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MetroDoctors

The Journal of the East and West Metro Medical Societies

September/October 2008

1

Doctors MetroDoctors tHe Journal oF tHe east and west Metro MedICal soCIetIes

Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines WMMS CEO Jack G. Davis EMMS 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 bi-monthly by the East and West Metro 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, East and West Metro Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

September/October Index to Advertisers Advanced Skin Care Institute. ...........................19 AmeriPride...............................................................18 Apple Valley Medical Clinic...............................32 Burnet Birkeland......................Inside Back Cover Classified Ads..........................................................13 Crutchfield Dermatology....................................23 Family Health Services Minnesota, P.A..........32 Healthcare Billing Resources, Inc....................... 8 HealthEast Spine Care Center............................. 1 Hennepin County Medical Center.......................

Inside Front Cover Independent Home Living. ................................22 Lockridge Grindal Nauen P.L.L.P....................... 2

Medical Billing Professionals, LLC................... 22 Midwest Spine Institute........................................ 17 Minnesota Epilepsy Group, P.A......................... 30 Minnesota Physician Services, Inc.. .......................

Inside Back Cover The MMIC Group................................................. 15 Reproductive Medicine & Infertility

Associates, P.A........................................... 10 Sterling Retirement Resources, Inc................... 21 University of Minnesota CME................................

Outside Back Cover Uptown Dermatology & Skin Spa, P.A..............8 Weber Law Office................................................... 10

Visit us at www.metrodoctors.com To find new career opportunities, archive issues of MetroDoctors and information on the latest news, events and legislative issues!

To promote their objectives and services, the East and West Metro 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 EMMS or WMMS. Send letters and other materials for consideration to MetroDoctors, East and West Metro 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: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com.

MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy.

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

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September/October 2008

MetroDoctors

The Journal of the East and West Metro Medical Societies

Contents VOLUME 10, NO. 5

2

Index to Advertisers

4

Feature

Comparing the Comparison Tools: Connecting the Pricing and Quality Dots for Patients

By John Fineberg

9 Page 11

Page 14

Page 19

SEPTEMBER/OCTOBER 2008

Doctor of Nursing Practice

By Frank B. Cerra, M.D., and Connie Delaney, Ph.D., R.N.

11

colleague Interview

David Satin, M.D.

13

Classified Ads

14

IT Outsourcing in the Medical Practice

By Trish Lugtu

16

Physicians Step Up to Take Out Colon Cancer

By Rebecca Thoman, M.D.

18

Colorectal Cancer Screening Rates Still Too Low

By American Association for Cancer Research

19

Joint Commission Standard MS 1.20—Stay Tuned

By Elizabeth Snelson

20

Lakeview Hospital, Stillwater, MN

By Curt Geissler, President

23

EAST METRO Medical Society

Sharpen Your Policy Skills at MMA Advocacy Rounds

President’s Message

32

Career Opportunities

24 25

On the cover: A look at three online tools that patients can utilize to rate physicians.

Article begins on page 4.

Advance Care Planning Informational Session/ Medical Market Reform Seminar

26

Dakota County Smoke-Free Communities Partnership/

Resolutions/New Members/In Memoriam

27

2008 EMMS Annual Community Service Award

28 29

WEST METRO Medical Society

Page 20 MetroDoctors

The Journal of the East and West Metro Medical Societies

30 31

Chair’s Report Time to Celebrate Partnership/Sr. Physicians Association/New Members In Memoriam Alliance News September/October 2008

3

Feature story

Comparing the Comparison Tools Connecting the Pricing and Quality Dots for Patients

Until recent times, the general public had little reason to pay attention to the true cost of health care. Those with insurance have been insulated from reality, simply focusing on their $10 co-payment. If you were to ask most of your patients the price of an office visit or a medical procedure, they would have no concept.

Not anymore! People can no longer afford to be that disconnected from reality.

Today, with more and more people opting for higher and higher deductible insurance plans and more and more out-of-pocket expenses, individuals are finally beginning to connect the dots. The pain is sinking in. Whether they like it or not, to get by in this economy, patients are having to take greater personal responsibility in how they spend their health care dollars.

Times have changed and patients really do care how much it’s going to cost them. When there could be a few hundred percent cost difference from one provider to the next, it is clear that their own choices will affect their bottom line. They now have a clear and direct reason to become better shoppers. But how?

Patients Doing Their Own Homework, Manually

In the past, patients have simply followed directions. Go down the hall and get these labs drawn. Go to this clinic and get that test. Go to this hospital and get that procedure. No questions asked about cost. People didn’t think twice about where to go. And, even if they did ask, most providers could not have answered their questions anyway.

This places the burden squarely on individuals to do their own homework. If they had the time and inclination to do so, they could call provider after provider, asking for their rates.

A diligent shopper might discover that a colonoscopy would cost $700 at one clinic and $3,000 at another. A prudent shopper would have follow-up questions. What does that include, specifically? Will there be additional charges that are not being mentioned? Are these estimates retail prices or are they reduced-cost prices negotiated by the insurance company?

Are deductibles being considered? And, lest we forget the most important element, how does this provider’s services rank in terms of quality?

Conducting this kind of phone research is not simple. The endless variables of comparing providers is not only complicated, it could be overwhelming.

By John Fineberg

4

September/October 2008

MetroDoctors

The Journal of the East and West Metro Medical Societies

Transparency Opens the Door to Easier Shopping

Enter the Hospital Pricing Transparency Act of 2006. In light of today’s health care environment, not only do consumers have a greater need to know what something is going to cost — in advance — they now have a right to know. Minnesota Statute 62J.823 stipulates that health care providers are obligated to provide a written good faith estimate, with insurance-specific rates, to any patient who requests it.

The statute does not require providers to offer such information electronically, nor does it require that administrative staff be available to help at any hour of the day. But, to become more competitive in the health care market, while complying with the transparency statute, many providers are choosing to increase their visibility through a new generation of Web sites.

As we all know, the Web has become a staple in the lives of many people when determining what, where and when to make purchases. The same is now true of health care. New online tools have the potential to make the shopping experience not only more tolerable, but more efficient and effective as well.

With the adaptation of tried-and-true online tools, making wise shopping decisions for health care has just gotten easier. That is, if you take the time to sift through what is factual and what is simply marketing hype.

MedCare Compare (http://www.medcarecompare.com)

The first online comparison tool in the market was MedCare Compare, a local company that was formed in 2005. The founders were small business owners who, themselves, had been on high-deductible health plans, and had really struggled in that environment. They took the opportunity to address their own problems head-on.

Accessible to anyone who registers and logs into the site is a prepopulated database of all registered health care providers in the region. Visitors can check to see if their provider-of-choice has opted to participate in this service. If not listed, the visitor can send an electronic request to a particular provider to ask that he or she join Medcare Compare. Dawn Lunde, director of Provider Relations, calls it a “grassroots effort to bring together the consumer and their health care provider.”

While some information is openly available to the general public, in order to get any serious value from the site, a consumer must become a member. When paid by individuals, the annual membership fee is $25 (a price nominal enough that the person could easily recoup the cost in what they save from just one search, and still have unlimited use of the site (Continued on page 6) MetroDoctors

The Journal of the East and West Metro Medical Societies

September/October 2008

5

Comparison Tools (Continued from page 5)

for the rest of the year). But in most cases, it is the employer or insurance broker that is sponsoring the membership, and then there is a volume discount.

In joining MedCare Compare, consumers need to submit a verification form to their employer or health insurance agent.

(Members are not allowed to alter this information.) Once verified, members can conduct searches of services offered by those providers who have chosen to be listed on the site. Members can select which providers to compare, based on their own criteria. If they so choose, they can establish a list of their own preferred providers, placing them at the top of all search results.

With this tool, members can match up the services they need, side-by-side, in “apples-to-apples” comparisons. They will find contracted rate pricing based on their own insurance plans (or, in the case of uninsured members, retail prices). In a future version, even deductibles and maximized benefits will be taken into consideration.

Information listed about the health care practice is supplied and maintained by the practice, not MedCare Compare. Besides costs, there could be information regarding the practice’s specializations, locations, hours, languages spoken, if children are seen, if there is valet parking, which credit cards are accepted, etc.

With the power to make updates around the clock, information displayed on the site is as accurate and up-to-date as the provider and the insurance company that enter it.

Lunde notes that MedCare Compare’s ability to operate in real time sets them apart in the market. “The other sites, being maintained by other parties, can take days, weeks, months. We’ve even seen one of the sites has information that is three years out of date.”

There is a feature on the site that streamlines writing good faith estimates for consumer members who request them by email. Accurate estimates are created quickly and easily using one of MedCare Compare’s predefined bundles of services, the provider’s 6

September/October 2008

own proprietary bundles, or individual line item services. Because the information is prepopulated, instead of taking days to produce an estimate, “it can really, literally, take the health care provider minutes,” says Mary Batzel, director of Communications.

Since MedCare Compare’s marketing and estimating tools are free for providers, there is no obvious reason why not to participate, other than the time required to maintain the site. As potential customers use online services more and more, it will be those with an online presence who are likely to expand their business.

T

ers’ medical needs, and less about comparing apples-to-apples pricing. In fact, he asserts, apples-to-apples match-ups cannot really be done, as services are never truly identical.

Miller explains that they like to talk about Carol more like “fruit” in general. “Sometimes you might want to have apples. Sometimes you might want to have an orange.” He says that thinking about health care as standardized is missing the point. Those who focus too much on price comparisons are “assuming that all providers deliver care in the same way, and they don’t.”

To paraphrase a MasterCard commercial: “Cost of an annual physical exam: $200.

Cost of an established physician-patient relationship: Priceless!”

MedCare Compare has chosen to start its business locally with listings of Twin Cities clinics only. Eventually, however, it wants to expand statewide, and then nationwide, with listings of hospitals, surgery centers, dental practices, nursing homes and other types of health care facilities.

Carol (http://www.carol.com)

Like MedCare Compare, Carol is a local online service. It is a privately held company, based in Minneapolis and founded in 2006. According to its Web site, it is “a true marketplace in which consumers compare health care services from Twin Cities’ clinics and hospitals before they purchase — and health care providers compete for their patronage.”

Still, CEO Tony Miller says he wouldn’t call Carol a comparison site, at least not in the same way that MedCare Compare might think about it. Carol, he emphasizes, is more about finding “care solutions” to consumMetroDoctors

According to the Carol philosophy, what consumers really want, more than simple price comparisons, is assistance in discovering the various possibilities that are available in the marketplace. Besides costs, visitors to the Carol site can see similarities and differences between providers, then make their own choices based on comparisons of services, credentials, quality, convenience, or whatever factors are important to that consumer personally.

Carol works with providers to market what it calls “care packages,” bundles of condition-specific medical services. Pricing of these packages is not limited by a focus on common procedural terminology codes.

“We think we can help providers change the underlying reimbursement system, to start getting them to be paid for value, rather than just worrying about CPT4 prices,” says Miller. Carol assists providers in packaging their products, so that consumers can see more clearly what services they are going to receive, “not just an office visit or a hospital The Journal of the East and West Metro Medical Societies

visit, but what that provider is actually going to do.”

Similar to MedCare Compare’s site, visitors to Carol’s site who choose not to log in with personal information are limited to seeing retail prices only. But once registered and logged in with the member’s insurance information, actual charges can be quoted accurately. “This is not a guess or an estimation,” claims Miller, because providers are required, by signed agreement, to honor any service or price they post on the site.

It’s a “certainty,” he says, providing that the consumer does not present with a different need later.

Besides Carol’s care packages, another major difference between the two online services is who pays the bills. In the Carol business model, looking at it from the point-of-view that providers need a vehicle to compete for the patronage of consumers, the revenue comes from providers, not consumers. Miller scoffs at the MedCare Compare contention that charging consumers, rather than providers, keeps health care costs down. On the contrary, he maintains, unless a consumer membership comes with wholesale purchasing power (like a membership in Costco), there’s no justification for charging the consumer ahead of their decision to purchase.

