate commerce. MetroDoctors
Senator John Marty
Representative Matt Dean
Representative Tom Huntley
Representative Dean: Language will be needed that deals with residency to answer the questions of how long a person must be in the state to be covered if the amendment is adopted. Documentation of citizenship will be an issue that may come up as well.
costs we will have a more efficient, cost-effective health care system. We are currently spending $6,400 per year per person in Minnesota on health care. I would rather pay $5,000 per capita. We need to have a more cost-effective health care system with less cost shifting.
Dr. Belzer: I hope that the coverage is not limited to legal residents of Minnesota as those who are not legally sanctioned need care when they appear in the ER and in other settings. They must be provided for in any effective system.
Representative Huntley: I think we will ultimately have a system with subsidies based on income levels. Those with no subsidies will purchase insurance in the marketplace. (Continued on page 8)
Dr. Cox: That is a difficult question. Ideally, I would apply it to Minnesota residents. Dr. Dehnel: If we are going to cover Minnesotans, we should cover legal residents of Minnesota. We cannot afford to cover everyone in the state regardless of legal status. Philosophically, it is wonderful to care for all, but that is not currently affordable. Dr. Dean: I think the legislation should cover Minnesota citizens. Coverage beyond that must be carefully and thoughtfully considered. Mr. Reimann: It should only apply to legal Minnesota residents and the problem is how to define the eligibility and remain in compliance with all the relative statutes and regulations. Mr. Minette: That is the big question. Will the “right to health care” be limited to Minnesota residents? The practical issues of how the program is administered and the cost of the program come into play. Balancing the rights and the costs could lead to health care rationing.
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How do you envision the financing of universal health care in Minnesota? Senator Marty: Patients and providers will make decisions and with lower administrative
The Journal of the Hennepin and Ramsey Medical Societies
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November/December 2007
7
Michael Belzer, M.D.
Feature (Continued from page 7)
Representative Dean: I prefer to use the terms single payer and consumer driven. If we look at single payer systems the costs go up and the quality declines. There is also decreased access. We will have access issues if the currently uninsured are added to the current MNCare, Medicaid, and GAMC programs. Many businesses would shift their employees to those plans if given the opportunity. We could have rationing if the costs get out of control. Dr. Belzer: In the long run, I am convinced the only system that will work is the singlepayer system. A marketplace solution will not be acceptable. Dr. Cox: According to the Minnesota Attorney General’s report a few years ago, 45 percent of
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November/December 2007
V. Stuart Cox, M.D.
Peter J. Dehnel, M.D.
the health care dollar was going to administrative overhead of Minnesota Health Plans. If that overhead was eliminated many dollars would become available. Dr. Dehnel: Substantial revenue must be redirected to health care. The entire provider tax payments made to the Health Care Access Fund must be directed solely to health care expenses. Dr. Dean: I support employer sponsored, individual health plans and the creation of larger pools of insureds. We must look at all options. Patients who are better educated about costs and choices will make better decisions when they use the health care system. Mr. Reimann: My fear is that the provider tax will be expanded from 2 percent to 5 percent to finance universal health care. The tobacco tax could also be increased, which is not stable as fewer and fewer people smoke. Mr. Minette: We could end up with a blended system using the current health plans with people below a certain level of income receiving state subsidies. If the level of reimbursement is inadequate such as the current MNCare schedule, there will be many future problems. How will the pricing structure be established? Senator Marty: The structure should enable the system to operate the most efficiently as possible. The administration should be operated as a not-for-profit or, in other words, a neutral system. Representative Huntley: There should be an individual market with guaranteed issue with some adjustments. I would support an adjustment for age. Many young people are not buying insurance today as they are gambling on being young and healthy. MetroDoctors
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Representative Dean: The costs of government reimbursements drive the private market. Fewer people in the private market with less competition and less choice will increase the costs. The benefit set will become restricted. Who will determine the reimbursement schedule for physicians and hospitals? Senator Marty: That will depend on the system of administration. We should have competitive reimbursement with a more equitable system that provides for an increase to primary care providers. Representative Huntley: It will be like it is today with the private market. We may pay more for chronic disease management and for primary care. Transparency and quality will be the most important factors. I prefer a system in which the state subsidizes private insurance based on the income of the insured. Physicians are all bright and they all work hard. We must be aware of the impact the system will have on physicians. Representative Dean: If we end up with a single payer that will not be good for patients. The Department of Human Services would likely be the state agency to set benefits and prices. Dr. Belzer: I am not in a position to answer that question. Dr. Cox: A legislative task force should be created with representation of consumers, businesses and providers to determine the reimbursement schedule. Dr. Dehnel: The Legislature will determine the schedule and it will be politically driven. It will probably be based on the MNCare fee schedule and it will be what the legislators believe the state can afford to pay. The Journal of the Hennepin and Ramsey Medical Societies
Dr. Dean: I think it should be a competitive market with negotiations between physician groups and the health plans. The fee schedules under the current MNCare program are too low and need to be reviewed and improved. Mr. Reimann: I believe the current health plan reimbursements will decline as the currently profitable small to midsize group business shifts to state plans. As reimbursements decline, physicians could end up leaving Minnesota. Mr. Minette: The system will end up as a blended system combining the existing health plans with some of the costs funded through the State of Minnesota. The state will provide the funding for public programs. The MNCare fee schedule is a possibility but the level of reimbursement is inadequate. A problem could arise if universal health care is established and it is underfunded. What level of care to provide; how to reimburse for the care; and how to pay for it will be major decisions to be made by the legislators. What will happen to our existing health plans? Senator Marty: The answer depends on the system we develop. They could morph into other entities with no marketing, no underwriting, less claims processing and lower administrative costs. Representative Huntley: The question is what value do they add beyond processing claims? Doctors should be rewarded for providing quality health care with good outcomes. Representative Dean: In a single-payer system we will have a transition from our current system of providing quality care to those who have coverage to providing less quality care to many more persons who are unable to supplement the coverage in the mandated program. We will have a two-tiered system. Dr. Belzer: In a single-payer system they will play a less significant role.
Dr. Dean: They will continue to be important players in our health care system. Mr. Reimann: I envision the health plans downsizing and essentially over the course of five years all health plans will be out of business. Mr. Minette: Barring the Jim Reimann Henri Minette, J.D., M.P.H. creation of a total government system of health care, the role of consequences that result when people are the health plans will continue. The plans will uninsured. The factor of being uninsured is be the mechanism for expanded access to care. I far more important than where people get do not predict that the health plans will disaptheir care. They have poorer health status by pear soon. The health plans are entrenched and every measure at every age. Being uninsured they are big business involving a large sector is the number three cause of death in the of our economy. United States. Universal coverage will result in an improvement in the health status of this What will be the advantages and disadvantages population. The disadvantage could result if for physicians if universal health care is enacted we have too low a rate of reimbursement, but in Minnesota? that should not be an impediment to providing Dr. Belzer: There is a great volume of universal health care. medical literature that speaks to the health (Continued on page 10)
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Dr. Cox: If there is a single-payer system that rations health care, the health plans would not be involved. Dr. Dehnel: If MNCare is expanded to cover more people, the health plans will continue to administer public plans and also offer coverage to employers for their employees. MetroDoctors
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November/December 2007
9
Feature (Continued from page 9)
Dr. Cox: The advantage would be that if universal care is appropriately applied and reimbursed, we could provide excellent care with potentially lower overhead costs. The disadvantage would occur if reimbursements are too low and negatively affect the ability of physicians to maintain their practices. Access will be diminished if sufficient numbers of physicians are not available to care for patients. Dr. Dehnel: One advantage could be that patients may choose to have their care coordinated through a clinic. That would result in more appropriate use of resources if ER access is reduced and other savings are realized. A disadvantage would result if physicians are not adequately reimbursed for their services and access is diminished. Will the 2008 Minnesota Legislature adopt a bill placing a universal health care Constitutional Amendment on the 2008 ballot? Senator Marty: The 2008 Legislature will give very serious consideration to the bill calling
for a Constitutional Amendment. The bill will be Senator Linda Berglin’s bill and it will be considered early in the Session. Bills calling for Constitutional Amendments do not go to the governor so Governor Pawlenty will not be signing or vetoing the bill. Representative Huntley: I predict the bill calling for a universal health care Constitutional Amendment will pass in the 2008 Session. The 2007 bill only has to go back through one committee in the House before it goes to the floor of the House.
Dr. Dehnel: It seems likely that the bill will be adopted. I believe it will be the same as the 2007 bill. I also believe organized medicine is obligated to launch a public education campaign warning our citizens of the full consequences of the approval of this Constitutional Amendment. Dr. Dean: I would rather not make a prediction. Mr. Reimann: I believe the bill placing the Constitutional Amendment on the 2008 ballot will be approved.
Representative Dean: I believe the bill will pass unless physicians become involved. Physicians need to speak up about access and quality issues. The governor cannot veto this bill because, unlike other legislation, Constitutional Amendments do not go to the governor for his signature or veto.
Mr. Minette: The bill from the 2007 Session could pass in the 2008 Session. People recognize health care as an important issue. Legislators believe the Constitutional Amendment is a first step. It will be more problematic to implement the amendment.
Dr. Belzer: I predict the 2008 Legislature will adopt the bill calling for the Constitutional Amendment to be on the ballot in 2008.
What is your prediction of the outcome of the vote on a universal health care amendment to the Minnesota Constitution if it is included on the 2008 general election ballot?
Dr. Cox: I believe the bill will likely pass in the 2008 Session.
Senator Marty: I predict it will be adopted by
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November/December 2007
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
the electorate. Movies like Sicko have increased the awareness of voters on health care issues. Representative Huntley: Polling indicates that 70 percent of the public supports universal health care. I believe the amendment will be approved. Representative Dean: It will be very expensive and very difficult to oppose the amendment. The public will be told they may lose their health care coverage if the amendment is not approved. Dr. Belzer: The voters will approve the Constitutional Amendment. Dr. Cox: Unless there is an extensive education campaign about the negative effects of the amendment, I predict it will be approved by the voters. Dr. Dehnel: Voters will vote for the amendment unless an effective educational campaign is launched to educate them about the consequences of adopting the amendment. The benefits will likely flow to the health plans and not to the patients. Dr. Dean: Currently, the language of the amendment is difficult to read without subsequently voting for the amendment. It will pass without a strong effort to educate the voters of Minnesota. The MMA, HMS and RMS should work with other organizations such as MMGMA to educate the voters about the potential negative effects the amendment will have on access and on quality of care. Mr. Reimann: If the language is a referendum on all Minnesotans having the right to health care it will be approved by the voters. Mr. Minette: I suspect it will be approved. The simple language of the amendment makes it more likely to be supported by the voters, as it requires less comprehension of complex issues. Legislators will be responding to voter interest in health care that is demonstrated by the polls. National polling on universal health care was conducted in February by the New York Times/CBS poll and released in March of 2007. That poll asked: Should the government guarantee health insurance for all? Sixty-four percent answered yes with 27 percent replying no. How much change does the U.S. health care system need? Eight percent replied for
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minor change. Fifty-four percent supported fundamental change. Thirty-six percent supported completely rebuilding the health care system. The devil, however, may be found in the complexities and the details included in the universal health care proposals. One national poll conducted by a paid consultant of known Republicans found 51 percent supporting universal health care coverage and 40 percent opposing it. Those opposed cited needing more specifics before they could consider supporting universal health care. What Actions are Other States Taking to Provide Universal Health Care?