Carol’s revenue comes from providers in two ways. First, there’s a “nominal” subscription fee that members pay, basically for help in creating care packages, putting them into a standard format, and getting their services listed. Subscription fees are “all over the map,” ranging anywhere from $200 to $20,000 per month, says Miller. But its primary source of revenue comes from an electronic referral fee. When online consumers click on services, providers are charged “anywhere from $2 to upwards of $70” per click, determined by the cost of the services. In order to pay for these referrals, Miller believes that providers simply need to mark up their services accordingly, like any other retailer.

Carol provider members currently include hospitals, clinics and sole proprietors, and it is working to bring a couple of pharMetroDoctors

macies into the mix. While it is completely focused on the Twin Cities and Seattle markets at present, it is looking at expanding into other U.S. markets in the next calendar year.

Main Street Medica (http://www.mainstreetmedica.com)

According to its Web site, Main Street Medica’s service includes: 1) inpatient and outpatient costs for common procedures and tests; 2) hospital comparisons by complications, patients-per-year, average length of stay, and more; and 3) cost information for several conditions commonly treated at primary care clinics.

The data on the site is in the public domain. Tina Frontera, a senior director who leads all of the transparency initiatives at Medica, calls it “a public, consumer-centric tool that gives consumers information on cost and quality.” She says that it is intended to encourage customers and non-customers alike to look closely at what they are buying and to shop wisely for their health care.

Main Street Medica is not a product, per se. There is no charge for providers to be listed on the site, nor is there a charge to consumers to view its contents.

While some sites appear to be more of a vehicle to make provider members more competitive in the marketplace than a service for consumers, Main Street Medica has a built-in protection against presenting subjective information. To ensure that the data it publishes is reliable, it demands a high level of historical performance that the other sites do not. “There needs to be certain statistical and volume thresholds to make that information credible,” explains Frontera, or it will not publish the information. “It really is meant to be a fair display of cost and quality, displayed on an equal basis, putting everyone on a level playing field,” she says.

Instead of promoting providers, adds Larry Bussey, director of Corporate Communications, it offers “useful, actionable information” for consumers.

Because Medica has such a large network of providers, with a long history of claims and quality information, there is

The Journal of the East and West Metro Medical Societies

plenty of competition listed on its site. “It’s very robust in terms of the number of providers that are included,” says Bussey. Although limited to just one payer, Main Street Medica has a far more extensive list of providers than the relative newcomers in the business. The downside of this is, of course, that some competent providers with too short a history in the market do not appear in its listings.

When it comes to objective information, Main Street Medica wins hands down.

The other two services, in allowing providers to write ads describing their practices and services, essentially invite biased information into their sites.

Even though Main Street Medica’s mission may be more altruistic than the other sites, it is not entirely that way. Besides making the public better consumers, it appears to be making public relations points as well. Making information readily available to everyone “gains us credibility in terms of being open about cost and quality in the marketplace,” admits Frontera.

Being useful to consumers in terms of pricing seems to be this site’s weakest point.

Unlike MedCare Compare and Carol that both offer retail prices as well as negotiated prices based on a consumer’s insurance plan, Main Street Medica only gives broad ranges. For example, there are tiers of providers offering colonoscopies for $600-800, $801-$1,275 and $1,276-$5,000. Surely, it is helpful to consumers to alert them to the fact that there could be a $4,400 cost difference in this procedure. But that is as far as it goes. There is no explanation of how the services are unique to justify such a huge disparity in pricing.

On the other hand, for those individuals who are Medica Health Plan customers, there is a separate Web site called “myMedica.”

There you can go deeper and find more precise figures, with estimates of in-network and out-of-network costs. You will also find the estimated total that will be paid by the benefit plan and the consumer, followed by the consumer’s estimated out-of-pocket costs (after deductibles are met).

(Continued on page 8)

September/October 2008

7

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Comparison Tools (Continued from page 7)

Main Street Medica lists hospitals, clinics, same-day surgery centers, radiology, pharmacies, medical equipment and supply companies, as well as a list of “all procedures and conditions.” Medica’s service region includes Minnesota, western Wisconsin, North Dakota and South Dakota.

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September/October 2008

MetroDoctors

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major insurance, offer free parking, same

For the record, only three online services were profiled for this article. Both providers and consumers may discover others available on the Internet that meet their unique needs better.

These three services are different, that much is for certain. They all bring good things to the table and they all have their value. And, at the same time, they all have their weaknesses.

Besides the ability to compare dollar figures, one critical element to look for in choosing a comparison site is whether or not consumers have the ability to view quality assessment ratings from an independent, third-party service like Minnesota Community Measurement. Another, similar element to look for is whether or not consumers have the ability to rate their own personal experiences with providers, and whether or not fellow consumers have the ability to view that information.

Regardless of the site one chooses, one thing will always be sorely missing and impossible to ascertain. Something intangible.

To paraphrase a MasterCard commercial: “Cost of an annual physical exam: $200.

Cost of an established physician-patient relationship: Priceless!”

John Fineberg, d.b.a. Ability Communications & Training is a freelance writer with a specialty in health care. He is an American Red Cross instructor and a volunteer E.M.T. on the Twin Cities Red Cross EMS Team.

The Journal of the East and West Metro Medical Societies

Doctor of Nursing Practice As the state’s only public research university, the University of Minnesota offers a wide range of high-level professional degrees. In fact, in the last year, we bestowed nearly 1,200 Ph.D.s, Ed.D.s, Juris Doctorates, Doctors of Physical Therapy, DDSs, PharmDs, Doctors of Veterinary Medicine, and M.D.s. Within that number were also 24 Doctors of Nursing Practice, or D.N.P.s, the first graduating class from the first such program in Minnesota.

We should add, as a point of clarity, that the University does not have programs for a few of the other medical specialties leading to health care doctoral degrees. We do not offer doctorates in chiropractic or naturopathy, for example, although both are recognized or licensed in Minnesota. Yet it is the D.N.P.s who are generating a significant amount of interest within the health care community, raising questions about the intent of developing such a program. There are also concerns that the existence of these professionals, out of all the others, is somehow confusing to the patients they serve. That certainly is not the intent.

We began the process of developing the Doctor of Nursing Practice, or D.N.P, degree program nearly three years ago. This degree is designed to educate and train providers to work as independent practitioners in specialty areas, participate as members of care teams providing services to patient populations, and provide a valuable perspective by serving as leaders in health care organizations.

Context for the development of this degree comes from the existing and projected health care needs of Minnesotans. Minnesota remains federally designated as underserved or disadvantaged in a number of areas, includBy Frank B. Cerra, M.D., and Connie Delaney, Ph.D., R.N.

MetroDoctors

ing primary care, mental health, dental care, and pharmaceutical care. This is difficult to understand as Minnesota is also designated the healthiest state in the nation. This access problem is not just in Greater Minnesota, but exists within areas of the Twin Cities. It is clear that this access problem will grow more severe in years to come. The number of people in Minnesota older than 60 is beginning to rise exponentially, far outstripping the capacity of current care delivery models to meet their needs, to say nothing of the needs for preven-

T

This range of professional disciplines within one university offers a distinct opportunity to learn to address individual and societal health issues in collaborative teams. One example of these communities of health is the “health home model,” written into health law in the 2008 legislative session. The health home model, also referred to as the “medical/health care home,” is a community-based care delivery model designed to coordinate care primarily for patients with complex and chronic conditions.

The model offers great promise in improving

This collaborative approach does not lessen the value of any of the providers, but rather supports them, bringing their particular competencies to the team to better serve the community’s health needs.

tion, wellness, chronic disease management, long-term care, and end-of-life care.

The University’s School of Nursing program offers specialty training in 15 focus areas, including gerontology, pediatrics, mental health, and public health nursing practice. Our graduates already are employed as advanced practice nurses, clinical experts, health care executives, policy experts and informaticians — all critically needed in today’s health care systems.

Providers with the D.N.P. degree also have great potential to help meet the rapidly expanding demand of an aging population for access to health improvement and health care.

The University’s Academic Health Center is home to six core health provider disciplines and a wide variety of joint degree programs.

The Journal of the East and West Metro Medical Societies

access, adding value and improving outcomes for people who participate. Understanding how these new approaches work, and which approaches will be needed from urban to rural Minnesota, requires more work and new competencies among participating providers, along with the development of educated users. All this is underway within the Academic Health Center, within communities throughout Minnesota, and within University-community partnerships.

All of us engaged in health practice today recognize the limits of the current health care system to address the true issues affecting the health of our population. We have inadequate

(Continued on page 10)

September/October 2008

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Colleen L. Casey, M.D. has joined Reproductive Medicine and Infertility Associates (RMIA). She will have her primary practice in Edina, across from Southdale Hospital, 3625 W. 65th Street.

Patients are now being scheduled by calling 651-222-6050.

10

September/October 2008

Doctor of Nursing Practice (Continued from page 9)

access to care for all Americans. Even for those with access, there are extreme differences in the care provided based on geographic location, income, and cultural or racial background.

Approaching the health workforce problem, in part, requires increasing the supply of providers, but also using a patient-centered, interprofessional approach to develop new models of prevention and care delivery for both acute and chronic diseases and conditions.

Educating the same kind of providers in the same way to provide the same level and type of care will not solve the access, quality, and cost problems we have in the system today.

It is time for new approaches to ensure access, emphasize health and wellness, and provide safe, quality chronic care management. This includes the full cultivation of D.N.P. prepared advance nurse practitioners. The effectiveness of these practitioners, working independently and also in collaboration with physicians, has been well researched and demonstrated — nurse practitioners provide quality and cost-effective care.

Fundamentally, we believe that innovation happens where the disciplines touch.

Professionals addressing problems as part of an interdisciplinary team frequently come to a better result or answer than what can be achieved within a single discipline. Innovation is critical to the health of our children and grandchildren because the system in place today will not serve the needs of the future.

That is why we work so diligently to ensure our disciplines have opportunities to interact and engage in new ways on behalf of both individual patients and communities.

This collaborative approach does not lessen the value of any of the providers, but rather supports them, bringing their particular competencies to the team to better serve the community’s health needs. Thus, clinical pharmacists bring their expertise in medication management, physicians perform differential diagnosis of medical conditions, and D.N.P.s bring competencies in care of the aging, children, mental health, anesthesia, prevention, and chronic disease management.

Such an approach also requires a redefinition of the care delivery model or models, of

MetroDoctors

which the health home is one example. Private practices and health systems throughout Minnesota are moving in this direction to greater or lesser degrees, with insurance companies having an interest in such developments and helping wherever possible. Clearly, electronic health records play a critical role, with the Minnesota e-Health initiative leading the way.

At its core, doctoral-level health sciences programs are directed at improving patient care and health. And, the University of Minnesota is not unique in recognizing the need and value for these advanced practice professionals. In fact, nationally, the D.N.P. program is offered in 72 schools, including several others in Minnesota, through Minnesota State Colleges and Universities and two private programs. These programs are committed to preparing practitioners who can address: the rapid expansion of knowledge that underlies practice; increased complexity of patient care; national concerns about the quality of care and patient safety; nursing faculty and personnel shortages that demand highly prepared leaders who can improve systems and increase access to care; and, increased educational expectations for the preparation of other health professionals.

The University of Minnesota has a unique role regarding health within the state of Minnesota. As the state’s only land grant university, we are the stewards of the state’s health through our mission to prepare the next generation of health professionals. Although our School of Nursing is not the only public school in the state, it is the first nursing school in the United States established within a University — a fact we look forward to celebrating as the school celebrates its centennial in 2009. For 100 years, the school has been a leader in not only educating nurses to care for Minnesotans, but in educating the teachers who instruct nursing students throughout Minnesota. This is one more example of our drive to lead within the transforming health care system.

Frank B. Cerra, M.D., is senior vice president for health sciences at the University of Minnesota. Connie Delaney, Ph.D., RN, FAAN, FACMI, is professor and dean of the School of Nursing.

The Journal of the East and West Metro Medical Societies

Colleague IntervIew

A Conversation With

David Satin, M.D.