Universal health care has become an important issue in many state capitols. With federal legislation appearing to be off the radar screen of Congress, many state governors and legislators have taken on the issue. Maine became the first state to enact universal health care with its DIRIGO Health Reform Act of 2003. Illinois adopted its All Kids Health Insurance Program in 2005. Both Massachusetts and Vermont adopted major legislation in 2006. The Massachusetts plan has the goal of all citizens having access to health care by 2009. Health insurance is mandatory in Massachusetts as of July 2007. The Catamount Health Care Affordability Act adopted in Vermont is a voluntary program providing subsidies for health insurance coverage in an effort to cover more of its citizens. The 2008 Session will be gaveled to order on February 12, 2008. Despite universal health care’s acknowledged place on the legislative priority list, its future could be affected by the I-35 bridge collapse and the resulting competing pressures on legislators and the governor to increase funding for road and bridge transportation infrastructure improvements. It is likely that legislators and the governor will need to find the needed revenue sources for both transportation appropriations as well as for any desired expansion of health care programs. Roger K. Johnson is the former CEO of the Ramsey Medical Society, and is currently a consultant and lobbyist with Lockridge Grindal Nauen P.L.L.P. of Minneapolis.
The Journal of the Hennepin and Ramsey Medical Societies
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November/December 2007
11
Amending the Minnesota Constitution — How Do You Do It?
T
The process for amending the state
constitution is governed by Article IX, Section 1 of the Minnesota Constitution and by state election statutes. In order to amend the constitution, the legislature must first pass an act proposing a change to the constitution. The act states a ballot question that the legislature would like to propose to the voters. In order for a proposed amendment to be submitted to the voters, a majority of the members of each house of the legislature must vote in favor of the proposal. For the purpose of proposing the amendment, a “majority” means a vote in favor of the proposal by a majority of all of the members of the legislature, not just by the members present at the time of the vote. After the legislature has approved the act with the proposed amendment, it is assigned a session law chapter number and published with other session laws. The proposed amendment is then submitted to the voters for approval or rejection during the next general election. Although the proposed amendment is submitted with the session laws, the governor may not veto a proposed amendment, and the governor’s veto of any session law does not affect the proposed amendment. Since 1858, Minnesota voters have considered 212 proposed amendments to the state constitution. Of those 212 proposed amendments, slightly over half, 119 amendments, have been ratified. The most recent amendment to be ratified was the Transportation Amendment, which was approved in 2006. According to state statute, the Attorney General must provide the Secretary of State with a statement outlining the proposed amendment’s legal effects at least four months B Y a nn a horn i n g ny g ren , jd And H enr i g . m i nette , jd , m p h
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November/December 2007
prior to the election. This statement must also show the existing text of the constitution and how the constitution would read if the amendment were ratified. The Secretary of State publishes the Attorney General’s statement in every qualified newspaper of the state. Two copies of the Attorney General’s statement are also posted in polling places on Election Day. An extraordinary majority of the voters must approve a proposed amendment in order for it to be ratified. This means that the proposed amendment must receive a majority vote from all individuals voting in the election, including individuals who do not cast a ballot on the constitutional provision. Individuals who do not vote to either accept or reject the amendment are considered “no” votes for the purposes of obtaining a majority vote to adopt the amendment. Therefore, of the voters
who do vote on the proposed amendment, a larger proportion (an extraordinary majority) must vote in favor of the amendment in order for it to be adopted. A notice explaining the extraordinary majority requirement to the voters is printed on the ballot. Because of the extraordinary majority requirement, a proposed amendment must typically receive a 60 percent “yes” vote in order to be ratified. For a detailed analysis of Minnesota constitutional amendments and their ratification, readers may wish to review the 2004 Minnesota House Research Department Report on Minnesota State Constitutional Amendments: http://www.house.leg.state.mn.us/hrd/pubs/ mnconst.pdf. Anna Horning Nygren and Henri Minette are attorneys with the Minneapolis law firm of Lockridge Grindal Nauen P.L.L.P.
Health Care Legislative Panel HMS and RMS physician leadership invited several members of the Minnesota State Legislature to participate in a “Health Care Legislative Panel” on August 28. This forum provided an opportunity for an open discussion and dialog on many of the issues that are currently being considered by the Legislative Commission on Health Care Access and various work groups. The Commission is co-chaired by Senator Linda Berglin and Representative Tom Huntley. Some of the discussion centered on the proposed Constitutional Amendment that would grant every Minnesotan the right to affordable health care.
The legislators from left to right are: Senator Mary Olson, District 4; Representative Julie Bunn, District 56A; Senator Linda Berglin, District 61; Representative Erin Murphy, District 64A; and Senator Tony Lourey, District 8. Standing at podium is Ted Grindal, Lockridge Grindal Nauen P.L.L.P., who served as the moderator.
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
Redesigning Our Health Care System Proposed Medical School Must Help Create New Models of Care
L
Last May, Allina Hospitals & Clinics
and the University of St. Thomas announced plans to study the feasibility of creating a new medical school for Minnesota. By the time you read this, we will have announced the results of our feasibility study (due to be completed in late October), but regardless of the outcome of that effort, the issues we are attempting to address are important ones for the broader medical community to continue to discuss. A Unique Focus The new medical school would be designed to support new models of health care delivery and train primary care physicians for the state. The intention is to complement, not compete with, the existing programs at the University of Minnesota and Mayo Clinic. However, both of those institutions have distinct, significant and important research missions. As a result, their main focus will never be on training primary care physicians to practice a new model of patient care in Minnesota. Allina has strong partnerships with the University and, whether or not we are involved in a new Medical School, we are committed to continuing and strengthening those partnerships. We’ve had extensive discussions with the University. Their leaders agree that new educational experiences need to be created, but do not have specific plans in this regard. As well, the University’s size and complex mission — teaching, research and outreach — make it difficult to develop innovative approaches to community care, and BY
p enny w heeler , m . d .
Chief Clinical Officer, Allina Hospitals & Clinics
MetroDoctors
the size of their medical school class makes it difficult to focus on continually supporting students who want to serve the high needs in the community. Our vision for a new medical school would be that community needs would be its entire focus. It would not be a research-driven institution, instead focusing on providing clinical experiences early to students committed to practicing primary care in new ways in our state. If we do not move forward with a new medical school (the challenges are significant), it will be incumbent upon all of us to work with our existing institutions to create innovative, new approaches. The Problem Clearly, the health care system in this country is broken: • Our costs are higher than those in any other developed country and, overall, our outcomes are middle of the road. • Patient care is too fragmented, impersonal, ineffective and unsafe. Moving the needle on quality and safety takes too long. • Our population is aging, and chronic illness is on the rise. By 2011, the number of Minnesotans over the age of 65 will grow by 12.3 percent, and by 2035 will grow 124 percent to nearly 1.4 million, making this age group the fastest growing in the state. • Chronic illness is growing. More than 90 percent of Americans over 65 have at least one chronic illness. Obesity, tobacco use and other lifestyle issues are increasing the burden of chronic illness. Today, chronic
The Journal of the Hennepin and Ramsey Medical Societies
illness accounts for an astonishing 83 percent of health care spending. Each of these trends stresses our health care system and begs for new approaches. Our vision is to create a fundamentally new model of health care, which has to involve new thinking in how we train the next generation of physicians. Patient-Centered Care Specifically, we need a new model of care that includes innovative approaches to change the practice of medicine across our population. We believe that the new model must, first and foremost, be patient-centered. For us, “patient-centered care” can best be defined as engaging patients in care decisions, giving them open and complete information, involving them in medical decision-making, responding to each person’s unique needs and values, and coordinating care across providers, settings and conditions. To practice in this model, we need to train physicians differently. Specifically, they must be able to deliver care that is: Multidisciplinary. We need to train the next generation of physicians to work in multidisciplinary care teams. Nurses, nurse practitioners, pharmacists, social workers, mental health professionals, integrative health specialists and other allied health professionals may be part of the care team. Expanding our care teams will reduce costs and allow providers at all levels to use their unique skills to support the patient. It
(Continued on page 14)
November/December 2007
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Redesigning Our Health Care System (Continued from page 13)
is estimated that 40 to 50 percent of a nurse’s or doctor’s time is spent overcoming barriers, hassles, and doing work that does not involve the direct care of patients. More effective teamwork will provide better care, at the right place and at the right time. Each member of the team will be better able to accommodate patients’ needs. Coordinated. Working with multidisciplinary teams, physicians must be trained to do a much better job facilitating the coordination of care. This includes handoffs between providers and care settings. Care team members must figuratively walk beside the patient to assure seamless care. We all know that one of the most significant dissatisfiers for patients is the fragmentation in our health care system. Fragmentation leads to discontinuity of care and sub-optimizes outcomes.
With an aging population and increasing burden of chronic disease, coordination of care will be more important than ever in the future. To absorb the increasing number of patients, it is imperative that the health care system do a much better job of managing chronic conditions and coordinating care. Continually improved. Students need to understand the latest improvement methods to ensure patient safety and continually improve the quality of care provided. They need to see quality improvement as part of their job and be given the resources and tools to identify and implement best practices and use new knowledge to inform their daily practice. Leverage electronic records and other technologies. With electronic medical records becoming widespread, the curriculum needs to show how the tools promote knowledge sharing for physicians, team members, and patients.
For example, this common knowledge platform can allow us to identify patients at risk for disease far before it strikes. We can also create point-of-care decision support which assures the patient receives the best care for his or her particular illness. This knowledge platform also allows us to develop shared care plans with patients so we can continually support them as the principal agent in their own healing. Evidence is that patient-centered care can improve health. At MCG Health System in Georgia, a neuroscience unit partnered with families to help monitor patients’ status in the intensive care unit. Surprise: communication dramatically improved and outcomes soared. The unit decreased medication errors by 62 percent, length of stay fell 50 percent, staff vacancy rates went from 7.5 percent to 0, and patient satisfaction rose from the 10th percentile to the 95th. While patients receive episodes of remarkable care in our hospitals and clinics, overall,
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The Journal of the Hennepin and Ramsey Medical Societies
21727 Metro Dr. Ad
people spend a tiny fraction of their life in a health care setting. We need to make every visit and every encounter count. In fact, I believe that we will not — we cannot — dramatically improve care until we engage our patients as our partners in care. To do that, we need to train physicians in new approaches. Care of the Community It has been said that there are three moral imperatives for health care — the care of each individual patient, making health care available and affordable, and improving the health of the community. Thus, in addition to enabling a patientcentered model of care, it is important to train physicians and other members of the health team to keep an eye on the broader public health. Population-based approaches will enhance our community’s vitality in ways that reach beyond physical health and all members can benefit. Whether or not we move forward with the medical school, Allina is committed to forging new models of care, partnering across our community to improve outcomes and innovate and lead the discussion to understanding options for addressing the complex issues facing health care. We need to build continuous healing relationships in partnership with patients, so they are continually supported in their care and their needs are best met. Patients are best served by care teams that support the patient’s ability to best prevent illness from occurring, reduce the burden of chronic illness, and compassionately care for patients at the end of life. If we do this well, we have an extraordinary opportunity to dramatically improve health and respond to the needs of our patients and community. And, we can reduce soaring health care costs for all the right reasons. To make this vision a reality, we will need physicians who embrace this philosophy. If we decide to go forward with a new medical school, it will be because the evidence is that it will make a lasting, positive difference in the way health care is provided in Minnesota. It’s a big idea, but with our ailing health care system, I’m convinced that now is the time to explore big ideas. MetroDoctors
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The Journal of the Hennepin and Ramsey Medical Societies
November/December 2007
15
Medicine and Public Health — It’s Time to Renew Our Vows “Medicine is politics. Public health is politics writ large.” Dr. Rudolf Ludwig Karl Virchow
L
Like spouses whose lives have gradu-
ally moved in different directions, the health disciplines of medicine and public health now find themselves in a mid-life crisis that begs for an analysis of their relationship and an opportunity for a renewal of vows. In this brief article, we will provide this analysis and then argue that given the nature of the diseases that now afflict our society, it is imperative that we revitalize the marriage. The essential nature of the relationship between medicine and public health is underscored by the fact that the Centers for Disease Control estimates that only 10 percent of the health of a given community can be attributed to the medical care received by that community.(1) The remainder is determined by the genetic mix of the community, personal health behaviors, and the environment (economic, social and physical). Given this reality, it is important to look at why and how medicine and public health have drifted apart over time. It was not always this way of course. In his classic text chronicling the history of public health in Minnesota to 1948, Philip Jordan describes the arrival of Civil War surgeon Dr. Charles Hewitt from New York to a new practice in Red Wing, Minnesota in 1867.(2) Jordan’s account of Hewitt’s first visit to Red Wing is instructive and prescient: As Hewitt walked the streets, his sharp eyes picked out piles of decaying rubbish. He saw butchers casually slaughtering hogs and cattle with disregard for cleanliness. Behind homes stood squalid lines of privies. Sometimes a well stood perilously
B Y J a mes H a rt, M . D . And J enn i f er Gunn , P h . d .
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close to refuse pits. Farmers came in with gashes on hands and arms, which had been smeared with mud or manure. It seemed to Hewitt that people were far more intent upon taking up land and working it than upon sanitation and careful treatment of their bodies. (p. 132) Working through the Minnesota State Medical Society, Hewitt would go on to be the driving force behind the establishment of the Minnesota State Board of Health in 1872. He served as its secretary for the next 25 years and worked tirelessly on such things as smallpox eradication, community health education, and the development of a public health network across the state. Hewitt’s career is a prime example of how medicine and public health were blended in that era and were largely driven by physicians. Meanwhile, our knowledge of human disease was evolving at a rapid pace. The discoveries of Louis Pasteur, Joseph Lister, and Robert Koch established the germ theory of disease. The findings that microorganisms caused specific diseases led to the era of sanitary engineering and bacteriology, during which much of our water and sewerage infrastructure was first introduced as a measure to prevent the spread of disease. The realization that much of health is related to our immediate environment was beginning to sink in, as was the possibility of managing that environment to protect and improve health. In the early 20th century, the consolidation and reform of medical schools raised the standards in medical education and reduced the number of physicians being produced. These reforms addressed both concerns about the quality of doctors and the difficulty of making a living in medical practice. The remainder of the 20th century would see medicine become MetroDoctors
more and more sophisticated in its practice and more respected with a concomitant rise in its income and prestige. But medicine also faced challenges: financing complex commercial enterprises and new technologies, negotiating with a multitude of third-party payers and buyers, and resisting the threat of fragmentation brought on by more and more specialization. These phenomena have tended to lead medicine away from public health and the public in general, toward a focus on more lucrative procedures and the treatment of individuals, especially those with insurance or the means to pay for medical services.(3) At the same time, the practice of public health has moved in its own way. Given its more community-based and social nature, much of public health practice has been located in government or non-profit agencies that are not well connected to medical practice. This has interfered with the coordination of the practice of prevention and with the care of chronic diseases. The roots of the School of Public Health at the University of Minnesota lie in the long, close association between the Medical School and the State Board of Health, whose staff did double duty teaching bacteriology and hygiene to the medical students for many decades. It is interesting, and perhaps ironic, to recall that when preventive medicine and public health was elevated from a department of the Medical School into a separate School of Public Health (SPH) in 1945, it was with the assistance of an endowment derived from the profits of the private Mayo Clinic’s medical practice, channeled through the Mayo Properties Association. The school is now based in the Mayo Building, the old university hospital, also built as a memorial to the Mayo brothers. Dr. W. W. Mayo served on the State Board of Health The Journal of the Hennepin and Ramsey Medical Societies
and Dr. Charles Mayo served as the Rochester health officer at one time. Under Dr. Gaylord Anderson’s leadership as dean, the SPH moved beyond its traditional focus on sanitation, biostatistics, and public health nursing to become internationally known for Ancel Key’s work on the epidemiology and prevention of heart disease.(4) The common roots of the practices of medicine and public health are especially clear in Minnesota, and fortunately their affections have not yet been totally lost. One need only consider the epidemiology of the current disease burden in our state (adult prevalence of 23 percent for obesity, 5.7 percent for diabetes, 5 percent for coronary heart disease, 3.2 percent for cancer)(5) to realize that the best approaches to prevention of disease and the care of chronic illnesses will require a renewed marriage of our disciplines. The most successful approaches to prevention are those that are public in nature such as smoking bans and fluoridation of water. The current “privatization of prevention” with its
focus on individual behaviors is clearly not working well in many cases. Furthermore, the care of chronic diseases is best accomplished by a decentralization of care into homes and communities that can be facilitated by practitioners such as public health nurses and communityfocused primary care physicians. So how might the average physician begin to partner with their local public health agency? The place to start is to develop a relationship with your local public health director (at the county level in most cases). Offer to meet your director for lunch and discuss how you might help with a public health initiative in your area. Documents such as the MDH Strategic Plan for Addressing Asthma in Minnesota or the report of the MMA Task Force on Obesity might be good ways to start the discussion. Were Dr. Hewitt to return to Minnesota today, his “sharp eyes” would undoubtedly notice our wide girths, our motorized vehicles, and our slow ambulation. He would likely be impressed by our sophisticated medical care system, but also disturbed by our persistent
burden of chronic disease and premature death. He would certainly chide us a bit, and then challenge us to take careful stock, renew the vows of medicine and public health to partner in promoting and protecting the health of our people, and build a health system that better attends to our current health needs. References 1) Centers for Disease Control Web site. 2) Jordan, Philip. (1953). The People’s Health: A History of Public Health in Minnesota to 1948. (St. Paul, Minnesota Historical Society). 3) Starr, Paul. (1982). The Social Transformation of American Medicine. New York: Basic Books, Inc. 4) Myers, J. Arthur. (1968). Masters of Medicine: An Historical Sketch of the College of Medical Sciences University of Minnesota, 1886-1966. St. Louis: Warren H. Green, Inc. 5) Minnesota Department of Health Web site.
About the authors: James Hart, M.D. is the director of the Executive Program in Public Health Practice at the University of Minnesota School of Public Health. Jennifer Gunn, Ph.D. is an assistant professor in the History of Medicine Program in the University of Minnesota School of Medicine.
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November/December 2007
17
Physician Perspective of the 35W Bridge Collapse: A Tragedy to Learn From
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On August 1, 2007 at 6:05 p.m., the 35W Bridge that comprised
the span over the Mississippi River collapsed. Built in 1967, it had the distinction of being the busiest bridge in the State (141,000 cars/day). At the time of the collapse, the bridge was packed with rush-hour commuters and fans attempting to attend a Twins baseball game. It is estimated that there were over 80 vehicles on the bridge. The collapse sent the center span directly into the river below while the north and south ends toppled toward the banks. The first arriving police, fire and EMS crews found a chaotic scene with numerous hazards and victims. It was immediately recognized that the resources dispatched were not adequate, and the response was upgraded. We will briefly describe the physician roles in the response. Physicians at the Scene The Minneapolis EMS system includes several emergency physicians with specialized EMS training and equipment to augment the usual two-tiered (fire and paramedic ambulance) response system. These physicians are on-call for consultation and field response when necessary and are also members of the statewide technical rescue team known as Minnesota Task Force 1. Three of these physicians responded directly to the scene within minutes of the collapse and provided support to the command post as well as providing direct field triage, patient care, and oversight of the paramedics. Additionally, because the incident took place near the University of Minnesota Hospital and Clinics, there were numerous physicians and medical professionals who came to the scene to offer help. This was appreciated but created safety concerns as they were ill-equipped and ill-trained to be working in such a hazardous environment. Hospital Physicians Hennepin County Medical Center (HCMC) became a focal point for the medical response due to several factors: • HCMC EMS provides primary paramedic ambulance service to the area of the bridge. • HCMC, as the closest Level 1 Trauma Center, became the default receiving hospital for critical patients. B Y je f f rey d . ho , m . d . , fa ce p, john l . h i c k , m . d . , fa ce p, a nd w i ll i a m g . hee g a a rd , M . D . , fa ce p
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•
HCMC houses the West Metropolitan Medical Resource Control Center (WMRCC), which provides information to regional hospitals and ambulances regarding bed availability, emergency department capacity, and closure status to coordinate patient flow. WMRCC, along with the Web-based “MN TRAC” hospital information system was able to keep information flowing to area hospitals regarding patient numbers, bed availability and patient destination. At HCMC, the lead emergency physician on-duty declared an external disaster condition shortly after the collapse in anticipation of the injured patients. This declaration put into process the medical center’s “Orange Alert” plan that included recalling of key personnel, holding all personnel on duty, clearing areas of the hospital for patient reception, and opening up a hospital command center staffed by key administrative and clinical personnel. Thirty-five emergency department beds, 25 ICU beds, 10 operating rooms, and three CT scanners were available within 30 minutes. Seventy-nine patients presented to nine metro area hospitals (50 by ambulance) with injuries shortly after the collapse. An additional 48 patients presented in subsequent days with less serious injuries. From our post-incident analyses, there are several important learning points: 1. Incident Communication: An incident of this magnitude taxed usual systems of communication. Busy phone lines and cell towers along with heavy radio traffic made intra and inter-hospital communications difficult. Some solutions were archaic (such as using intra-hospital personnel to act as “runners” of information from point to point) but worked well. Reconfiguration of our phone system and staff education to improve internal phone performance when external phone lines are busy is in process. 2. Media/Public Relations: We were surprised at the intense national and international media coverage of this incident. We found it beneficial to have a small set of designated spokespersons to systematically provide information and interviews on a scheduled basis. This allowed the information provided to be consistent and focused. Early in the event, media broadcasts required monitoring to detect and correct misinformation (e.g.: any medically trained person should respond to the bridge to help, or persons should go to hospitals to donate blood) that might be detrimental to the response.
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
3. HIPAA Considerations: Patient tracking was difficult, and because patients were taken to different hospitals, there was concern that sharing information between hospitals could represent a HIPAA violation. This was addressed before the incident through an interhospital compact that allows for sharing of information for public safety tracking purposes and re-unification of families. Questions remain about sharing patient information with other agencies and are being clarified with the Minnesota Department of Health (MDH). 4. Disaster Plan: This incident went smoothly for HCMC because we have a comprehensive pre-plan in place and drill it regularly. This plan includes notification procedures for off-duty personnel, Web-based job action sheets to follow depending on the type of incident, job action information availability at every work station on the campus, the ability to expand and contract the plan depending on the magnitude of the incident and pre-assignment of leadership job tasks to on-duty personnel so that they can easily transition into disaster mode while using call-back personnel to back-fill less critical positions. 5. Supplies and Equipment: It was noted that select ED supplies and medications became temporarily exhausted. Hospitals may wish to have disaster supplies brought to the ED by default and must have a good mechanism for obtaining supplies quickly when an incident occurs. Stockpiles of commonly needed items should be available based upon guidance supplied by MDH as part of recent hospital preparedness program efforts.