D

avid J. Satin, M.D. received his medical degree from the University of Western Ontario, London, Canada and participated in a medical education student fellowship at the University of Western Ontario, Faculty of Medicine and Dentistry, London, Canada. He completed a residency in family medicine at the University of Minnesota Medical Center (Smiley’s) Residency Program, Minneapolis and is currently a postdoctoral fellow in Bioethics at the University of Minnesota, Center for Bioethics. He is board certified by the American Board of Family Medicine; and is a fellow of the Royal College of Physicians and Surgeons of Canada. He is an assistant professor, Department of Family Medicine and Community Health, University of Minnesota, University of Minnesota (Smiley’s) Residency Program and is a Compliance Officer and Risk Management Leader for the Department of Family Medicine and Community Health, University of Minnesota Physicians, Minneapolis. Dr. Satin also serves as a Family Physician/Ethicist, on the American Medical Association Physician consortium for quality improvement: Geriatric Pay for Performance Work Group. He developed Pay for Performance measures for submission to the Centers for Medicare and Medicaid, National Committee, coordinated through AMA headquarters, Chicago. He is a member of the Minnesota Medical Association and Minnesota Council of Health Plans P4P Measurement Alignment Work Group.

Questions were provided by Drs. Peter Bornstein, Ronnell Hansen and Robert Geist; David Allen and Becky Schierman.

Pay for performance (P4P) programs often encourage reimbursement for hitting clinical targets based on process or outcome measures. If possible, what metrics of ethical behavior could be included in P4P programs?

P4P programs are predicated on the notion that better outcomes should be rewarded with better pay. What are the ethical conflicts physicians face when evaluating whether to participate in such programs?

I would not recommend any P4P metrics of ethical behavior. Judging behavior as ethical or unethical requires knowing many contextual factors that cannot be accounted for in even the most sophisticated P4P system. Ultimately, it is only the moral agents themselves that can truly know if their behavior is ethical. We may ask for metrics that might reflect patients’ perception of a given clinician’s professionalism, but that becomes more of a patient satisfaction survey. Indeed, many P4P programs are including patient satisfaction surveys as a factor for determining clinician reimbursement. But again, this is not a metric of ethical behavior. Other metrics that try to approximate ethical behavior are those that measure compliance with laws and institutional policies.

These are interesting in that they help us understand how ethics, law and policy are distinct yet related concepts.

On a personal level, there is something perverse about the notion of an economic incentive for ethical behavior. Nevertheless, one can view the entire enterprise of striving for better patient outcomes in moral terms.

In this light, all clinical P4P measures are measures of ethical behavior.

I would caution us against viewing P4P in this light for reasons I began with above.

The premise of this question, that “P4P programs are predicated on the notion that better outcomes should be rewarded with better pay” is not universally accepted. There is a competing view that “P4P programs fund successful quality improvement projects.” This is a subtle yet critical point. If one views P4P as personal financial reward for better outcomes, then one is more likely to take the payers judgment personally, as if P4P is measuring ethical behavior as described in question #1. In contrast, if one views P4P as a reflection of your quality improvement projects, positive or negative judgments become objective benchmarks for continuous quality improvement. In reality, the working premise of P4P programs is often a mixture of these two distinct views.

Now to answer the question, the most salient ethical conflicts physicians face under P4P are conflicts of interest. Should you recommend that your 50-year-old patient with pancreatic cancer get a screening colonoscopy? Should you terminate, dismiss, or fire a diabetic patient who fails to adhere to his or her medication regimen? Should you refuse new diabetic patients who smoke? Facilitating non-coerced, informed consent will be a greater challenge when your P4P bonus rides on what

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The Journal of the East and West Metro Medical Societies

(Continued on page 12)

September/October 2008

11

Colleague Interview (Continued from page 11)

your patient chooses. There is a finer line than one might think between teaching with a keen awareness of what is on the test and teaching to the test. P4P programs are not yet sophisticated enough to be completely fair. The great moral challenge for clinicians under P4P is to accept the occasional bad P4P outcome when you know it’s the right thing for your patient.

P4P criteria tend to measure clinical statistics that are believed to make a difference in the average health of a population. But, to an individual, quality probably has much more to do with whether the physician really listened and understood, whether the physician gave actionable treatment guidance, and such things as affordability, convenience, service, etc. If P4P criteria are at significant divergence to what individuals seek in terms of quality, then how can P4P ever lead to quality that individual’s value?

When I travel by commercial airliner, I assume that the airline is diligent and that the pilot is sufficiently skilled to get me to my destination safely.

I rate the quality of an airline according to their timeliness, friendliness, and whether I got peanuts on the flight. Now what if I were to discover that airlines actually do differ significantly with regard to safety? That is, for better or for worse, what patients are starting to discover about health systems.

For years, patients have assumed that their clinics are diligent and that their doctors are sufficiently skilled. The public reporting of outcomes is revealing that there are differences in the more important criteria we took for granted. The current data tells us that patients will typically not change doctors in response to the outcomes. Indeed, they say quite sensible things like, “Well that doctor must have sicker patients!”

But the current data also tells us that at least some patients choosing a doctor for the first time will take the outcome data into account. Finally, P4P programs are increasingly taking into account the items listed in the question such as affordability, convenience, service, etc.

The Massachusetts health plan while reducing the rate of uninsured by half (14 percent to 7 percent), has had the state medical society file a lawsuit to block or change a ranking program it says harms doctors and patients. Are such P4P methods really useful in actually evaluating and improving systems versus their overhead cost and complexity?

First, I think it’s great that the medical society stood up for its doctors who felt they were being unfairly rated. I have heard story after story from clinicians whose “efficiency” rating was poor. Upon further investigation, “efficiency” often means “how much you cost in comparison to your peers.” I have not yet seen a program that calculates efficiency in terms of cost per outcome, taking into account the baseline illness and complexity of the patient population. But most importantly, what your efficiency means according to a given health plan is typically not conveyed to patients in a fair and transparent fashion.

That said, the question asks, “Are such P4P methods really useful 12

September/October 2008

in actually evaluating and improving systems versus the overhead cost and complexity?” My answer is, “I don’t know, but I know that it is not known.” That is, nobody knows yet. I do know that P4P programs (not necessarily ranking programs) have been shown to improve intermediate level markers of health such as blood pressure, blood sugar, daily aspirin use, smoking cessation, and lipid levels in patients with Type 2 diabetes.

It has not demonstrated similar success with hospital based end-points such as repeat myocardial infarction and all cause mortality. So the jury is out on even the benefits side of the equation. Much of my work concerns the burden side of the P4P equation. What we know about the benefits is 1,000 fold what we know about the burdens. So it’s too early to sensibly predict if the benefits are worth the burdens. Given the international scope of P4P, I do predict that some form of P4P will have net worth.

I see the United States’ 150-plus P4P programs as a giant experiment.

Unfortunately, we didn’t all consent to be research subjects in this great experiment.

Is Minnesota ready to link the incentives from P4P more directly to the physicians whose behavior is being measured (individual physician level measures)? What are the ethical concerns when moving toward this level of granularity?

Personally, I think this would be a mistake, especially for public reporting.

There are too many unsettled questions before we are ready to purport we can judge the quality of a physician’s care based on these measures.

Imagine treating this as a research question. Randomizing patient populations to negate confounding variables would only get us halfway there. We would still be left to answer questions like, “are these measures representative of this clinician’s overall care?” and “What is the ideal rate of Chlamydia screening given that this is ultimately a patient choice?”

Different styles of doctoring will get different results. As someone who participates in both medical school and residency admissions, I can say with confidence that even physicians are not unanimous on what constitutes the ideal style of doctoring. Moreover, different styles of doctoring can be a good thing given the heterogeneity of patient styles.

That said, there is certainly a role for individual physician level measures. I think they can tell us who the outliers are and from a quality improvement perspective, that can be helpful. I enjoy seeing where I rank on various measures, knowing that perhaps I ought to pay more attention to whether or not I prescribe aspirin to my patients with diabetes. I enjoy it more when the rankings are private because I know how hard it is to resist seeing a rank list as anything other than a ranking of how good a doctor you are. The science of this kind of individual level measurement is too young. Its shoulders are not yet broad enough for us to stand on and dole out bonuses or rank clinician quality. So my ethical concerns here turn out to be primarily pragmatic concerns.

How can we improve data collection methods to account for noncompliant patients and to eliminate confounding variables?

Britain has two fairly elegant solutions. I describe them in the April 2006 issue of Minnesota Medicine. www.minnesotamedicine.com/PastIssues/ April2006/CommentaryApril2006/tabid/2386/Default.aspx.

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The Journal of the East and West Metro Medical Societies

In brief, Britain risk adjusts and allows for specific exceptions. Their risk adjustment formula is based on the average household income of your clinic’s postal code. With economic status as the greatest single predictor of outcomes, the British decided that some adjustment was necessary in order to be fair to clinics serving poorer neighborhoods. Britain also allows for specific exceptions. For example, one P4P measure of quality is to perform an annual in-person medication review with each patient taking psychiatric medications. But rather than losing out if you serve a transient population, British P4P allows for an alternative process measure of due diligence. Clinicians attempting to recall their patients to clinic via registered mail and telephone, demonstrating a quality system, earn the same bonus afforded to their colleagues lucky enough to have their patients show up.

In addition to these suggestions for improving quality and fairness, New Zealand has some tricks we can learn. These include bonuses for “case finding” of patients who have not had a recommended screening test such as a PAP smear within five years.

There will always be a trade off between maximal fairness and minimal complexity in a P4P system. Nevertheless, we need only look abroad and at one another’s P4P programs to see great innovations available to us all.

As care becomes more coordinated between primary care and specialty care, how will P4P programs determine to which provider the attribution of patient outcomes goes? Will they pay incentives to both providers for improved outcomes?

Let’s begin with what has not worked. If one attempts to assign responsibility for a patient outcome to the clinician who has seen that patient most frequently within a year, oftentimes you get unintuitive and inappropriate assignments, such as an ophthalmologist being responsible for a diabetic patient’s A1c and cholesterol. If one assigns responsibility based on primary clinic designation, as is typically the case, then you get so-called “invisible” patients whose outcomes are the responsibility of a doctor whom they have never seen.

One solution that has been proposed is a quasi capitated system in which clinicians are reimbursed per-patient per-month (PMPM) to be responsible for that patient’s outcomes. That is, clinicians are reimbursed on a PMPM basis, over and above any fee-for-service and P4P arrangements. This small degree of capitation is meant to reimburse clinicians for the added administrative expenses required to reach out to the “invisible” patients. Additionally, the PMPM capitation reimburses for the added difficulty of caring for patients who rarely attend the clinic and who are cared for frequently in non-traditional ways such as phone calls with doctors and nurses.

Speaking specifically to the issue of primary care and subspecialty care, the Centers for Medicare and Medicaid, as well as many private P4P programs, have designated certain measures to be specialty specific.

Once such a designation is made, I believe the PMPM capitated approach may or may not be appropriate depending upon the circumstances of the measure and the specialty. I am open to the possibility of a split bonus between two specialties, but I am not aware of a model for this complex arrangement.

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The Journal of the East and West Metro Medical Societies

There is not transparency in the formula used to determine tiering decisions, and in the relative weight of quality and cost more importance is placed on cost than quality. Should we seek to separate cost and quality measures to more easily allow assessment of the clinical outcomes by patients?

Yes — see Question #4.

Nevertheless, we should consider that there may be a legitimate role for an additional measure of “efficiency” that recognizes clinicians who achieve similar outcomes as other clinicians with similar patient populations, but at half the cost.

Does the new Minnesota health care reform statute mean that the “medical home” will become a corporate gatekeeper house for carve out “packages” of services (e.g., for all orthopedic services including hospital services) with fixed annualized capitated prices?

I don’t know.

As an educator, I think it’s important that my students occasionally hear me say, “I don’t know.” Someone who never says, “I don’t know” can’t be trusted because no one knows everything. The unfortunate consequence of appearing to know everything is that bright students will eventually treat everything you say as equally suspect. A good teacher and a good physician, since all physicians are teachers, occasionally says, “I don’t know, but I’ll find out.”

So check in with me again. I’ll find out.

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September/October 2008

13

IT Outsourcing in the Medical Practice

T

he medical industry as a whole is under a great amount of pressure to implement the paperless environment using technology to enable movement of data between the players in health care and increase quality of care. Therefore, more attention is being paid and more effort is being made to make IT more efficient and robust for health information systems in medical practices. Fortunately, most practices are not starting from zero. Most practices have basic computer networks and some type of computer system for physician billing and patient accounting.

Practices have even experienced iterations of upgrades with the passing of Y2K and patient privacy mandates in the last decade.

However, with the adoption of electronic medical record systems (EMR), the pain tolerance for unavailable systems and broken networks is reaching zero. As more clinical data is made available electronically, IT continues to become more complex and brings to the forefront issues that practices must concern themselves about. Urgency increases the need for higher availability of patient data, security over networks, and disaster recovery strategies to be in practice.

According to a report by the Medical Group Management Association, the average expenditure for IT costs by multispecialty practices is 1.5 percent of their total medical revenue with a .6 percent range difference between hospital-owned (1.2 percent) versus not hospital-owned (1.8 percent) averages1. So, while hospital-owned practices have the advantage of access to resources through hospital information technology (IT) staff, independent practices must turn to more creative options,

By Trish Lugtu

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September/October 2008

such as outsourcing, to manage their basic IT needs.

The options between what to staff and what to outsource are plenty. So how should a practice approach a decision to invest in its own technology and staff versus outsource IT resources? While the solution of what and when to outsource is not a one-size fits all answer, we can look at various components to determine what formula is right for a clinic.

The biggest factors in determining staffing to outsourcing ratios are the size of practice and its philosophy on technology. The size of the practice correlates with the number of providers, the amount of staff needing support, and the total medical revenue. The philosophy on technology stems from the values of the leadership within the practices, their comfort level around technology, and the ability to manage change. Does the leadership shy away from computerized systems or do they embrace technology and create excitement around its advantages?

Typically, the more progressive a practice is with technology, the higher is their IT staffto-user ratio. For example, high-tech practices, which depend on more complex and higher numbers of computerized systems such as EMR, practice management, accounting, digital imaging and radiology systems, wireless environments, unified messaging, various lab systems and clinical devices, will tend to have a ratio closer to 1:25 to 1:50 IT staff to users2. The IT staffs tend to be hierarchical MetroDoctors

including an IT manager or coordinator and subordinates.

Most practices have philosophies that fall in the range of IT with “full service and overall value� at a ratio of 1:60 to 1:100 IT staff per users2. Practices with this philosophy will tend to have practice management systems, may or may not have EMR, and peripheral diagnostic systems.

All sizes of practices, depending on how knowledgeable or strained for capacity a staff is, will employ some combination of outsourcing.

Most practices with less than 100 users typically outsource all of their IT resources. IT vendor coordination usually falls onto the list of responsibilities of an office manager or business office supervisor. Practices that choose to keep their IT under closer control will more likely employ staff rather than outsource. Practices with 100-200 users will employ an IT generalist who also coordinates outsourced network specialists. Practices with 200 or more users will grow a hierarchical IT staff. But because of the vast and increasing amounts of knowledge needed to support computer systems with today’s technology, it is difficult to encompass The Journal of the East and West Metro Medical Societies

all the specialized skills within an individual person or a small team. Therefore, even larger practices will outsource the specialized skills for their more complex systems and devices.

Practices may choose to outsource their complete IT support through managed services, which may include help desk, personal computer (PC) and server maintenance. Gartner reported up to a 42 percent savings on managed PCs3. Practices can choose to lease printers, computers, and servers to avoid old hardware, which usually means more support.

Practices can choose to deploy “thin” environments where all processing is done on a server minimizing the need for hands-on help desk support, as opposed to “thick” or “fat” environments where all applications are installed locally.

The outsourcing options also continue to grow as internet technologies improve, available bandwidth for transferring data increases, and cost for added telecommunications and data lines decrease. Managed hosting services have grown by 30 percent in the last year4.

Some practices choose to have their systems hosted for a fixed fee through an Application

Trish Lugtu, technical services manager, has spent over seven years with MMIC Technology Solutions providing solution architecture and consulting for internet and data technologies for medical practices. For more information about MMIC Technology Solutions and how they can help your practice, contact Trish Lugtu at Trish.Lugtu@mmihc.com or via telephone at (763) 201-0306.

Service Provider (ASP) model where the ASP is responsible for keeping their systems maintained, secured, and backed-up. Backups and disaster recovery are also becoming offered as a managed service, offloading the need for staff to manage the backup for the servers.

To choose the right combination for your practice, the best place to start is by defining your technology philosophy and goals based on a best practices budget percentage. Then get help from a trusted advisor who can help you identify what your needs are, analyze cost scenarios, interview staff, and select systems and vendors.

References 1) Leeds, Stacy K., Ph.D. Performance and Practices of Successful Medical Groups: 2006 Report Based on 2005 Data. Medical Group Management Association Survey Operations, 2006.

2) Piot, Jon; Baschab, John. “Executive’s Guide to Information Technology.” John Wiley and Sons, 2003. p172.

3) Gartner Press Release. “Gartner Says Effective Management Can Cut Total Cost of Ownership for Desktop PCs by 42 Percent.” http://www.gartner.com/ it/page.jsp?id=636308.

4) Business Wire Article. “Tier1 Research: Several New Trends Help Managed Hosting Sector Experience Tremendous Growth.” http://www.reuters.com/article/ pressrelease/idUS160124+15-Apr-2008+BW20080415.

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September/October 2008

15

Physicians Step Up to Take Out Colon Cancer Across the metro area, physicians are fulfilling an important unmet need while highlighting the connection between lack of adequate health insurance and cancer risk.

Doctors, nurses, administrators and volunteers at two sites — Fairview Southdale Hospital and Regions Digestive Center — generously donated their time and expertise in providing free colonoscopies for under — and uninsured men and women.

Gastroenterologists are eager to help underinsured and uninsured people find health care — especially screening for colon cancer,” according to John Allen, M.D., medical director of Minnesota Gastroenterology, Inc., a leading partner in a charitable collaboration that provides free colon cancer screening services to Minnesotans who might otherwise fall through the cracks. “Our physicians feel a sense of accomplishment after a day of providing exams to people in need,” he added.

Participating in a free screening event was an easy decision for us,” said Brian Rank, M.D., medical director of HealthPartners Medical Group. “HealthPartners and Regions Hospital strongly believe in and are committed to prevention, screening and early detection of cancer for all patients — including those who may lack access to those services,” he stated.

A total of 67 patients have been screened at free colonoscopy clinics to date. Polyps were resected in 27 patients. At least 21 patients were found to have adenomatous polyps, of which nine were determined to be at high risk of becoming cancer.

A number of patients who took advantage of the free screening events had inadequate insurance with large deductibles or steep co-pays.

Most had good jobs. The uninsured included

By Rebecca Thoman, M.D.

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September/October 2008

self-employed small business owners who couldn’t afford health insurance, workers whose employers didn’t provide health insurance benefits and qualifying individuals who couldn’t afford the MinnesotaCare premiums.

Sandra Young, R.N., manager of Regions Digestive Care Center, was surprised at how many middle-class Minnesotans were in need of this service. “When I delivered the preps to patients in Bloomington, Richfield and around the metro, I could see that this service is needed all over. These were nurses, teachers and others I never would have thought were uninsured.

T

brainchild of members of the Colorectal Cancer Screening Task Force. In 2002, the Centers for Disease Control and Prevention provided seed money for a state-based comprehensive cancer control plan. The resulting Cancer Plan Minnesota 2005-2010 identified initial priority areas, one of which was colorectal cancer screening. Although it is the third most common cancer and the second-leading cause of cancer-related mortality, colorectal cancer is highly preventable when screening recommendations are followed. Minnesota leads the nation in screening rates (66 percent) as

The Cancer Alliance, which grew out of development of Cancer Plan Minnesota 2005-2010, is a coalition of health organizations, community groups and volunteers dedicated to reducing the state’s cancer burden. Priorities include increasing colorectal cancer screening, reducing disparities, and reducing the harmful effects of tobacco. Read more about the Cancer Alliance at www.mncanceralliance.org.

Lots of them had to make choices between their mortgage payment and their health insurance payment,” she commented.

Some of the patients who took advantage of the free screenings included: • A 22-year-old, fresh out of college and with no insurance whose 25-year-old brother had recently been diagnosed with colon cancer.

• The mother of a family of six, whose deductible ($5,000 per person, maximum $15,000) made a colonoscopy cost prohibitive.

• A self-employed, uninsured 60-year-old with a history of breast cancer and a family history of colon cancer.

These free colonoscopy clinics were the MetroDoctors

compared to the national average (53 percent).1 But for the uninsured, the screening rate is less than 20 percent.2 Thus, the Task Force was determined to reduce the incidence of colorectal cancer by increasing screening rates among those most at risk. Two main strategies emerged — providing free colonoscopy screening clinics and advocating for a legislative solution that would make these lifesaving services more broadly available.

“The free screening clinics’ success demonstrates that if we build it, they will come,” said David Arons, Minnesota director of government relations for the American Cancer Society. “And while we commend the clinicians The Journal of the East and West Metro Medical Societies

and staff who stepped up to fill this critical gap in care, the free screenings are a drop in the bucket when compared with the need,” he added. In 2001, there were nearly 41,000 uninsured Minnesotans between the ages of 50 and 64.3 That’s why, fresh from its victory passing Freedom to Breathe, the American Cancer Society is making colorectal cancer its top state priority, and physicians are stepping up to help.

According to David Perdue, M.D., gastroenterologist and researcher, American Indians have the highest incidence of colorectal cancer in Minnesota — nearly double that of non-Hispanic Whites. To address the disparity, Perdue helped found Minnesota’s Intertribal Colorectal Cancer Council, bringing tribal leaders, health professionals and researchers together to find effective strategies to increase screening rates.

In 2008, the Minnesota Colorectal Cancer Prevention and Early Detection Act, which was endorsed by the Minnesota Medical Association, won hearings in both the House and Senate. Modeled after the state’s breast

Big solutions through small incisions

and cervical cancer screening program (Sage) the colorectal bill would direct the Minnesota Department of Health to partner with private and community clinics to help the under- and uninsured obtain colorectal cancer screening services they might otherwise delay or neglect entirely due to lack of coverage.

The colorectal cancer bill takes us in the right direction with regard to health care reform,” according to House author Rep. Maria Ruud (Minnetonka), a nurse practitioner with Park Nicollet Clinic, Brookdale. “Every day in the clinic I see patients who delay care or don’t get screened because they have high deductible plans. In a tough economy, they postpone coming in until they have symptoms,” she added.

The American Cancer Society’s goal is to reduce cancer incidence by 25 percent and cancer mortality by 50 percent by the year 2015.

Current trends show that while both incidence and mortality rates are declining, we will need to redouble our efforts in order to meet this ambitious goal.

Physicians can help reduce the cancer burden in Minnesota.

• In the clinic, continue to urge your patients to be screened for colorectal cancer. More than a third of Minnesotans who have access to screening services are not taking advantage.

• Volunteer. Offer to provide screening services to the uninsured.

• Advocate. Physicians were instrumental in passage of the smoke-free law. Our voices are needed to convince lawmakers that colon cancer is a highly preventable disease and that state investment in screening is well worth it.

In the words of American Cancer Society Chief Executive Officer, John Seffrin, M.D., “the ultimate control of cancer is as much a matter of public policy and advocacy as it is a scientific issue.” Please contact Rebecca Thoman, M.D., at the American Cancer Society to learn more about opportunities to participate.

1) Minnesota Cancer Facts & Figures 2006. American Cancer Society.

2) Cancer Facts & Figures 2008. American Cancer Society.

3) Minnesota Dept. of Health, Health Access Survey, 2001.

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September/October 2008

17

Colorectal Cancer Screening Rates

Still Too Low

A

lthough colorectal cancer screening tests are proven to reduce colorectal cancer mortality, only about half of U.S. men and women 50 and older receive the recommended tests, according to a report in the July 2008 issue of Cancer Epidemiology, Biomarkers and Prevention, a journal of the American Association for Cancer Research.

The Centers for Disease Control and Prevention conducted a National Health Interview Survey and found only 50 percent of men and women 50 and older had received screening in 2005. Although this was an improvement over the 43 percent of screened individuals reported in 2000, it is still far from optimal, investigators say.