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Conclusion This tragedy was an excellent test of metro area health care disaster planning, and generally was viewed as extremely successful. An integral part of this plan is our area physician’s and hospital’s response and coordination capabilities. This incident demonstrated that we have a system that the community can be proud of. It reacted swiftly, appropriately, and compassionately to care for the victims of the bridge collapse. Without this system in place, there is little doubt that this incident could have played out much differently, with additional chaos, disorganization and potential morbidity and mortality. We intend to apply the lessons learned to our system and hope that other systems can also learn from this as they plan for their own future incidents. All three authors serve as senior faculty physicians, department of Emergency Medicine, HCMC and hold academic positions of Associate Professor of Emergency Medicine at the University of Minnesota. In addition, Dr. Heegaard is the Assistant Chief of Emergency Medicine at HCMC; Dr. Hick is an associate EMS Medical Director, the medical director for Hospital Disaster Preparedness and the medical director of the State Disaster Preparedness Effort. Dr. Ho is a licensed deputy sheriff in the state of Minnesota, is currently a medical director for several Minnesota EMS agencies, has over nine years of reserve military experience, and is an independent, expert medical consultant to TASER International.
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
November/December 2007
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Minnesota Responds Medical Reserve Corps: Physician Volunteers During Disasters “Never doubt that a small group of thoughtful, committed citizens can change the world: indeed it is the only thing that ever has.” Margaret Mead
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Minnesotans have unfortunately experienced several disasters in their communities in recent months. In early August 2007, the I-35W bridge collapsed during the evening rush hour in Minneapolis; several weeks later southeastern Minnesota experienced severe storms resulting in extensive flooding in multiple counties and displacing hundreds of families without potable water, sewer or electricity. When a disaster strikes a community, it is easy to imagine how hospitals and health care providers could become overwhelmed and need help from outside medical resources. “Medical surge” is the term used to define the ability to provide additional resources for increased medical care needs. “Surge capacity” is the ability to handle increased volume of patients, whereas “surge capability” is the ability to manage patients requiring unusual or specialized medical evaluation or care.1 During times of disaster, it is common to suddenly have patient care needs that temporarily overwhelm a community’s ability to provide services. On one extreme, America watched as New Orleans not only faced increased patient care needs from Hurricane Katrina, but then the city lost a number of its hospitals and most capabilities to provide primary care when the levee broke. A New York Times article reported, “Only one of the city’s seven general hospitals is operating at its pre-hurricane level.”2 The same article points to the continued lack of health care services as b y R o b e rt c a r l s o n , m b a , J o hn H i c k , M . D . , a nd R u th ly n f i e l d , m . d .
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a major hurdle in rebuilding the city. Smaller events may also temporarily overwhelm a community, such as was observed during the I-35W bridge collapse in Minneapolis when ambulances from surrounding communities answered the call to assist victims. The entire health care system responded to the event well because they had regional plans for surge staffing and distribution of patients among the metropolitan hospitals. A scenario that emergency preparedness planners are very concerned about and preparing for, is the response to an outbreak of pandemic influenza. This type of disaster involves extensive planning because multiple communities will be impacted simultaneously for an extended period of time. Surge capacity will need to be provided throughout the state and alternate care site facilities will need to operate with limited resources. A coordinated and carefully planned health care response can make a big difference in the impact of a pandemic. To illustrate the role for medical volunteers providing surge capacity in such a disaster, see the following scenario. A mutation in the H5N1 influenza virus creates a new, virulent influenza strain, which begins to spread across Asia and enters the United States several weeks later. About 20 percent of Minnesota’s population becomes ill over a two-month period. Thousands of persons experience severe symptoms including respiratory distress and are taken to local hospitals, which are quickly overwhelmed. In addition to lacking adequate space and supplies, many hospital staff become ill and are unable to work. In order to accommodate the large number of critical patients, hospitals must move the less acutely ill to alternate care sites (for example the St. Paul Xcel Energy Center). From there, the patients may be discharged, transferred MetroDoctors
to other hospitals out of the area, moved to more distant cities, or transferred to long-term care or rehabilitation facilities. Local units of the Minnesota Responds Medical Reserve Corps are activated to provide assistance to public health and health care providers. Duties performed include staffing hotlines, providing support or patient care at alternate care sites, screening patients or providing vaccinations at centers in local neighborhoods, and staffing behavioral and family support centers. Additionally, hospitals around the state are requesting staffing assistance. While the Medical Reserve Corps members don’t receive specific training for critical or pandemic patient care, they have skills and training to provide support for medical or healthoriented operations around the state, under the supervision of mentors at each location. Over the subsequent weeks the number of victims decreases, and conditions at the hospitals improve. Medical Reserve Corps members continue to provide telephone, home visit, screening center patient triage, and other support for home health, public health, and other agency activities until the initial wave of the pandemic is over, and the Medical Reserve Corps demobilizes until they are needed again. To help health care systems increase their ability for medical surge capacity and capabilities, the federal government has required that every state and territory develop systems for pre-registration and pre-credentialing of volunteer health professionals. The program, Emergency Systems for Advanced Registration of Volunteer Health Professionals (ESAR-VHP), helps health care systems plan for increased medical resource and equipment needs. The need for such a system was highlighted by a report written by the U.S. Department of Health and Human Services — Health Resources Services Administration (HRSA). The Journal of the Hennepin and Ramsey Medical Societies
It found that, “the experiences of New York City hospitals in the aftermath of the World Trade Center destruction were instructive about the issues confronting the use of health care professional volunteers in an emergency or mass casualty event. According to reports, hospital administrators involved in responding to the World Trade Center tragedy reported that they were unable to use medical volunteers when they were unable to verify the volunteer’s basic identity, licensing, credentials (training, skills, and competencies), and employment. In effect, this precious, needed health workforce surge capacity could not be used.”3 Congress therefore authorized the development of an ESAR-VHP Public Law (PL) 107-108, the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Section 107. HRSA was initially delegated the responsibility to carry out the legislation and assist each state to establish a standardized volunteer registration system. In 2006, the ESAR-VHP program was transferred to the Office of the Assistant Secretary for Preparedness and Response (ASPR). One requirement for state-based systems is to quickly identify and better utilize health professional volunteers in emergencies and disasters. In addition, the state systems would enable the sharing of these pre-registered and credentialed volunteers across state lines and nationally. In Minnesota, the ESAR-VHP system is the Minnesota Responds Medical Reserve Corps (MRC). Health professionals and others who are available to assist during a disaster must first register into Minnesota Responds by going to www.mnresponds.org. Registration assures the volunteer is provided liability and worker’s compensation coverage when volunteering to the local jurisdiction or during a state coordinated event. When the health care professional registers, the license and other credentialing information can be matched and verified against databases at the Minnesota Medical Practices or other health licensing boards, Inspector General, Drug Enforcement Agency, and National Practitioner Data Bank. Mechanisms are also being put in place to verify hospital employed health care professionals to make it easier to use these persons in the event of a disaster that requires volunteers to go within a hospital setting. Minnesota Responds MRC is a partnership MetroDoctors
that integrates local, regional and statewide volunteer resources to assist the Minnesota public health and health care systems. Along with the local programs, there are a few statebased volunteer systems such as the Minnesota Veterinary Reserve Corps (MVRC), Disaster Mortuary Emergency Response Team (DMERT), and the University of Minnesota Medical Reserve Corps. The MVRC supports animals during a disaster, but if a biological disaster strikes humans, and the MVRC is not needed for animals, they are available to assist. The University of Minnesota Medical Reserve Corps provides expertise for mass dispensing and other health care needs. Of note, a team from the University of Minnesota Medical Reserve Corps provided health care surge capacity in Louisiana during the aftermath of Katrina. The Disaster Mortuary Emergency Response Team (D-MERT), joined the Minnesota Responds MRC system in 2007, and focuses on care for the fatalities in a disaster. Later in 2007, tribal governments will also have the opportunity to use the Minnesota Responds MRC. Health volunteer programs in Minnesota are coordinated at the state level but organized
and managed locally, primarily through local public health agencies. Either the individual county assigns a program administrator to manage the health volunteers or partners with other counties in the region to share responsibilities. The health care preparedness planners in the region work with these local and regional programs to identify how volunteers will be used for events needing health care resources, or support local public health when the mission is mass dispensing of drugs to prevent an illness. All local programs share a single Web-based operating system. Minnesota Responds MRC is part of a national initiative to coordinate and mobilize volunteers during an emergency. Minnesota Responds MRC integrates health volunteers from local units into a single program that can coordinate the need for volunteers across city, county and state lines. Although the goal is to recruit volunteers from all health professions, both active and retired physicians remain a high priority. During a disaster, a group of physicians can be valuable in determining the ongoing medical needs of evacuees to a temporary (Continued on page 22)
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The Journal of the Hennepin and Ramsey Medical Societies
November/December 2007
21
Minnesota Responds (Continued from page 21)
shelter or alternate care site and provide a variety of health care services. When a public health or health care emergency happens, the need for health care volunteers could be tremendous. Physicians have extensive skill sets to apply to a disaster response and can work more independently. A major component to any volunteer program is quick notification and mobilization of the volunteer resources when needed. The Minnesota Responds MRC allows program administrators to send out an automatic voice notification to everyone in their local unit or to a selected subset. When the volunteer answers the phone, he or she receives a digital voice message that begins “This is an emergency message from the Minnesota Responds Medical Reserve Corps,” and the message continues to instruct them on how to obtain more information. A prompt can be put into the message that instructs the volunteer to press “1” if they are available, or “2” if they are not. The information is fed immediately to the program administrators. Thousands of persons can be contacted in minutes, and their availability quickly determined. No one is ever required to respond — but are encouraged to participate if they are available when called. The program can also track training and experience so it is easier to match the appropriate resources with the need. An equally important component of any volunteer health system is training for volunteers. As local programs develop throughout the state, volunteers are being invited to orientation classes to help them better understand what their role in a disaster might be. Most of the programs are offering incident command training, psychological first aid, mass dispensing, and training to prepare volunteers to staff an alternate care site. Much of the training can be done online, but many of the program administrators prefer the initial orientation training to be on site. As of this writing, there are 5,670 persons registered in the Minnesota Responds MRC system statewide. Of these, 172 are physicians and 2,130 are nurses. Approximately 41 percent (2,316) of all the volunteers reside in the seven-county Minneapolis-St. Paul metropolitan area. In addition, the University of Minnesota 22
November/December 2007
Medical Reserve Corps has approximately 900 faculty, staff, and student volunteers that could be part of an emergency response. A goal for 2008 is to recruit two thousand more health care professionals. We need your help. To register in Minnesota Responds MRC, go to www.mnresponds.org. The registration will take about 30 minutes and you are encouraged to have a copy of your license, certifications, and other contact information you may need to reference. After you register, you will be contacted by an administrator for the local Medical Reserve Corps unit in the county of your residence. If you have any questions regarding the Minnesota Responds Medical Reserve Corps you are encouraged to contact your
local public health department, e-mail Minnesota Responds MRC at minnesotaresponds @health.state.mn.us, or call (651) 201-5700. Footnotes: 1) Medical Surge Capacity and Capability, the CNA Corporation, August 2004 2) New Orleans Recovery is Slowed by Closed Hospitals, New York Times, July 24, 2007 3) http://www.hrsa.gov/esarvhp/ Report on Emergency System for Advance Registration of Volunteer Health Professionals
Robert Carlson, MBA, Office of Emergency Preparedness, Minnesota Department of Health; John Hick, M.D., Medical Advisor, Office of Emergency Preparedness, Minnesota Department of Health; and Ruth Lynfield, M.D., State Epidemiologist, Minnesota Department of Health.