“Colorectal cancer is one of the leading cancer killers in the United States, behind only lung cancer. Screening has been shown to significantly reduce mortality from colorectal cancer, but a lot of people are still not getting screened,” said Jean A. Shapiro, Ph.D., an epidemiologist at the Centers for Disease Control and Prevention (CDC).

Shapiro says a major problem appears to be insurance coverage. Among people without health insurance, researchers found the rate of colorectal cancer screening was 24.1 percent compared to over 50 percent of insured Americans, depending on the type of insurance. Among patients without a usual source of health care, the screening rate was 24.7 percent compared to 51.9 percent of patients with a usual source of health care.

“If we can increase the number of people who have health care coverage, we should be able to increase colorectal cancer screening rates,” said Shapiro.

Shapiro says the increase in colorectal cancer screening rates observed from 2000 to 2005 may have been due in part to increased media coverage of the importance of colonoscopy as a measure

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September/October 2008

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to prevent cancer and detect it early, including a broadcast of Katie Couric, then co-host of NBC’s Today show, undergoing a colonoscopy.

However, Shapiro adds, the increase was probably also due to the fact that in 2001, Medicare expanded its coverage for colonoscopy screenings to a wider range of patients.

“Health care access and insurance are important,” Shapiro said.

Beyond health insurance, researchers at the CDC reported the following factors influenced the use of colorectal cancer screening tests: • Education: 37 percent of people with less than a high school education received screening vs.

60.7 percent of college graduates.

• Household income: 37.4 percent of people earning less than $20,000 in annual household income received screening vs. 58.5 percent of people earning $75,000 or more.

• Frequency of physician contact: 19.5 percent of patients who had not seen a physician in the past year had received screening vs. 52.5 percent of patients who had seen their physician two to five times in the previous year.

Approximately 50 percent of patients who did not receive testing said they had “never thought about it,” while about 20 percent said their “doctor did not order it,” researchers found.

“Many doctors are aware, but some may still need to be educated about the importance of colorectal cancer screening,” said Shapiro.

These data were derived from the CDC’s 2005 National Health Interview Survey which interviewed 30,873 adults in a demographically representative sample of Americans. Interviews were conducted in person with a 68 percent response rate. For the current analysis, Shapiro and colleagues focused on 13,480 patients who were age 50 and older.

News Release, American Association for Cancer Research.

The Journal of the East and West Metro Medical Societies

Joint Commission Standard MS 1.20

Stay Tuned THE JOINT COMMISSION’S revised standard for hospital medical staff self-governance remains a work in progress — but the final edition may be nigh.

In July, 2007, the Joint Commission published a final version of MS 1.20, after years of committee work, two field reviews, and considerable resistance from the hospital industry. For the most part, the hospitals’ opposition stemmed from the standard’s elements of performance requirements that important matters, including privileging processes, fair hearing procedures, and credentialing requirements, had to be in medical staff bylaws. Hospitals objected, preferring to convince physicians that their rights and responsibilities should be hidden in separate plans and manuals that physician members of the medical staff had no right to vote on. Of course, the hospital industry is also well aware that in many states, bylaws have been ruled to be a contract, binding on the hospital and physician and enforceable in court. By diverting physicians’ rights and standards into plans and manuals, and away from bylaws, the hospital can conveniently avoid them. The 2007 Joint Commission standard MS 1.20 would have effectively stopped such schemes.

In addition to delineating what is to be in medical staff bylaws, MS 1.20 also required that the medical executive committee work for hospital medical staffs. Specifically, the July, 2007 version called for the medical executive committee’s duties to be delegated by the medical staff, which was also to be authorized to revoke such delegation. Further, medical staff bylaws would have to include the right for a medical staff to recommend medical staff bylaws amendments directly to the governing board, whether or not the medical executive

By Elizabeth Snelson, J.D. MetroDoctors

committee had acted on the changes. That requirement would relax the control some medical executive committees hold over medical staff bylaws amendments. Interestingly, the hospital industry strongly opposed all measures to lessen the power of the medical staff’s executive committee. The intense objection exposed the hospitals’ need to control medical staff recommendations and decision-making, despite the fact that most medical staff recommendations are subject to governing body approval. Any Joint Commission standard that interferes with the hospitals’ ability to control physicians was challenged.

As a result of the hospital industry’s rejection campaign, the Joint Commission established an Implementation Task Force comprised of hospital administrators, hospital board members, and medical staff leaders and advocates, including a medical staff leader from the West Metro Medical Society (Paul A. Kettler, M.D. and alternate representative T. Michael Tedford, M.D.). Unfortunately, hospital representatives on the Task Force refused to allow the group to focus on implementation, and were successful in convincing the Joint Commission board to revise the Task Force charge to rewrite the standard, which it authorized at its May meeting. Since then, the Task Force has devoted untold hours to word-smithing a standard that will require hospitals to let clinicians actually handle clinical issues, while giving the hospital administrators and board members a comfort zone for the responsibilities they carry for the provision of tertiary care.

The most contentious issues have to do with whether the medical staff should be permitted to choose its leadership. Astonishingly, despite the Joint Commission standard that requires that medical staffs self-govern, hospitals are blocking any requirement that medical staffs be permitted to choose who sits on the medi-

The Journal of the East and West Metro Medical Societies

cal executive committee of the medical staff, preferring to allow hospitals to select the medical staff’s leadership. Meanwhile, the current MS 1.20 stays in force. Stay tuned to the West Metro and East Metro Medical Societies for information on what comes next for your medical staff.

Elizabeth “Libby” Snelson, J.D. represents medical staffs and serves as a member of the Joint Commission MS 1.20 Task Force. She can be reached at her St Paul office at easesq@snelsonlaw.com.

Bylawg, her blog on medical staff issues, can be accessed at www.snelsonlaw.com.

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September/October 2008

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Lakeview Hospital, Stillwater, MN Bringing the Best to You The MetroDoctors editorial board has invited several hospitals located in the east and west metro communities to submit an article that would “showcase” their hospital and community health outreach initiatives. Lakeview Hospital in Stillwater is the fourth hospital to be highlighted in this series.

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estled in a quiet Stillwater neighborhood in the St. Croix River Valley is a seemingly unassuming community hospital — Lakeview Hospital. It is Minnesota’s second oldest hospital, founded in 1880 by a group of 12 local women. Today, Lakeview continues to be independent and communitycontrolled by a 12-member volunteer board. Its independence allows it to provide the services most needed by the community, right where they live and work. The committed community members who serve on the hospital board take pride in upholding the Lakeview legacy of providing high quality medical care that is state-of-the-art and competitively priced.

Part of the Lakeview Health System — which consists of Lakeview Hospital, Stillwater Medical Group, and Lakeview Foundation — Lakeview Hospital employs 825 people, has 169 admitting privilege physicians on medical staff, and has 297 active volunteers. Its mission is “to promote and sponsor superior health services in the St. Croix Valley.” The values of Lakeview — service, integrity, compassion, quality, collaboration, and performance — help to define its course of action and provide clear direction.

Lakeview Health is an integrated, nonprofit clinic and hospital system serving the eastern Twin Cities metro area and western

By Curt Geissler, President, Lakeview Hospital

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September/October 2008

Wisconsin. More than 300,000 residents in its core service area across Minnesota and Wisconsin have access to Lakeview’s continuum of services — from the prevention of illness and injury to the care of patients with complex medical conditions.

In 2006, there were over 4,000 inpatient admissions at Lakeview Hospital and over 10,000 emergency room visits. Nearly 5,500 surgeries were performed and 726 births took place. Lakeview Homecare provided over 17,000 home health visits, and Lakeview Hospice served nearly 300 patients and their families.

Many of these patients see the providers of Stillwater Medical Group. In addition, Lakeview Hospital has established valuable partnerships with other health care providers, such as St. Croix Orthopaedics, Midwest Spine Institute, St. Paul Heart Clinic, Valley Anesthesiology Consultants, St. Croix Radiology Consultants, United Hospital, Minnesota Gastroenterology, Three Rivers Pathology, Associated Eye Care, Pain Clinic of Northwestern Wisconsin, Regions Hospital and Pulmonary Critical Care Associates. These partnerships provide the residents of the St. Croix Valley with easy access to some of the best specialists in the metro area.

Licensed for 92 beds, Lakeview Hospital has always been about the community it serves. From the birth of a child to hospice care, Lakeview Hospital is a steadfast resource for individuals and families throughout the region.

Lakeview has historically allocated a portion of the previous year’s operating margin for grants to non-profit organizations in the St. Croix Valley. Organizations funded by Lakeview include those it considers partners in building and sustaining a healthy community.

In addition to patient education classes, MetroDoctors

ranging from childbirth to advanced cardiac life support (ACLS), Lakeview Hospital promotes health and wellness through varied programs for the community.

Lakeview Hospital, as part of Lakeview Health, helps fund a program that helps low income individuals obtain free or low cost medication from pharmaceutical companies.

The program funds a prescription assistance counselor who works with individuals to identify assistance programs for which they are eligible. For qualifying participants, an average of 20.4 percent of gross household income is saved by obtaining medications through the Prescription Assistance Program.

Lakeview Hospital is a partner in a senior living community in Stillwater managed by Presbyterian Homes and Croixdale Homes of Bayport. Boutwells Landing has grown to a community that accommodates up to 410 residents with options for independent living, assisted living and memory care. A 107-bed skilled care center is currently being developed as well.

Lakeview Hospital partners with six area church congregations to provide congregationbased health education services. The St. Croix Valley Parish Nurse Program began in 1998 as a partnership between area faith communities and Lakeview Hospital to provide physical, emotional and spiritual care for parishioners.

Parish nurses act as health educators, health counselors and volunteer coordinators. When parishioners require medical attention, parish nurses are available to help coordinate the necessary resources.

Lakeview Hospital partners with five other hospitals in the metro area to provide temporary health insurance coverage to low income people who do not have health insurance.

Portico HealthNet provides access to primary The Journal of the East and West Metro Medical Societies

and preventive care while assisting enrollees in transitioning to permanent health insurance, such as MinnesotaCare.

Born to Read focuses on the value of reading aloud to young children and the importance of early learning on brain development. Before parents leave Lakeview Hospital with their newborn, an Early Childhood and Family Education instructor visits with the family, providing educational materials and a children’s book to take home.

Teddy Bear Clinic is a unique educational

program designed to help kindergarteners become familiar with a hospital setting. Children learn about the emergency department, the ambulance and ways to stay healthy and safe.

During the 2007-2008 school year nearly 900 area children participated.

Lakeview Hospital collaborated with the St. Croix Valley Recreation Center and the Stillwater Area School District to promote active lifestyles for area residents. Step it Out for

Health offers indoor walking venues and special fitness events for community members.

The Stillwater Area School District Wellness Center (located in the Stillwater Area High School) provides educational and preventative services to youth, families and staff, encouraging them to make healthy lifestyle choices. Mental health, chemical health, nutrition and health education services are provided. Lakeview Health is a major contributor to the Center, and played a major role in its creation and opening.

In 2005, Lakeview Hospital was awarded the Community Health Commitment award for small hospitals by the Minnesota Hospital Association. This award recognizes community programs that hospitals provide to address broader health challenges. The award was given in recognition of Lakeview Hospital’s role in opening the Wellness Center at the Stillwater Area High School. The (Continued on page 22)

Case Studies in Financial Planning When you’re ready to retire will your financial plan be ready too?

A workshop presented by: Steve Finkelstein, C.F.P. and Joel Greenwald, M.D., C.F.P. Saturday, September 27, 2008 or Saturday, October 18, 2008 | 9:00 to 11:30 a.m.

Location: Minnesota Medical Association | 1300 Godward Street NE, Suite 2500 | Minneapolis, MN 55413 To register for one of these complimentary workshops, please contact Vicki Westling at 612/362-3764 or vwestling@mnmed.org.

Some advisory services are offered through Sterling Retirement Resources.