Medical Reserve Corps Programs in the Twin Cities Metro Area MRC of Anoka County
(763) 323-6071
www.anokacounty.us/mrc mrc-anoka@co.anoka.mn.us
MRC of Carver County
mrc@co.carver.mn.us
MRC of Dakota County
www.co.dakota.mn.us/public_health
(952) 361-1314 (651) 554-6100
MRC of Hennepin County
(612) 543-5234 www.mrc-hennepin.org mrc-hennepin@co.hennepin.mn.us
MRC of Ramsey County
(651) 266-2480 www.co.ramsey.mn.us/ph/ei/volunteer.htm mrc-ramsey@co.ramsey.mn.us
MRC of Scott County
(952) 496-8555
www.co.scott.mn.us/xpedio/groups/public/documents/web_files/cs_cspublichealthframe.hcsp (click on “Medical Reserve Corps of Scott Co. website” in left hand column)
MRC of Washington County
(651) 439-7434
www.volunteercvs.org barbara@volunteercvs.org
University of Minnesota Medical Reserve Corps
(for U of M students, staff and faculty)
www.ahc.umn.edu/outreach/epp/home.html medcorps@umn.edu
The MRCs are working in partnership with the Minnesota Department of Health and its health professional registry, the Minnesota Responds Medical Reserve Corps. The Minnesota Responds Web site has links with MRCs in greater Minnesota (Clay County, Steel County and the northeast region) and to Minnesota Responds volunteer coordinators in other regions of the state. The Minnesota Responds Web site is: minnesotaresponds@health.state.mn.us
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
Thank you to the following HMS and RMS physicians who served as delegates to the Minnesota Medical Association:
2007 Minnesota Medical Association Annual Meeting
T
President’s Awards: John R. Balfanz, M.D. (RMS), and Roger K. Johnson (former RMS CEO) The President’s Award is presented to those who have made outstanding contributions to the Minnesota Medical Association but have never been elected to a major office or recognized by the MMA for their dedication and commitment.
Photo by Scott Smith
he 154th Annual Meeting of the Minnesota Medical Association was called to order on Wednesday, September 19, 2007. Thirty-seven Hennepin Medical Society members and 31 Ramsey Medical Society members served as delegates presenting a total of 34 resolutions for consideration. The work that was accomplished throughout the two-day meeting determines the policies and agenda of the Minnesota Medical Association for this and future years. Please visit our Web site, www.metrodoctors.com for a complete report of the final actions taken on the HMS and RMS resolutions. These photos celebrate several members of the Hennepin and Ramsey Medical Societies who were honored with awards and recognition throughout the MMA Annual Meeting.
John R. Balfanz, M.D. receives the President’s Award from G. Richard Geier, M.D.
Photo by Scott Smith
Distinguished Service Award: Blanton Bessinger, M.D. (RMS) The MMA’s highest honor, bestowed upon a physician who has made outstanding contributions to medicine and to the MMA.
Michael Ainslie, M.D., Chair, MMA Board of Trustees, presents Blanton Bessinger, M.D. with the Distinguished Service Award. Also pictured is Bonnie Bessinger.
Community Service Award: Lindsey C. Thomas, M.D. (HMS) This award honors MMA members who are actively engaged in the practice of medicine and have an outstanding record of community service. Dr. Lindsay Thomas with her Community Service Award.
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Minority Affairs Meritorius Service Award: Clifford Phibbs, M.D. (HMS) This award is presented for meritorious service to minority populations on behalf of the Minnesota Medical Association. Decade Award: Physicians who have practiced medicine and maintained their MMA membership for 50 or 60 years: Margaret M. Anderson, M.D. (RMS) – 60 years Stuart W. Arhelge, M.D. (HMS) – 60 years John P. Cooper, M.D. (HMS) – 60 years Jesse E. Edwards, M.D. (RMS) – 60 years James R. Fox, M.D. (HMS) – 60 years Neal L. Gault, Jr., M.D. (HMS) – 50 years Eugene W. Haywa, M.D. (HMS) – 50 years Dean J. Hempel, M.D. (HMS) – 50 years John S. Huff, M.D. (HMS) – 50 years Robert E. Kasper, M.D. (HMS) – 50 years Frederic J. Kottke, M.D. (HMS) – 60 years Bradley W. Kusske, M.D. (RMS) – 60 years John H. Linner, M.D. (HMS) – 60 years Elmer J. Martinson, M.D. (HMS) – 60 years
The Journal of the Hennepin and Ramsey Medical Societies
RMS Delegates John Balfanz, M.D. Richard Baron, M.D. Arthur Beisang, M.D. Blanton Bessinger, M.D. Peter Boosalis, M.D. Todd Brandt, M.D. V. Stuart Cox, M.D. Laura Dean, M.D. Linnea Engel (medical student) Robert Geist, M.D. J. Michael Gonzalez-Campoy, M.D., Ph.D. Samuel Hall, Jr., M.D. Ronnell Hansen, M.D. Frank Indihar, M.D. James Jordan, M.D. Nick Meyer, M.D. Robert Moravec, M.D. Elena Polukhin, M.D. Vernon Sommerdorf, M.D. Stephanie Stanton, M.D. Lyle Swenson, M.D. Nicole Te Poel (medical student) Charles Terzian, M.D. David Thorson, M.D. Junior Tshibangu (medical student) Kimberly Viskocil (medical student) Ann Wendling, M.D. Kent Wilson, M.D. Peter Wilton, M.D. Marie Witte, M.D. Jo Ann Wood, M.D. HMS Delegates Michael Ainslie, M.D. Beth Baker, M.D. Lee Beecher, M.D. Kristin Benson, M.D. Carl Burkland, M.D. Stuart Cameron, M.D. Benjamin Chaska, M.D. Roger Day, M.D. Peter Dehnel, M.D. Karen Dickson, M.D. Laurie Drill-Mellum, M.D. David Estrin, M.D. Melanie Fearing (medical student) Carol Grabowski, M.D. Gary Hanovich, M.D. Philip Hoversten, M.D. Mary Kathol, M.D. Roger Kathol, M.D. Kenneth Kephart, M.D. Brent Kudak (medical student) Ernest Lampe, M.D. Louis Ling, M.D. Virginia Lupo, M.D. Carolyn McKay, M.D. Jason Meyers (medical student) Michael Mohning (medical student) Anne Murray, M.D. Bruce Norback, M.D. Aaron Potretzke (medical student) Frank Rhame, M.D. James Rohde, M.D. Karin Tansek, M.D. T. Michael Tedford, M.D. Lindsey Thomas, M.D. David Wallinga, M.D. Benjamin Whitten, M.D. James Young, M.D.
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Members in the News
The Members in the News section recognizes the appointments, presentations, awards, honors and other professional accomplishments of RMS and HMS members. Submit physician news by fax (612) 623-2888, e-mail (dhines@metro-doctors.com) or mail to Editor, MetroDoctors, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413 for consideration by the editorial board. Questions? Call Doreen Hines at (612) 362-3705.
GORDON L. ALEXANDER JR., M.D., president, University of Minnesota Medical Center, Fairview, received the 2007 Courageous Leadership Award. The award recognizes a Fairview leader who moves the organization in new directions, who has created lasting, positive results and who creates a legacy. TOM AYRE, M.D., Minneapolis Otolaryngology, a Fairview Physician Associates clinic, received the newly created Chief’s Award. The award recognizes service to the medical staff and patients and is given at the discretion of the medical chief of staff. Dr. Ayre was recognized for his efforts to improve the surgical services culture at Fairview Ridges Hospital. HENRY BALFOUR, M.D., received the 2007 Clinical Virology Award from the Pan American Society for Clinical Virology. Dr. Balfour is a professor of laboratory medicine and pathology and pediatrics at the University of Minnesota. BRUCE BLAZAR, M.D., professor of pediatrics in the Division of Hematology-Oncology and Blood and Marrow Transplantation in the University of Minnesota Medical School, was inducted into the Academy of Excellence in Health Research. This award is the highest recognition of excellence given by the Academic Health Center. 24
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CHARLES E. CRUTCHFIELD, III, M.D., medical director, Crutchfield Dermatology, and a clinical professor at the University of Minnesota, was one of eight recipients of the 2007 Health Care Heroes award presented by Twin Cities Business magazine and Medica. Recipients are chosen as outstanding contributors to the quality of health care in our state. KAREN DICKSON, M.D., Nystrom & Associates, Ltd., received the Minnesota Psychiatric Society’s Distinguished Service Award. SANDRA ELIASON, M.D., Urgent Care physician for Columbia Park Medical Group, has recently been selected as one of only three consultants in the nation for the American Medical Association (AMA’s) Ethical Force Program’s Patient-Centered Communication Initiative: Quality Assessment and Improvement Study. As a consultant, Dr. Eliason will review the performance reports from nine participating sites, assist in the revision of the toolkit, and work with the Ethical Force Program staff and participating sites to develop and improve quality improvement activities. DAVID INGBAR, M.D., is the new president of the American Thoracic Society. Dr. Ingbar is a professor of medicine, physiology, and pediatrics at the University of Minnesota and executive director of the Center for Lung Science and Health. LORI LENARZ, M.D., Fairview chief clinical officer, is a recipient of the 2007 Archibald and Edyth Bush Medical Fellowship grant. This yearlong fellowship will allow her to pursue her interest in care delivery design, performance improvement and physician leadership development. The Minnesota Academy of Family Physicians elected LYNN LILLIE, M.D., a family medicine MetroDoctors
physician at Woodwinds Health Campus, as their president and University of Minnesota Physicians PATRICIA FONTAINE, M.D. as vice president. Also receiving awards were: JAMES VAN VOOREN, M.D., teacher of the year; MRINALINI MUDKANNA, M.D., resident of the year; and DIANE MADLON-KAY, M.D., researcher of the year. They are all University of Minnesota Physicians. MARK W. MAHOWALD, M.D. and CARLOS H. SCHENCK, M.D., renowned experts on parasomnias, received the American Academy of Sleep Medicine’s William C. Dement Award for 2007. The award recognizes members of the sleep field who have displayed exceptional initiative and progress in the areas of sleep education and academic research. Dr. Mahowald and Dr. Schenck are colleagues at the Minnesota Regional Sleep Disorders Center at HCMC. Dr. Mahowald is medical director of the Minnesota Regional Sleep Disorders Center and is also a professor of neurology at the University of Minnesota. Dr. Schenck is an assistant professor at the University of Minnesota and a senior staff psychiatrist at the Minnesota Regional Sleep Disorders Center. CARL MALMQUIST, M.D., a University of Minnesota sociology professor and author, received the Manfred Guttmacher Award for his new book, Homicide: A Psychiatric Perspective. DEBORAH E. POWELL, M.D., dean of the University of Minnesota Medical School and assistant vice president for Clinical Sciences, has received the Distinguished Service Award from the Association of Pathology Chairs. Dr. Powell is the first woman to receive this award, which is awarded to an individual who has made substantial contributions to academic pathology in research, in education, or in advancing the discipline of pathology in the medical community and to the public.