Registered Representatives offering securities and some advisory services through FINANCIAL NETWORK INVESTMENT CORPORATION Full Service Broker Dealer, Member SIPC Financial Network is not affiliated with Sterling Retirement Resources

MetroDoctors

The Journal of the East and West Metro Medical Societies

September/October 2008

21

Creating a better experience for your caregiver patients: 9 Real Caring 9 Real Benefits 9 Good Practice Learn how IHL can provide your practice with an easy to use solution for your caregiver patients.

952-746-1280 www.ihlcaregiver.com

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September/October 2008

Lakeview Hospital (Continued from page 21)

Wellness Center was built on a community partnership and shared responsibilities with the Stillwater Public Schools, Washington County and FamilyMeans.

Just as Lakeview Hospital is centered on meeting the health care needs of its community, Lakeview has a long legacy of receiving support from the community, beginning in 1880 with the formation of the County Benevolent Society to promote the building of a hospital in Stillwater. In 2007, Lakeview Foundation completed a successful $20 million capital campaign. This campaign supports: • The new 90,000 square-foot Stillwater Medical Group clinic at Curve Crest and the renovation and expansion of a specialty service clinic.

• The Lakeview Heart Center, in partnership with St. Paul Heart and United Hospital, which provides cardiovascular care delivered in one convenient location.

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• The 17,500 square-foot Stillwater Medical Group Women’s Center with a full range of services, from preventative care exams to in-office procedures including pregnancy care, osteoporosis screenings, breast health and infertility care, designed to meet the needs of women through all stages of life.

• Future expansion of the emergency department, including doubling the number of patient treatment areas.

• Forthcoming creation of an Oncology Center with facilities and staff dedicated to the diagnosis, care and treatment of cancer.

• Continued integration of latest technology into all facets of the health care system to provide for significant patient care benefits, including improved diagnoses and screenings.

• Funding for land acquisition, so property can be purchased as the need for future health system expansion is identified.

Employees are Lakeview’s most important asset, and they take the privilege of caring for members of the community very seriously.

Based on employee responses to surveys, Lakeview Hospital was recognized as one of Minneapolis/St. Paul Business Journal’s “Great Places to Work” in 2006, 2007 and 2008.

Lakeview Hospital has a low turnover rate for its employees.

Thomson Healthcare, a leading provider of information and solutions to improve the cost and quality of health care, named Lakeview Hospital a winner in the 100 Top Hospitals Benchmarks for Success in the small community hospital category in 2003, 2006 and 2007.

The 100 Top Hospitals identify the nation’s top providers, using the two most recent years of data. These studies benchmark the industry’s management and clinical outcomes. In 2007, Lakeview Hospital was the only metro area hospital to receive this honor. In 2006 and 2007, it was one of only two hospitals in Minnesota to receive the honor, and the only Minnesota hospital in the small community category.

Lakeview Hospital takes pride in its history, its accomplishments and in its commitment to meeting the health care needs of the community it serves. Bringing the Best to You is not only its tagline — it is each provider, employee, volunteer and board member’s goal — each and every day.

The Journal of the East and West Metro Medical Societies

Sharpen Your Policy Skills at MMA Advocacy Rounds

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he MMA, in cooperation with WMMS and EMMS leadership, is offering a new way for members to engage in a dialogue on health care policy. With the Legislative Session adjourned for the year, advocacy on health care policy takes on a new, grassroots form. West Metro and East Metro leaders, as well as local MMA Trustees, will host a series of meetings across the metro area.

This 60-90 minute roundtable will consist of two parts: MMA staff will conduct a short briefing on the 2008 Legislative session; the remaining time will provide an opportunity for dialogue on health care policy as well as other issues, facilitated by a local MMA/EMMS or WMMS leader.

When: September 8 – 7:00-8:30 a.m.

Where: Southdale Hospital – Au Fait Room Speaker: Janet Silversmith, MMA Director of Department of Health Policy When: October 20 – 11:30-12:30 p.m.

Where: Boynton Health – Conference Room 101: Garden Room Speaker: Dave Renner, MMA Director of State and Federal Legislation When: October 24 – 12:00-1:00 p.m.

Where: North Memorial Medical Center – Vance DeMong Room Speaker: Dave Renner, MMA Director of State and Federal Legislation 21727 Metro Dr. Ad

Six Great Opportunities to Participate!

East Metro Locations When: September 3 – 7:30-8:30 a.m.

Where: Stillwater (Lakeview) Hospital – Hewlings Education Center Speaker: Janet Silversmith, MMA Director of Department of Health Policy

More Information: Dennis Gerhardstein, MMA Manager of Physician Outreach, dgerhardstein@mnmed.org. (612) 362-3745.

West Metro Locations

11/22/05

8:43 AM

“Usually these kinds of briefings are a one-sided affair, but this series really broadened the conversation to include the entire group.”

Noel Peterson, M.D.

MMA Southeast Trustee, Olmstead Medical Center

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Crutchfield Dermatology “Remarkable patient satisfaction from quality, service, convenience and excellent results” “Exceptional care for all skin problems” Charles E. Crutchfield III, M.D. Board Certified Dermatologist

When: September 10 – 6:30-8:00 p.m.

Where: United Hospital – St. Lukes Room Speaker: Janet Silversmith, MMA Director of Department of Health Policy When: September 24 – 6:30-8:00 p.m.

Where: St. John’s Hospital–Maplewood Professional Building: Watson Education Center 1&2 Speaker: Dave Renner, MMA Director of State and Federal Legislation

Psoriasis &

Acne Specialist Your Patients will Look Good & Feel Great with Beautiful Skin www.CrutchfieldDermatology.com

MetroDoctors

The Journal of the East and West Metro Medical Societies

1185 Town Centre Drive Suite 101 Eagan, MN 55123

Appointments 651-209-3600 Prompt Appointments via Physician Requests

September/October 2008

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President’s Message

Professionalism in a Changing Environment Peter b. wilton, M.D. Historically, the obligations and expectations of our profession were clear. The physi-

EMMS Officers

President Peter B. Wilton, M.D. President-elect Ronnell A. Hansen, M.D. Past President V. Stuart Cox, M.D. Treasurer Thomas Siefferman, M.D. EMMS Executive Staff

Sue A. Schettle, Chief Executive Officer (612) 362-3799 sschettle@metrodoctors.com Katie R. Snow, Administrative Coordinator (612) 362-3704 ksnow@metrodoctors.com Doreen M. Hines, Manager, Member Services (612) 362-3705 dhines@metrodoctors.com

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cian underwent rigorous training to master the art and science of medicine, and acquire a body of knowledge that was unavailable to the general public. A physician’s duty to care for patients could not be limited to suit the physician’s convenience. In return, society accorded the physician deference in medical decisions, and independence and autonomy regarding medical practice.

I am concerned that the ethical foundations of our profession are being undermined. Many societal forces are changing the framework in which we practice. Among these are the public availability of medical knowledge, increasing physician regulation by government and corporate institutions, the trend away from independent medical practice to corporate employment, and limitation by training institutions of residents’ obligation to patients. These changes are occurring against the backdrop of the commercialization of medicine. The large sums of money in the medical system, and the many opportunities to profit from practice, act as barriers to our being true fiduciaries for our patients. This is reflected in the current vocabulary of medicine, increasingly framed in the jargon of commerce — doctors are “health care providers,” patients are “customers.”

It appears that we are inexorably changing from a profession to a business. It is noteworthy that until 1980 (when antitrust concerns forced a change in its ethical code) the AMA maintained that the practice of medicine should not be commercialized, nor treated as a commodity. It is my contention that medicine is not a business, nor should it be. The ideology of a profession involves social benefit rather than profitability.

What does professionalism mean in this new environment? Professionalism is difficult to define, though elements of professionalism are identifiable. Chief among these is altruism — placing the patient’s welfare above our own. We operate on patients with chronic hepatitis, despite risk to ourselves; we care for patients with infectious diseases, though we might fall ill; and traditionally we have cared for patients regardless of time of day or ability to pay. Other essential characteristics including honor, integrity, duty and excellence are necessary, but not sufficient. A profession requires extensive study to acquire a specialized body of knowledge and skills used for the good of the public; professional practice involves transformative interchanges that affect the lives of our patients rather than financial transactions; and professionals are expected to comport themselves so as to reflect honor on their calling.

Can we protect medicine from becoming a commercial enterprise? The essence of professionalism occurs at the clinical interface. If we truly care about our patients and their welfare, all else follows. Although the context of the doctor-patient relationship may change from an authoritarian to a more collaborative model, patients know when physicians care about them, and accord them — and the profession in general — professional privileges in proportion to that concern. In addition to this fundamental tenet, doctors must remain mindful of our private and public persona; we are judged by our behavior, which reflects credit or dishonor on our profession.

We must avoid conflicts of interest that could undermine public and individual trust in physicians. Physicians should defend the house of medicine when it is attacked, and advocate for the profession as well as for our own practices. We must support reforms that enhance the standing of the health care system as a service provided to all. If we are able to do all this, our profession will weather the changing environment, and the practice of medicine will continue to be a privilege and a pleasure.

MetroDoctors

The Journal of the East and West Metro Medical Societies

Advance Care Planning Informational Session

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Next Steps: Board president from EMMS Foundation, Dr. Kent Wilson, and Sue Schettle, CEO of EMMS will convene a meeting of interested parties for the purpose of developing community-wide consensus on next steps related to this project. We will take into consideration the Respecting Choices® model as proposed by Dr. Hammes. Stay tuned.

To learn more about this project, please contact Sue Schettle at (612) 362-3799 or e-mail her at sschettle@metrodoctors.com.

Attendees registering for the conference August 5.

Keynote speakers Kent Wilson, M.D. and Bud Hammes, Ph.D.

Over 40 people attended representing 25 organizations.

Save the Date “Medical Market Reform That Could Actually Help Somebody” Speaker: Stephen T. Parente, Ph.D. • • • •

Associate Professor, Department of Finance, Carlson School of Management, University of Minnesota Adjunct Faculty, Department of Health Policy and Management, Johns Hopkins University Director, Medical Industry Leadership Institute, Carlson School of Management, University of Minnesota Principal, Health Systems Innovation (HSI) Network, LLC

Friday, November 21, 2008 7:30 a.m. – 8:30 a.m.

United Hospital John Nasseff Medical Center (formerly the Heart and Lung Center) Miller and St. Luke’s Conference Rooms, 255 N. Smith Ave., St. Paul, MN 55102, Lower Level Sponsored jointly by the East Metro Medical Society and the medical staffs of United Hospital and HealthEast Hospitals.

The public is welcome. CME and CEU credits are available.

Please contact Deborah Egger, Continuing Medical Education Specialist, at (651) 241-8821 with questions.

The Journal of the East and West Metro Medical Societies

September/October 2008

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Metro Medical Society

MetroDoctors

demonstrated clear success in increasing the prevalence of planning, making plans available when needed, and honoring plans. The East Metro Medical Society’s role in this project is to act as a convener and coordinator.

It was the consensus of the group that assembled on August 5 that there are indeed barriers to moving a project of this magnitude forward, yet there are far more benefits that outweigh the barriers.

East

n August 5, 2008 at the University of Minnesota’s Continuing Education and Conference Center in St. Paul an exploratory conference on advance care planning was held and attracted nearly 40 participants representing over 25 organizations. The meeting was hosted by the East Metro Medical Society Foundation. Speakers included Dr. Kent Wilson, EMMS Foundation President and Dr. Bud Hammes, Ethics Consultant and Director, Respecting Choices® from the Gundersen Lutheran Medical Foundation. The purpose of the three-hour conference was to explore ways to make an advance care planning system more effective in honoring patients’ preferences by developing a common, community approach.

This idea of a community approach to advance care planning came forward to the EMMS Foundation by constituent members about one year ago. Since then research and many hours of meetings with key stakeholders has occurred by EMMS staff and members of the EMMS Foundation board of directors. The idea for the community-wide conference was presented to the Foundation’s parent board, EMMS, for discussion and approval. After thoughtful debate, the board supported the idea for a conference as a mechanism to gauge the interest level of the community. Based on the attendees and the discussion at the conference, we believe there is indeed an interest in this issue. The EMMS will likely partner with the WMMS on this project so that we can offer a metro-wide option.