The Journal of the Hennepin and Ramsey Medical Societies
PRESIDENT’S MESSAGE V. Stuart cox, M.D.
The Zero Sum Game RMS Officers
President V. Stuart Cox, M.D. President-Elect Peter B. Wilton, M.D. Past President James J. Jordan, M.D. Treasurer Ronnell A. Hansen, M.D. RMS Elected Board Members
RMS Appointed Board Members
Stephanie D. Stanton, M.D., Resident Physician Kimberly C. Viskocil, Medical Student Marie L. Witte, M.D., Young Physician MMA Officers and Board Members
Lyle J. Swenson, M.D., MMA Vice Speaker of House Todd D. Brandt. M.D., MMA East Metro Trustee Charles G. Terzian, M.D., MMA East Metro Trustee David C. Thorson, M.D., MMA East Metro Trustee RMS Ex-Officio Board Members & Council Chairs
Blanton Bessinger, M.D., AMA Alternate Delegate Peter F. Bornstein, M.D., MPS, Inc. Chair Kenneth W. Crabb, M.D., AMA Delegate Robert W. Geist, M.D., Professionalism & Ethics Council Chair Neal R. Holtan, M.D., Community Health Council Chair Frank J. Indihar, M.D., AMA Delegate, Chair of MN Delegation Carolyn A. Johnson, M.D., Sr. Physicians Association President Mark J. Kleinschmidt, Clinic Administrator Anthony C. Orecchia, M.D. Education Resource Council Chair RMS Executive Staff
Sue A. Schettle, Chief Executive Officer Katie R. Snow, Executive Assistant Doreen M. Hines, Manager, Member Services
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
contract negotiations we still have to employ approximately five business office employees to collect the claims that we agreed on in the contract. While this allows the insurers to hold on to more of their premiums — and for a longer period of time, it adds a significant increase in our overhead and does not benefit the patients we serve in any way. The bigger question is, “is there a better way?” Insurers’ basic role is to collect premiums and pay claims. For this service how much of the premium should they hold back? While they claim to have razor thin margins — former Attorney General Hatch showed some insurers hold back far more than they claim. While these numbers were not widely publicized, currently the State’s Legislative Auditor is reviewing the insurers, and we should have more information in the next few months. Insurers have set themselves up to ration health care, however, over the last decade they have simply failed. The health insurance industry would also have us believe they are disease managers and even act as medical home, but there is little evidence they have been effective in these roles. What are some other options? The most common answer to this is government-based universal coverage, however, there are certainly problems with this — and there is yet a country that has done it convincingly well. In 1993 the State of Utah developed the Utah Health Information Network. This utilizes electronic data interchange in a standardized format for all health care transactions in the state. Not only is this a cost saving for all parties, but it also provides a central repository for public health for the state instead of being splintered among several dozen companies. While this certainly is not a panacea, it is a step in the right direction with significant benefits. The MMA Plan for Healthy Minnesota also encourages insurance reform. While this plan is unlikely to be fully adopted by the State Legislature, hopefully pieces will be used. As physicians, we need not only to articulate the problems in our current health care system, but also work toward changing them for the better.
November/December 2007
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Ramsey Medical Society
Arthur A. Beisang III, M.D., Director Charles E. Crutchfield, III, MMB, M.D., At-Large Director Laura A. Dean, M.D., Specialty Director, Obstetrics & Gynecology Andrew S. Fink, M.D., At-Large Director Thomas J. Losasso, M.D., At-Large Director Nicholas J. Meyer, M.D., Director Robert C. Moravec, M.D., At-Large Director Jane C. Pederson, M.D., Specialty Director, Internal Medicine Jerome J. Perra, M.D., Director Lon B. Peterson, M.D., Director Thomas D. Siefferman, M.D., Specialty Director, Pediatrics Jacques P. Stassart, M.D., At-Large Director Christina J. Templeton, M.D., Specialty Director, Psychiatry Scott A. Uttley, M.D., Director
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At the most recent Minnesota Medical Association meeting, I served on a reference committee that reviewed a resolution titled “Zero Sum Cost Savings.” The gist of the resolution was that a lot of “cost savings” touted by the insurers are actually cost shifts often to physician practices. The most recent (and possibly the most egregious) is the imaging prior authorization required by the insurers. They have loudly proclaimed to anyone who would listen that they are saving millions of dollars. Unfortunately, they have just shifted a large part of the cost to our clinics. For example, in our nine-physician group we have had to add a full-time nurse to get the prior authorizations, and as more insurers add this hurdle, we may have to increase this even further. While one of the insurers has started to compensate clinics for the authorizations, it is not close to covering the increased cost. The first insurance company to introduce the prior authorizations claimed they are doing this to “educate physicians.” However, they refused to tell us what the criteria were for imaging. We are supposed to blindly call in for a prior authorization and they would accept or deny it — not much of an education. One insurer has a straightforward electronic form that clearly shows the appropriate indications for specific imaging and takes only a few minutes to fill out. Unfortunately, the majority of insurers continue with a “black box” and time-consuming process. Further evidence of cost shifting arose during a testimony to the State Legislature. The insurers were very happy to brag about how much money they had saved — but refused to divulge how much they are paying the third party vendor who reviewed the prior authorizations. There is talk at the MMA about working in concert with the Minnesota Medical Group Management Association to poll clinics about the excess costs incurred from the prior authorizations. If you get a survey on this please fill it out. This latest cost shift only adds to the frustration clinicians already face. Another problem with a fractured third party payor system is the significant increase in overhead of the providers required by non-standardized forms, coding and authorizations. Again, for example, at our clinic after undergoing months of often contentious
RMS UPDATE
2007 RMS Community Service Award — Calling for Nominations
Join Us for the 11th Annual Winter Medical Update 2008 in San Diego
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re you looking for a way to escape the bleak Minnesota winter while discussing issues relevant to the practice of medicine? The Ramsey Medical Society Foundation has planned a conference for primary care and specialty physicians, nurse practitioners, PAs, and nurses to be held February 23-March 1, 2008 at the Loews Coronado Bay Resort in San Diego. While enjoying the weeklong escape, attendees will be able to apply current principles of diagnosis and management for conditions commonly encountered in the clinic office setting (wound management, literature reviews, diabetes, coding, and dealing with difficult families are some of the topics).
Some comments from attendees at last year’s conference were: “Terrific conference, well organized, very informative;” “I picked this meeting based on location and time of year. I can’t express how overall pleased I am with the course content and location;” “Excellent lectures;” “Outstanding presenters, will come again.” For more in-depth information please go to www.metrodoctors.com and click on the “Winter Medical Conference” under “Upcoming CME Conferences.” For additional questions please call Doreen Hines at the Ramsey Medical Society office at (612) 362-3705.
Do you have a colleague who should be recognized for his/her many volunteer activities in the community? Please consider nominating someone who has made a positive contribution to our local community. To nominate someone you can go to www.metrodoctors.com and click on “Ramsey Medical Society” and then “Community Service Award.” Print out the form and fill in the information and mail or fax to our office by December 10, 2007. You could also call us at (612) 362-3704 and provide us with the information on your nominee. This award will be presented at the 2008 RMS Annual Meeting on January 25, 2008, at the Town & Country Club.
New Members RMS welcomes these new members to the Society. Schools listed indicate the institution where the medical degree was received.
Active
Shivani Rawal, MB, BS Seth Gordhandas Sunderas Medical College, Bombay Family Medicine Smiley’s Clinic
Wayne O. Adkisson, M.D. University of Kansas School of Medicine Cardiovascular Disease University of Minnesota Physicians
Asad Saeed, M.D. Rawalpindi Medical College, Pakistan Internal Medicine/Endocrinology University of Minnesota Physicians
Michael D. Alter, M.D. Medical College of Ohio at Toledo Pulmonary Disease/Internal Medicine University of Minnesota Physicians
Himanshu S. Sharma, MB, BS Dayanand Medical College, Punjab Family Medicine/Geriatrics United Family Practice Health Center
Patrick J. Brod, M.D. University of Minnesota Family Medicine Stillwater Medical Group
Sarah E. Shefelbine, M.D. University of Texas Otolaryngology/General Surgery Aspen Medical Group
Matthew C. Byrnes, M.D. University of Kansas School of Medicine General Surgery/Critical Care University of Minnesota Physicians
Erica C. Dahl Warlick, M.D. University of Minnesota Internal Medicine University of Minnesota Physicians
Anne M. Joseph, M.D. University of Michigan Medical School Internal Medicine University of Minnesota Physicians Lawrence J. Lorbiecki, M.D. University of Minnesota Internal Medicine Stillwater Medical Group Kevin J. Mullaney, M.D. Albany Medical College Orthopaedic Surgery Twin Cities Spine Center
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Part Time Linda O. Bergum, M.D. University of Minnesota Family Medicine West Side Community Health Services
Resident Physicians Lavanya Bellumkonda MB, BS Kakatiya Medical College, India Cardiology U of MN Graduate School Michael J. Hervey II, M.D. University of Virginia Family Medicine U of MN Graduate School Adam S. Hoverman, D.O. Kirksville College of Osteopathic Medicine Family Medicine Bethesda Clinic
2nd Year Active Practice Heidi K. Roeber Rice, M.D. University of North Dakota School of Medicine, Grand Forks General Preventive Medicine/Occupational Medicine HealthPartners – Riverside
1st Year Active Practice Matthew R. Gerlach, M.D. University of Minnesota Orthopaedic Surgery Midwest Spine Institute, LLC MetroDoctors
Joel A. McCauley, M.D. University of Wisconsin, Madison Pulmonary and Critical Care U of MN Graduate School Adam F. Nicholson, M.D. Tulane University Urologic Surgery U of MN Graduate School Alan Y. Wong, M.D. Family Medicine Bethesda Clinic
The Journal of the Hennepin and Ramsey Medical Societies
Physicians Host “Meet and Greet” for Rep. Murphy
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work; Mark Pohl, pediatrician working with Minnesota Department of Human Services; Kristin Gendron, otolaryngologist from Midwest ENT; Bob Geist, retired urologist from Metro Urology; Inell Rosario, otolaryngologist with Midwest ENT; Mr. John Morgan, Hamm Clinic board member; Roger Johnson, Lockridge Grindal Nauen P.L.L.P; Dave Renner, MMA; and Sue Schettle, Ramsey Medical Society.
From left: Michael Alter, M.D., Representative Erin Murphy, and Anjali Goel, M.D.
Stillwater Physicians Meet with Representatives
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From left: Bruce Bartie, D.O., St. Croix Orthopedics; Laura Dean, M.D., Stillwater Medical Group; Peter Boosalis, M.D., Valley Anesthesiology Consultants; Bruce Dennison, M.D., Stillwater Medical Group; Representative Matt Dean; Representative Julie Bunn; and Mr. Curt Geissler, CEO, Lakeview Hospital. Not pictured: Zis Weisberg, M.D., Stillwater Medical Group; Charles Bransford, M.D., Stillwater Medical Group; Sue Schettle, Ramsey Medical Society; Dave Renner, MMA; and Matt Schafer, Lockridge Grindal Nauen P.L.L.P.
akeview Hospital in Stillwater was the location for a recent tour and meeting with Representative Matt Dean, Republican, 52B, and Representative Julie Bunn, DFL, 56A and Stillwater area physicians. The meeting provided both Representatives with a good perspective on health care issues facing physicians.