We know that hospitals and health care systems are compliant with the current standards and regulations regarding advance directives. Improvement in both understanding and honoring patients’ values and goals could be enhanced and could be achieved through a community effort. Such improvement has the opportunity of providing more respectful care and better utilization of health care resources at the end-of-life.

The conference outlined the Respecting Choices® program which originated in La Crosse, Wisconsin and is now employed regionally, nationally and internationally. This program has

Dakota County Smoke-Free Communities Partnership

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

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he Dakota County Smoke-Free Communities Partnership has just kicked off its fourth year. The Partnership continues to engage community members, elected officials, and East Metro Medical Society physicians in its activities, including a recent “Smoke-Free St. Paul Saints,” game in honor of Asthma Awareness month in May 2008. The community fairs and festivals season is also in full swing. The Partnership has been at the Eagan 4th of July FunFest, the Beyond the Yellow Ribbon 5K in South St. Paul, the Hastings Rivertown Days Family Fun Run, and the Eagan Relay for Life. The Partnership also helped host the first-ever “Honoring Our Volunteers” Day at the Dakota County Fair on August 10.

The Partnership welcomes summer interns, Charlie Rybak and Lindsay Johnson. Charlie is a sophomore at George Washington University in Washington, DC studying Political Communication. Lindsay has just graduated from

Charlie Rybak

Lindsay Johnson

Public and Community Relations Associate, John Fineberg, and community volunteer, Danielle Waldschmidt, educate baseballlovers about smoke-free air and healthy decisions at the St. Paul Saints game.

St. Mary’s University of Minnesota with a degree in Public Administration and Policy Analysis.

Both are great assets to the Partnership, serving as the face of the smoke-free movement at local community fairs and festivals, as well as working specifically on new projects for the fall which will focus on college campus organizing and engagement in non-partisan election activities for the 2008 season.

This fall, the Partnership will have an art contest along with other creative ways to commemorate the one-year anniversary of the Freedom to Breathe Act. Check the Partnership Web site at www.smokefreedakota.org for updates on activities and opportunities to become engaged.

The Partnership welcomes physician advocates and spokespersons to become involved with their efforts throughout Dakota County. Please contact Diane Tran, Project Coordinator, at dtran@smokefreedakota.org or (651) 789-0036.

EMMS Submits 10 Resolutions

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MMS will be bringing at least 10 resolutions to the Minnesota Medical Association Annual Meeting September 17-19, 2008 at the Crowne Plaza Hotel-Riverfront in St. Paul. The resolutions cover a variety of topics including asking the MMA to study the rapid changes taking place in medical insurance and care delivery sectors to asking the MMA to address the methods and processes by which physician input is obtained on advocacy issues.

The resolutions titles are listed below. The full resolution can be viewed on our Web site at www.metrodoctors.com. Then click on East Metro Medical Society and EMMS Resolutions.

1. MMA Advocacy Outreach 2. Study Capitation Effects 3. MMA Study of System Reforms

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September/October 2008

4. MIIC Data Repository for Immunization History on Physicians 5. Clarity from Joint Commission on Credentialing and Privileging Low Volume Physicians 6. High Deductible Health Plans (HDHPs) for the Public Sector 7. Educating Physicians and Patients about the Mental Health Parity Act of 2007 8. Major Depression, Evaluation and Treatment 9. Commendation of Frank Indihar, M.D. 10. Transparency in Risk Sharing Contracts These resolutions, along with others from across the state, will be discussed and voted on at the upcoming MMA annual meeting. If you’ve not attended an annual meeting in the past, please consider doing so. Call Katie Snow at (612) 362-3704.

MetroDoctors

Active Lori R. Arnesen, M.D. University of Minnesota Medical School Dermatology/Internal Medicine Dermatology Consultants, P.A. James M. McGreevy, M.D. University of Washington School of Medicine General Surgery St. Paul Surgeons, Ltd. Tanya A. Sale, M.D. University of Minnesota Medical School Dermatology Dermatology Consultants, P.A. 1st Year Active Practice Cortney D. White, M.D. University of Iowa College of Medicine Dermatology Dermatology Consultants, P.A.

In Memoriam SAMUEL W. HALL, M.D., died on July 19 at the age of 64. Dr. Hall earned his medical degree from Northwestern University. He served in the U.S. Navy as a lieutenant in the Medical Corps. Dr. Hall completed his residency at the University of Minnesota.

He was board certified in internal medicine, occupational medicine, and medical toxicology. He practiced 24 years at Regions Hospital. A founder of the statewide poison control services in Minnesota, Dr. Hall helped craft the legislation which established the Minnesota Regional Poison Center in 1982, the first poison center in the state, and where he served as its medical director for 17 years. He was serving as the Director of Occupational Health Services for the Minneapolis V.A. and a founding partner of Damarco Solutions, LLC. Dr. Hall also volunteered at the Neighborhood Involvement Program Clinic in Minneapolis.

He joined EMMS in 1978.

The Journal of the East and West Metro Medical Societies

2008 East Metro Medical Society Annual Community Service Award

North Oaks Country Club EMMS Annual Meeting

Nomination Form

Metro Medical Society

Presented to Recipient Thursday, January 22, 2009

East

Nomination Deadline Monday, December 8, 2008

How to Nominate a Colleague Email the name of the physician you wish to nominate to East Metro Medical Society CEO, Sue Schettle at sschettle@metrodoctors.com or call 612-362-3799. Include a description as to why you are nominating this physician, including specific community activities above and beyond his/her professional medical work.

You may also use a separate page and fax the above information to 612-623-2888.

Award Criteria • •

•

Nominee must be an active or retired EMMS physician member Service(s) by candidate must be voluntary in nature, performed locally, and should include one or more of the following elements: (a) leadership and development of special community projects or programs; (b) participation in civic or service organizations/ groups; (c) participation in educational, charitable, church, or other projects; or (d) public offices held.

EMMS presidents are ineligible for the award until two years after the completion of his/her term of office.

MetroDoctors

The Journal of the East and West Metro Medical Societies

Sponsored by

September/October 2008

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CHAIR’S REPORT Geriatrics: Who Needs It? Anne M. Murray, M.D.

WMMS Officers

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. WMMS Executive Staff

Jack G. Davis, Chief Executive Officer (612) 623-2899 jdavis@metrodoctors.com Jennifer Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Assistant Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Kathy R. Dittmer, Executive Assistant (612) 623-2885 kdittmer@metrodoctors.com

Earlier this year at a geriatric nephrology conference sponsored by the National Institute on Aging, the chief of geriatrics of another large Big 10 land grant university asked me why the medical school at the University of Minnesota has no geriatrics division. Turns out he grew up in Minnesota and is embarrassed for us that we have no geriatrics. “Just plain inexcusable” were his words. “We used to” didn’t cut it.

The history of geriatrics in Minnesota is not a rosy one. The University did have a geriatrics division until about eight years ago, when it was dissolved due to financial constraints; the geriatric clinic was losing too much money, among other losses. Valuable geriatric faculty were recruited

by Johns Hopkins University, displaced to other parts of the University or dispersed elsewhere.

Then about six years ago, “Aging” was designated as a priority research area in a strategic planning process organized by the previous dean of the medical school and others. An enthusiastic group of researchers in aging and geriatric clinicians was gathered and energized. We were told there would be funding to jump-start aging research and a potential Institute on Aging. In the end, the money ended up going to sexier priorities such as stem cell research. The geriatrics division at the Mayo Clinic also met its demise years ago, primarily due to poor Medicare reimbursement for geriatric primary care, although they still maintain a geriatric fellowship.

Both the University and Mayo, however, have been shortsighted in their financial approach to clinical geriatrics. A financial analysis of geriatrics clinical operations at the University of Arkansas led by Dr. David Lipschitz documented the “trickle down factor” of geriatrics. Each dollar spent on a geriatric patient entering their health system generated $17 downstream via laboratory tests, imaging, subspecialty referrals, and hospitalizations. Furthermore, now that the “medical home” concept is finally gaining ground and promising greater than the current abysmal reimbursement for primary care, the negative image of geriatrics as a business model could be about to be turned on its head.

Leaders of successful geriatrics programs at UCLA, Wake Forest University and the University of Pittsburgh understand that there are two critical components needed to “grow” geriatrics in an academic institution: a geriatrics division housed in the medical school paired with a center for translational aging research, or an Institute on Aging. Without the clinical care core provided by the faculty of a geriatrics division, there can be no translational geriatric research. An Institute on Aging led by a geriatrician is the necessary fulcrum that will bring interdisciplinary investigators from across the University together, and in turn be capable of generating millions in funding from the National Institutes of Health, Hartford Foundation and others. Without this research funding a geriatric division is not sustainable.

There is no question that the need for increased geriatrics training and clinicians in Minnesota has gone beyond dire. How many Minnesotans are struggling to find a physician to care for an aging parent with complex comorbidities and memory problems? The primary role of the geriatrician is to serve as the medical home for complex, frail geriatric patients. But there will never be enough geriatricians to care for the burgeoning aging population. Instead, we need to implement geriatric training in every health science curriculum to train other providers throughout the health care spectrum. In May 2008 the Institute of Medicine released a White Paper that outlined the necessary steps to achieve this goal nationally. Without it, the current shortage of nursing aids, nurses, nurse practitioners, physical therapists, social workers and geriatricians will only explode.

(Continued on page 30)

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MetroDoctors

The Journal of the East and West Metro Medical Societies

Time to Celebrate Partnership

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highlighting the partnership and our efforts to bring Freedom to Breathe into Minnesota.

St. Francis provided staff support, office space and physician support in Scott and Carver counties during late 2006 through the spring of 2008.

WMMS could not have been successful in our policy efforts without the dedicated commitment of St. Francis and their physicians.

The appreciation breakfast was attended by over 70 staff.

Active John T. Chow, M.D. Endocrinology Clinic of Minneapolis, PA Endocrinology Grant Cravens, M.D. Metropolitan Anesthesia Network, LLP Anesthesiology Phillip M. Ecker, M.D. Uptown Dermatology and Skin Spa, PA Dermatology

W e st M e t r o M e d i c a l S o c i e t y

ith the successful completion of the Communities for Healthy Air contract with Blue Cross Blue Shield’s Center for Prevention, the West Metro Medical Society celebrated our partnership with St. Francis Regional Medical Center with a staff appreciation breakfast on Thursday, June 26, 2008.

WMMS President-Elect, Dr. Ed Ehlinger presented Kathy Schultz, respiratory therapist, smoke-free coalition member and St. Francis employee, with a plaque of appreciation

Welcome New WMMS Members

Dariusz W. Gawronski, M.D. Minneapolis Clinic of Neurology Neurology Cassandra C. Harrison, M.D. Regency Hospital of Minneapolis Internal Medicine Kristine Hentges, M.D. Park Nicollet Clinic Family Medicine David S. Josephitis, D.O. Medical Hair Restoration, Minneapolis Transplantation Surgery Gregory A. Plotnikoff, M.D. The Institute for Health and Healing, ABNW Hospital Internal Medicine/Pediatrics From left: Jennifer Anderson, project coordinator; Tamara Severtson, mission integration coordinator; Kathleen Schultz, smoke-free coalition member; Edwin Bogonko, M.D., WMMS board member; and Edward Ehlinger, M.D., WMMS president-elect.

Senior Physicians Association

S

enior Physicians Association welcomed Patricia Porter on June 10. Ms. Porter is program director at the Minnesota Medical Foundation and oversees the professional and administrative fundraising staff, prospect management and research giving.

Join us on Tuesday, September 16 at 11:30 where our guest will be Senator David Durenberger. He will speak to us about Health Policy and Physician Leadership.

For additional information, contact Kathy Dittmer at (612) 623-2885 or kdittmer@metro doctors.com.

MetroDoctors

Joshua J. Riff, M.D. Target Corporation David A. Romans, D.O. Emergency Physicians Professional Association Emergency Medicine Sandra M. Skovlund, M.D. Park Nicollet Clinic Otolaryngology Gregg A. Teigen, M.D. Obstetrics & Gynecology West, PA Obstetrics/Gynecology John D. Zurn, M.D. Metropolitan Anesthesia Network, LLP Anesthesiology

Edward Spenny, M.D. poses with Patricia Porter, Minnesota Medical Foundation Program Director.