RMS’ For-Profit Subsidiary Expands to Reach All Minnesota Physicians
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innesota Physician Services, Inc. (MPS, Inc.) is the for-profit subsidiary of the Ramsey Medical Society. Its purpose and mission is to partner with value added businesses that provide physicians, their clinics, and their staff members with discounts on products and services that they would have otherwise not been able to obtain. In turn, our business partners provide MPS, Inc. with the opportunity to participate in a revenue sharing agreement that can range from a percentage of their overall sales to a finders fee, or some other arrangement. These revenue sharing agreements help to offset the operating expenses of the medical society. Under the leadership of Dr. Peter Bornstein, MPS, Inc. has expanded its reach from the east metro to the entire State of Minnesota and Western Wisconsin. We realized that the business relationships we have entered into up to this point have no boundaries, and we MetroDoctors
didn’t want to limit them, or MPS, Inc., from providing benefits to all physicians. Our business partners are listed below. More information can be found on our Web site at http://www.metrodoctors.com/ services.cfm. • AmeriPride Linen Services (gowns, linens) • Bank of America (credit card) • Berry Coffee Company • IC Systems (debt recovery) • InforMED Group • Orbit Systems, Inc. (IT outsourcing) • Safe Assure (OSHA compliance) • Schwarz Williams (group and individual insurance) If you are looking for ways to support your local medical society, please consider this opportunity. If you have questions, please contact Sue Schettle at (612) 362-3799, or e-mail her at sschettle@metrodoctors.com.
The Journal of the Hennepin and Ramsey Medical Societies
Help us Celebrate… Installation of Peter B. Wilton, M.D., as the 138th President of Ramsey Medical Society at the
2008 RMS Winter Gala and Annual Meeting Friday, January 25, 2008 Town & Country Club 300 Mississippi River Blvd. N. St. Paul, MN 55104 Social Hour — 5:30 p.m. – 6:30 p.m. Dinner — 6:30 p.m. – 7:30 p.m. Program and Award Presentations — 7:30 p.m. – 8:30 p.m. Social Time — 8:30 p.m. – 10:00 p.m. Watch your mail for your invitation or call (612) 362-3704 to make a reservation.
November/December 2007
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Ramsey Medical Society
njali Goel, M.D., pediatrician from Fairview Children’s Clinic and Michael Alter, M.D., pulmonologist from the University of Minnesota hosted a “meet and greet” in their home for Representative Erin Murphy, DFL, 64-A on Thursday, September 27. Those in attendance included: Representative Murphy; Drs. Goel and Alter; Stuart Cox, otolaryngologist from Midwest ENT; Charles Rich, anesthesiologist from Metro Anesthesia Net-
Smoke-Free Dakota Celebrates the Implementation of Freedom to Breathe
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n October 1, several students from Farmington Middle and High School waved homemade “Honk if you love smoke-free air!” signs before the start of the school day. The group brought great energy to a chilly Monday morning traffic hour and their message was well received. Morning goers passing by seemed eager to show support and honks could be heard up and down Akin Road throughout the morning. A small group of Smoke-Free Dakota community volunteers joined staff that afternoon at the Cherokee Sirloin Room, a newly smoke-free venue, for the first “Get Out the
Dining” event! They brought information on smoking cessation and QuitPlan mints for the restaurant staff and left “Thanks for the smokefree air” stickers and cards with the lunch tip. Smoke-Free Dakota volunteers also attended smoke-free celebratory evening events at the Granite City Brewery in Eagan and Black Dog Café in St. Paul. Smoke-Free Dakota is excited to make Minnesota history with the Freedom to Breathe and looks forward to continuing to engage in implementation efforts with community members and businesses throughout the coming months. For more in-
formation on Smoke-Free Dakota activities, visit www.smokefreedakota.org or contact Diane Tran, Project Coordinator, at (651) 789-0036.
Students from Farmington Middle and High School show their support for smoke-free air.
Smoke-Free Washington County Celebrates a Smoke-Free Minnesota
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n October 1, Minnesota celebrated the implementation of the Freedom to Breathe act. The new smoke-free law protects all workers in the state from the harmful effects of secondhand smoke. In celebration, Smoke-Free Washington County held a dinner at Gorman’s restaurant in Lake Elmo. There were 65 people in attendance who received a complementary dinner. Everyone also received a t-shirt, grab bag with items from our supportive organizations and, of course, a piece of smoke-free cake! There was a program that followed dinner with remarks by: Senator Kathy Saltzman; Representative Julie Bunn; Dr. John Sweet, an Asthma and Allergy specialist in Stillwater; and Dr. Paul McGinnis who spoke on behalf of the Wisconsin smoke-free coalition. This event kicked off a year celebration for Smoke Free Washington County. They will
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be working throughout the year continuing to aid in implementation efforts and to educate on the new law. We are encouraging everyone to get out and enjoy some Fresh Air at your favorite establishment!
Dr. John Sweet addresses the group. Enjoying dinner at Gorman’s are from left: Stephanie Kimmes, and her daughter, Lucy; Senator Kathy Saltzman; and Dr. Maureen Reed.
MetroDoctors
The Journal of the Hennepin and Ramsey Medical Societies
CHAIR’S REPORT Anne M. Murray, M.D.
Technology and Geriatric Care HMS‑Officers
HMS‑Board Members
Lauren Baker, M.D. Alan L. Beal, M.D. Carl E. Burkland, M.D. Laurie Drill-Mellum, M.D. Kenneth N. Kephart, M.D. Stephen MacLeod, M.D. J. Riley McCarten, M.D. Frank S. Rhame, M.D. Janette H. Strathy, M.D. Thomas C. Tunberg, M.D. David J. Walcher, M.D. David A. Willey, M.D. HMS‑Ex-Officio Board Members
Michael B. Ainslie, M.D., MMA Trustee Martha Arneson, Co-Presiding Chair, HMS Alliance Beth A. Baker, M.D., MMA Trustee Christian L. Ball, M.D., Resident Representative David L. Estrin, M.D., AMA Alternate Delegate Melanie Fearing, Medical Student Representative Donald M. Jacobs, M.D., MMA Trustee Roger G. Kathol, M.D., MMA Trustee Candace S. Simerson, MMGMA Representative Richard E. Streu, M.D., Sr. Physicians Association Representative Karin M. Tansek, M.D., MMA Trustee Trish Vaurio, Co-Presiding Chair, HMS Alliance Benjamin H. Whitten, M.D., AMA Alternate Delegate James A. Young, II, M.D., MMA Trustee HMS‑Executive Staff
Jack G. Davis, Chief Executive Officer Jennifer Anderson, Smoke-Free Project Coordinator Nancy K. Bauer, Assistant Director, and Managing Editor, MetroDoctors Kathy R. Dittmer, Executive Assistant
MetroDoctors
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On October 10 I transitioned from
President to Chair of the Hennepin Medical Society, soon to be called “West Metro Medical Society” (effective 1/1/08). It is an honor to serve you in this position, and I look forward to your input on issues critical to your practices this year. I am a geriatrician, internist and epidemiologist. I practice with Hennepin Faculty Associates and conduct research with the United States Renal Data Systems and the Chronic Disease Research Group, both based at Hennepin County Medical Center. I also co-direct our Geriatric Fellowship at HCMC. I am married to an interventional radiologist, George Edmonson, who works with St. Paul Radiology, and we have two teenage sons. Although I thoroughly enjoy my geriatric patients, I now spend much of my time conducting research in dementia, funded by a career grant by the NIH. Specifically, I measure cognitive function in dialysis patients and in diabetics, and identify potential risk factors for cognitive impairment. My geriatric practice consists primarily of frail elderly with a mean age of about 88 years, many of whom have some level of cognitive impairment. Today I would like to discuss the challenges of lifesustaining treatment decisions in geriatrics. Geriatricians face multiple disease management decisions for each patient, often complicated by the patient’s cognitive impairment. Like other primary care providers, we must choose between which imaging study to order and which medication to begin. But the bottom line we most often face is whether to test or treat at all. Whether a given patient would benefit from the “best” that medical technology can offer can be the most challenging decision. Given a patient’s comorbidities, will a potentially “life-sustaining” intervention actually sustain or even improve a patient’s function and quality of life long enough to warrant the cost and difficulty of going through that procedure? One specific example of the technology dilemma for geriatric patients is the decision
The Journal of the Hennepin and Ramsey Medical Societies
to start hemodialysis. Our research group recently reported that 73 percent of hemodialysis patients 55 and older in the Twin Cities had moderate to severe cognitive impairment, equivalent to dementia.1 This finding raises many clinical and ethical questions. How can such patients be compliant with dietary and fluid restrictions, much less take 10 to 20 medications accurately? More importantly, does a 75 year old with multiple comorbidities and cognitive impairment possess adequate judgment to make an informed decision to start dialysis, much less withdraw from dialysis? No one knows, because Medicare does not require a cognitive assessment or reimburse for a discussion of the pros and cons of dialysis before initiating maintenance dialysis. It is doubtful that older dialysis candidates or their physicians are fully aware of their 15 percent annual risk of stroke,2 30 percent first year mortality, $67,000 annual Medicare hemodialysis costs,2 and for many, overall poor quality of life on dialysis. Yet, the 75 year old and older group is the faster growing segment of the 350,000 hemodialysis population in the U.S. 2 So why are so many cognitively impaired patients maintained on dialysis? Once hemodialysis is initiated, there are again no required or reimbursed family meetings to discuss their prognosis and dialysis withdrawal. It is difficult for physicians to address withdrawing a life-sustaining technology when it will almost certainly lead to death within days. Hospice after dialysis withdrawal has recently made inroads as a reasonable alternative for end of life care. But this too takes time to explain. An editorial (Sadler) in October’s American Journal of Kidney Disease (AJKD) bemoans the loss of the cognitive aspects of dialysis care.3 (Continued on page 30)
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Hennepin Medical Society
Chair Anne M. Murray, M.D. President Richard D. Schmidt, M.D. President-elect Edward P. Ehlinger, M.D. Secretary Peter J. Dehnel, M.D. Treasurer Eric G. Christianson, M.D. Immediate Past Chair Paul A. Kettler, M.D.
Chair’s Report (Continued from page 29)
One could draw similar parallels to other treatment decisions in the elderly, such as whether to recommend an implantable defibrillator, diagnostic procedure, or even begin a medication. As technology accelerates we can only anticipate these decisions will become more difficult, and at the same time hope that CMS will see the wisdom of increased reimbursement for cognitive services to encourage critical and thoughtful discussions with our patients. This would enable us to pursue our goal to try to maintain the highest possible function and level of independence for our patients. That’s what geriatrics is all about. References 1) Murray AM, Knopman DS, Tupper D, Gilbertson DT, Pederson SL, Li S, Smith G, Hochhalter AK, Collins AJ, Kane RL. Cognitive impairment in hemodialysis patients is common. Neurology 2006; 67:216-22. 2) U.S. Renal Data System. USRDS 2006 Annual Data Report. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2006. 3) Sadler JH. With the pursuit of quality comes a retreat from personal care: the path of medical practice and dialysis care in America. AJKD 2007; 50: 535-537.