The Journal of the East and West Metro Medical Societies

Resident Physician Julia D. Jacobson, M.D. HealthPartners Occupational Medicine September/October 2008

29

Chair’s Report (Continued from page 28)

To answer this call, a geriatric education program has been proposed to incorporate creative geriatric curriculum across the University’s Academic Health Center and affiliated campuses. Geriatric training would extend from the first year of medical school through completion of primary care, medical and surgical residencies, and include nursing, pharmacy and other affiliated health science programs. The lauded geriatric fellowship program at Hennepin County Medical Center is a designated model for other clinical geriatric fellowships, but only produces two geriatricians a year. It could be expanded into a citywide fellowship, and lengthened to two or three years, to include the research experience critical for the development of academic geriatricians.

On the research side, the Scientists in Aging Research, a group of nationally renowned basic and clinical scientists at the University, is poised to take part in an eventual Institute on Aging.

The Center on Aging, housed in the School of Public Health, and the new Minnesota Hartford Center for Geriatric Nursing Excellence, could also play pivotal roles.

Dean Deborah Powell of the medical school recognizes the importance of geriatrics and is committed to developing a geriatrics division. There are also encouraging developments and interest brewing in establishing an Institute on Aging. However, the University and the Minnesota community need to find ways of supporting these initiatives now. They need to provide funding to create an endowment that will enable a geriatrics division and Institute on Aging to eventually become self-sustaining.

On another note, as my term ends, it has been a real privilege to serve as chair of the West Metro Medical Society over the past year. I have benefitted greatly from the guidance of our CEO Jack Davis, and inspired by the tremendous commitment of the West and East Metro Medical Society officers and staff to the public health of Minnesota. We look forward to the dedicated new leadership that will take over in October — Drs. Richard Schmidt as chair, and Edward Ehlinger as president. Thank you all for the opportunity to serve our membership.

Minnesota Epilepsy Group is the largest and most comprehensive epilepsy program in the Midwest. As a regional referral facility, we are the recognized leader in treating epilepsy and other seizurerelated conditions in patients of all ages, from infants to the elderly.

Adult Epileptologists Deanna L. Dickens, MD Julie Hanna, MD El-Hadi Mouderres, MD Patricia E. Penovich, MD Pediatric Epileptologists Jason S. Doescher, MD Michael D. Frost, MD Frank J. Ritter, MD

www.mnepilepsy.org 225 Smith Avenue N. Suite 201 St. Paul, MN 55102

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September/October 2008

Functional Neuro-Imaging Wenbo Zhang, MD, PhD

Appointments (651) 241-5290

MetroDoctors

In Memoriam ANDREW R. “ANDY” AGEE, M.D. died recently at the age of 70. He graduated from Howard University College of Medicine, Washington and completed his residency at the University of Minnesota. Dr. Agee was the first black practicing OB/GYN in Minneapolis.

He was a U.S. Navy veteran and served in Vietnam. He was affiliated with North Memorial, Abbott-Northwestern and Fairview Southdale Hospitals and he was also in private practice in Edina.

ROBERT H. BUGENSTEIN, M.D., passed away peacefully in his sleep on July 16, 2008 at the age of 80. Born and raised in Cedar Rapids, Iowa, he graduated from the University of Iowa College of Medicine. Dr. Bugenstein was a pediatrician at Bloomington Oxboro Clinic for 42 years. He was a longtime resident of Bloomington and an avid supporter of the arts. He was a dedicated child advocate and volunteered as a guardian ad litem for children in need.

NIKOLA KOSTICH, M.D., died July 4, 2008 at the age of 77. He was born in Belgrade, Yugoslavia. He graduated from Medicinski Faultet Universiteta U beogradu, Beograd. Dr. Kostich was a leading pathologist at Abbott Northwestern and United Hospital.

RICHARD J. “DICK” SODERBERG, M.D., passed away peacefully on July 27, 2008. He was 81. He grew up in Chicago, served in World War II, and returned to graduate from Bowling Green State University. He earned his Medical Degree at the University of Illinois.

He moved to Minnesota in 1955, accepting a general practitioner position in Grand Marais, MN in 1956. In 1962 he started a residency in radiology at the VA Hospital in Minneapolis and moved to the Twin Cities. Dr. Soderberg had a successful career at the former Eitel Hospital, the Nicollet Clinic, and Consulting Radiologists. He retired in 1994.

The Journal of the East and West Metro Medical Societies

ALLIANCE NEWS dianne fenyk

Life as Members of Minnesota’s Medical Family

Minnesota for his residency (could it really have been that long ago?!), we were pleasantly surprised by the warm welcome we received from the University of Minnesota Medical School. When he decided to open a solo practice, we were amazed by the support local physicians gave him. Recently, he closed his practice and returned to the University, where he is now full-time on the faculty of the Department of Dermatology. Once again, the support has been overwhelming — and deeply meaningful.

Why do I tell you this? Because I believe it’s indicative of the strength and spirit of the medical family in the Twin Cities and Minnesota.

The Alliance is part of that medical family, too. The work of the Alliance is an extension of the work physicians do — we advocate for better health for all in our communities; we advocate for health and medicine — friendly legislation so you can spend your time helping your patients and we raise funds to help lessen the debt of those in medical school. We are your partners. When I joined the Alliance I was welcomed into the family of medicine as if I’d always been a member — your spouses welcomed me just as you welcomed my physician husband.

What I’m leading up to is a deeply heartfelt thank you to each of you for the support you have given me over the past several years as I became involved with the AMA Alliance.

The work we do in the West Metro Medical Society Alliance is a reflection of what is done nationwide to ensure better health for all Americans. The interest you and your spouse have shown for Alliance efforts has kept me going because I know you understand what it means to make a difference in the world.

MetroDoctors

The only way I could ever repay you was to honor the name of the West Metro Medical Society and its Alliance wherever I went and to tell the country that the medical community here reflects the population of Minnesota. The members of WMMS and WMMSA have an incredible sense of doing the right thing and a strong work ethic; they are intelligent, proactive and honorable. I knew I was representing the finest of physicians and their spouses; it was a privilege I did not take lightly.

One of the most tangible ways to show my gratitude and respect for your work as physicians was to work toward eliminating smoking among youth. The AMA Alliance is a leader in this area through the Screen Out! project.

This initiative works to change to an “R” rating any film that has smoking in it and is aimed

at a youth audience. Studies show that many young kids smoke their first cigarette simply to emulate movie characters. WMMS is justifiably proud of its successful efforts to make the Twin Cities smoke-free. Unfortunately, the fight is not over. Please go to www.screenout.org to help ensure today’s young people are protected from on-screen smoking.

I have enjoyed representing the WMMS Alliance — I hope you realize how proud I was to represent you, too. I promise to continue working toward better health for all in the Twin Cities — and to welcome every eligible member of the family of medicine as you have so kindly done for John and me during our happy life in this family.

Thank you from the bottom of my heart!

West Metro Medical Society Alliance Opening Event FRIDAY, OCTOBER 3, 2008 Join WMMS Alliance members at the Minnesota Zoo for their 2008 Opening Event. A highlight of the day will be a tour of Russia’s Grizzly Coast exhibit. This exhibit is a first, featuring the region, landscapes, and animal combinations of the Russian Far East. Russia’s Brown Bears are the “cousins” of America’s western grizzly and are among the largest in the world.

9:30 a.m. — Gather at the main restaurant inside the Zoo for coffee and treats 10:00 a.m. — Tour (Marlene Ellis, Zoo Volunteer/WMMSA member will be our guide) 12 Noon — Lunch at the Zoo Cost: Adults–$20 Age 65 or older–$15 Ages 3-12–$10 Under 3–Free Payable to WMMSA at the event (Includes Zoo pass and lunch) **Handicap parking and wheelchairs available RSVP by Friday, September 26 to: Kathy Dittmer, WMMS at (612) 623-2885, or kdittmer@metrodoctors.com.

The Journal of the East and West Metro Medical Societies

September/October 2008

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W e st M e t r o M e d i c a l S o c i e t y

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hen John and I moved to

Please also visit www.metrodoctors.com for Career Opportunities.

Apple Valley Medical Clinic A full service, independent family practice clinic serving the fast-growing south suburbs of the Twin Cities, has a fulltime opening for a BC/BE family physician. In addition to our family practice program with 14 family physicians, we operate a unique 24/7 urgent care program, occupational health services, and offer convenient on-site access to medical imaging (CT, MRI, US, X-Ray & Mammography), a pharmacy, physical therapy, and full array of medical specialties on our modern campus.

Our practice is physician-owned and governed.

Please e-mail your resume to:

aberry@applevaleymc.com

For more information contact: Adam Berry, administrator 952-953-9285

Career Opportunities

Career oPPortunItIes

Introducing the “Career Opportunities” section of MetroDoctors!

A great avenue for professionals to learn about job opportunities AND a perfect place for recruiters to promote openings!

Recruiters, call for our special recruitment rate.

Betsy Pierre, ad sales 763-295-5420 betsy@pierreproductions.com

Great Partners, Great Staff, Great Patients, Excellent Income & Lifestyle Family HealthServices Minnesota, P.A. is looking for several Board Certified/Eligible Family Physicians to fill fulltime, part-time or shared positions.

Join our Independent Group of 64 physicians serving 13 clinic sites.

FOR MORE INFORMATION PLEASE CONTACT: Paul Berrisford, 2025 Sloan Place, Suite 35, St. Paul, MN 55117 651-772-1572 • email: pberrisford@fhsm.com

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September/October 2008

MetroDoctors

The Journal of the East and West Metro Medical Societies

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BurnetBirkeland.com 612.925.8405 Discounts by Physicians for Physicians � You do not need to be an EMMS member to participate • • • •

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a subsidiary of East Metro Medical Society

Visit www.metrodoctors.com/services.cfm to read more about ways that you can save through our business partnerships.

inforMED GROUP

Sound Advice. Solid Results.

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Call EMMS at 612-362-3799 for details.

2008 Fall CME Courses www.cmecourses.umn.edu

PRIMARY CARE

PSYCHIATRY FOCUS

Update in Critical Care September 11-12 Recent research and updates on issues, barriers, and strategies for best practice.

Psychiatry Review: Pleasure and Motivation: Addiction, Impulsivity, and Compulsivity NEW DATES! September 18-19 Recognize addictive, compulsive, and impulsive behaviors in a clinical setting, and offer viable treatment options

Obstetrics, Gynecology and Women’s Health Seminar September 29-30 Education, shared research findings, and innovations in women’s health.

Twin Cities Sports Medicine October 3-4 Updates on the evolving field of sports medicine through expert talks, panel discussions, and hands-on workshops.

Geriatric Orthopaedic Trauma Summit October 9-11 Clinically-important topics about the geriatric fracture patient.

Practical Dermatology: Basic & Advanced Topics for Primary Care October 24-25 (Nisswa, MN) 50 of the most common skin disorders seen in primary care.

Emerging Infections in Clinical Practice and Public Health November 14 Infection control forum for clinicians and public health officials.

Heart Failure: The Update November 14-15 State-of-the-art review of the pathophysiology and treatment of heart failure.

Internal Medicine Review November 19-21, 2008 Experts in various sub-specialties share updates on current topics.

Office of Continuing Medical Education 612-626-7600 or 1-800-776-8636 www.cme.umn.edu email: cme@umn.edu

Schizophrenia Treatment: Bridging Science to Clinical Care October 6-7, 2008 Up-to-date information on research implications and application for clinical practice.

Borderline Personality Disorder: Research Across The Lifespan October 18-19 Latest education and access to the most current research on this disorder

ALSO OFFERED Glaucoma Symposium September 13 Provide practicing ophthalmologists with latest advances in glaucoma diagnostics, overview of therapeutic options, and better understanding of practice management issues.

SimPORTAL Workshop: Developing Endoscopic Techniques for Thoracic Diseases October 4 Thoracic surgeons and pulmonologists will learn invasive endoscopic techniques that are challenging, rarely taught programs, and novel in their approach, technology, and application E. T. Bell Pathology Symposium November 7 Practical, comprehensive coverage of a wide variety of topics, highlighting a specific theme each year.