Alliance (Continued from page 32)
meeting of the American Lung Association in Miami in May of 1984. Another fun memory, that she recalls, is placing a pin on Tim Laudner, the catcher for the MN Twins World Series Champs, in honor of the D-Day (Stop Smoking) event in 1987. Arlene was witness to successes in making airports, schools, medical clinics, the Metrodome, and shopping centers smoke-free, and now today, to the Freedom to Breathe Amendment, that guarantees all restaurants and bars in Minnesota be smoke-free. Truly, this is a memorable piece of legislation that all of us in the medical community can appreciate, both for its positive health outcome and for the value of “never giving up.” As we celebrate the implementation of Freedom to Breathe on October 1, we owe a huge THANK YOU to Arlene Wilson and Dr. Stuart Hanson for their vision, leadership and dedication to seeing this goal to fruition. 30
November/December 2007
Senior Physicians Association
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he September Senior Physicians Association lunch welcomed George Archibald, Ph.D., co-founder and vice chairman of the International Crane Foundation’s Board of Directors. ICF is located in Baraboo, WI. Today, 11 of the 15 living species of cranes are threatened. We learned that captive cranes live to be 80 years old; wild cranes, 30 years. The Whooping Crane is the rarest with 450 birds today; they were down to 16. At the end of March/first of April 500,000-600,000 cranes gather on the Platte River for four to six weeks gaining strength before migrating north to nesting grounds.
For more information about this organization, contact Kathy Dittmer at (612) 623-2885 or kdittmer@metrodoctors.com.
From left: Richard Burman, M.D., President, George Archibald, Ph.D., and Richard Engwall, M.D.
In Memoriam RONALD N. BERRY, M.D., died August 14, 2007 at the age of 75. He graduated from the University of Minnesota Medical School and completed his residency at the Mayo Clinic in Rochester. He was a psychiatrist at the Oakdale Psychiatric Clinic. Dr. Berry joined HMS in 1964. E. HARVEY O’PHELAN, M.D., died on September 21, 2007 at the age of 91. He graduated from the University of Minnesota Medical School. After finishing his residency at Fordham Hospital in New York City, he began his military service as a physician for the U.S. Army at Waltham Regional Hospital in Boston. He was later transferred to Germany to care for the occupying forces. During this time he attended the Nuremburg Trials and furthered his medical education at the University of Vienna. After completing his military service, Dr. O’Phelan joined Orthopaedic Consultants. In 1957, he became an investor in the Minneapolis Lakers and developed a further specialty treating athletic injuries. In 1962, he started his tenure with the University of Minnesota Gophers as their physician and continued this association through the 1983 season. In 1968, he was asked to handle the orthopaedic needs for the Minnesota Twins. This association continued through spring training of the 1991 season. During his tenure with the Twins, he formed an association of Major League Baseball team physicians to further the treatment of athletic injuries. In 1972, the United MetroDoctors
States Olympic team selected Dr. O’Phelan as their orthopaedic specialist for the Summer Games held in Munich, West Germany. This experience led to similar opportunities with USA teams competing in the World University Games (WUG) in 1977 and 1979. In 1980, Dr. O’Phelan joined the International Medical Commission governing the treatment and doping control of athletes competing in the WUG. In 1986, he joined USA Hockey and along with Dr. George Nagabods attended to the medical needs of U.S. teams competing in the World Championships of Hockey. His association with USA Hockey continued into 2007. Dr. O’Phelan joined HMS in 1986. MURRAY JAMES MYLREA, M.D., died on September 18, 2007. He was 79. He was born and grew up in Kindersley, Saskatchewan Canada. He graduated from the University of Manitoba Faculty of Medicine, Winnipeg. He began a general practice in Rosetown, Sask. in 1955. In 1964, his family immigrated to Minnesota and he completed a radiology residency at the University of Minnesota in 1968. Dr. Mylrea practiced radiology in Mora, Princeton and Milaca until 1998. He joined HMS in 1967. JOHN R. BOHROD, M.D., died May 6, 2007. He was 74. He graduated from the University of Michigan Medical School in Ann Arbor. Dr. Bohrod practiced psychiatry for 40 years. He joined HMS in 1979. The Journal of the Hennepin and Ramsey Medical Societies
Celebrating Freedom to Breathe!
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Several members of the Scott County community celebrate Freedom to Breathe on October 1 at Pablos Restaurant in Shakopee.
Senator Claire Robling (far right), Mike Baumgartner, President of St. Francis Regional Medical Center (center), and Jennifer Anderson, Project Coordinator, Partnership for a Smoke-Free Scott County, participate in the Freedom to Breathe kick-off event. Brandon Severtson presents a framed letter of thanks to Jennifer Anderson, Project Coordinator, Partnership for a Smoke-Free Scott County.
Welcome New HMS Members Active Constance A.S. Adkisson, M.D. HCMC Newborn Intensive Care Unit Pediatrics
Carolyn George, M.D. University of Minnesota, Department of Pediatrics Pediatrics
F. Glen Seidel, M.D. University of Minnesota, Department of Radiology Radiology
Joseph W. Akornor, M.D. Minnesota Urology, PA Urology
Thomas N. George, M.D. University of Minnesota, Division of Neonatology Pediatrics, Neonatology
Ann B. Sidwell, M.D. Allina Medical Clinic Buffalo Internal Medicine/Pediatrics
Giovanni C. Casillas Murphy, M.D. Paparella Ear, Head & Neck Institute Otolaryngology Wilfrido R. Castaneda, M.D. University of Minnesota, Department of Radiology Radiology, Diagnostic Radiology Stephanie L. Devaney, M.D. Metropolitan Anesthesia Network, LLP Anesthesiology Amy Anne Donatelli Lassig, M.D. University of Minnesota Otolaryngology Department Otolaryngology
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Ian J. Heath, M.D. Hennepin County Medical Center Psychiatry Mark A. Janiga, M.D. Minnesota Interventional Pain Associates Anesthesiology/Pain Management Stephen C. Kaufman, M.D. University of Minnesota, Department of Ophthalmology Ophthalmology Rufino R. Rodriquez, M.D. Metropolitan Anesthesia Network, LLP Anesthesiology
The Journal of the Hennepin and Ramsey Medical Societies
Boris Sudel, M.D. University of Minnesota, Department of Pediatrics Pediatric Gastroenterology Ramachandra P. Tummala, M.D. University of Minnesota, Department of Neurosurgery General Surgery, Neurosurgery Laura A. Vose, D.O. University of Minnesota, Division of Pediatric Emergency Medicine Pediatrics Resident Physician Ryan W. O’Hare, M.D. University of Minnesota November/December 2007
31
Hennepin Medical Society
he Partnership for a Smoke-Free Scott County celebrated the Freedom to Breathe law on Monday, October 1, 2007 at Pablo’s Mexican Restaurant in Shakopee. Over 65 people attended the event including Senator Claire Robling and Mike Baumgartner, President of St. Francis Regional Medical Center. According to Jennifer Anderson, Project Coordinator, “The community celebration was a great success not only for its residents, but also for everyone who works and lives in Scott County.” Guests were able to meet new people, share their stories, and enjoy a great Mexican dinner while dining completely smoke-free!
HMS ALLIANCE NEWS kathy iverson
HMSA Played a Unique Role in Freedom to Breathe Legislation
T
Take a walk back in time to October
1982, when smoking was occurring in hospitals, medical clinics, airplanes, daycares, shopping centers, yes...virtually everywhere. Twenty-five years later, the Freedom to Breathe Amendment has been implemented. Many health organizations advocated for this comprehensive legislation over the years, but one organization played a unique role in defining how to achieve that goal. In 1981, Arlene Wilson R.N., was on the board of the Hennepin Medical Society Auxiliary, as a liaison to the American Cancer Society. She had been to an Auxiliary meeting with Tukie Malmquist, when just two days later, her friend, Tukie, was taken to the ER, with severe pains. Cancer was diagnosed and surgery was performed, but it had spread to her liver. She died 10 months later. Arlene thought that although a great deal was being done against cancer, she wanted to see if there was any additional effort that could be made. That summer, in 1982, she read an article in the Norseman published by Nordmansforbundet. It said the Norwegian Medical Association set an ambitious goal for itself. It had embarked on a program to achieve a smoke-free society by the year 2000. Colleagues in the other Nordic countries had, by and large, supported the project that was endorsed by 100 cancer researchers at a symposium in Finland. Arlene asked the Auxiliary board for approval to contact the Norwegian Medical Society for a copy of the resolution. The resolution was as follows: “The representative body of the Norwegian Medical Society urges the government to work towards making Norway a smoke-free society by the year 2000.” In the resolution, health hazards of smoking were listed. The HMSA passed this resolution in January of 1983, and MMAA passed the same resolution in February 1983, which became the first resolution ever sent by MMAA to the AMAA. The national auxiliary met and passed it on, June 22, 1983. After Arlene had spoken to Thomas Hoban, Executive Vice President of the HMS, about how to proceed in getting the resolution
32
November/December 2007
passed by the medical society, he advised having her husband send him the resolution for consideration by the caucus and, if approved, to forward on to the MMA meeting in May 1983. Dr. Thomas Wilson sent the letter, including the major change that Arlene had added, which was urging the medical community and related groups besides the government to work on this goal. She could see that the political and economic power of the tobacco companies required more than government intervention to achieve this goal. The MMA passed this resolution on May 19, 1983. Dr. Oren Arnar had testified at the reference committee for the resolution. The AMA, which met in June 1983, had Dr. Frank R. Reynolds, as Chairman. Dr. Stuart Hanson introduced the resolution from the Minnesota delegation. One doctor said it was the best resolution that had ever come before the AMA. It was passed unanimously by the AMA. A similar resolution was introduced at the Minnesota Public Health Association meeting in 1983, and sent on to the American Public Health Association meeting in Dallas, where it too, was adopted in November 1983. With encouragement from the AMA and the APHA, our Surgeon General studied the resolutions and on May 20, 1984, in his lecture for the annual meeting of the American Lung Association, he said that his number one health goal for the nation...should be a smoke-free society by the year 2000. Having the resolution passed was just the first step, but now action was required. Dr. Arvid J. Houglum, from Rochester, was chairman of the MMA committee on public health, which hosted a number of meetings to debate the development of a “coalition” effort to achieve a smoke-free society. The efforts bore fruit on September 21, 1984. The MN Coalition for a Smoke-free Society 2000 was incorporated. The HMS and HMSA, along with the MMA and MMAA joined this coalition. Working in conjunction with the Minnesota Department of Health, a goal was set
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to encourage and aid in the development of smoke-free hospitals throughout Minnesota by 1990. In the summer of 1987, then Governor Rudy Perpich signed the smoke-free hospital legislation. Arlene offered her voluntary support over many years, by writing articles for various organizations’ newsletters, advocating for smoke-free schools, (starting in Edina where her daughter was a student), and testifying frequently at the state capitol when measures to increase the tobacco excise tax, and strengthen the MN Clean Indoor Air Act were introduced. She had the privilege of meeting personally with Dr. C. Everett Koop, U. S. Surgeon General from 1982-1989. He laid out the goal of his Campaign for a Smoke-Free Society by the Year 2000, or SFS-2000, in a speech at the (Continued on page 30)
Arlene Wilson pictured with Dr. C. Everett Koop, U.S. Surgeon General.
In 1987, Governor Rudy Perpich signed the smoke-free hospital legislation.
The Journal of the Hennepin and Ramsey Medical Societies
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