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Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

CONTENTS VOLUME 8, NO. 6

NOVEMBER/DECEMBER 2006

2

LETTERS

3

Reducing the Harm of Influenza: The Compelling Case for Universal Pediatric Influenza Vaccination

6

FEATURE

Gubernatorial Candidates Respond to Questionnaire on Health Care Issues

9

PHYSICIAN’S SOAP BOX

Let the War Begin

10

COLLEAGUE INTERVIEW

Terril H. Hart, M.D.

12

Classified Ads

To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of HMS or RMS.

13

What Does the Surgeon General’s Report on Secondhand Smoke Mean for Physicians?

15

MinuteClinic Offers Patient-Centered Care as Complement to Twin Cities Primary Care Providers

17

Minimially Invasive Spinal Fusion

Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: bauerfamily@earthlink.net.

19

Index to Advertisers

20

2006 MMA House of Delegates HMS and RMS Resolutions Report

25

Members in the News

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

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

MetroDoctors

RAMSEY MEDICAL SOCIETY

26 27 28

President’s Message RMS In Action Save the Date/Connections Mentoring Program/ In Memoriam/Meeting with Congresswoman McCollum

Photo by Ann Marsden

Physician Co-editor Y. Ralph Chu, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio

HENNEPIN MEDICAL SOCIETY

29 30 31

Chair’s Report

32

HMS Alliance

In Memoriam Nancy Bauer Rejoins HMS/Jennifer Anderson Joins HMS/ Senior Physicians Association/Alcohol Use Initiative

The Journal of the Hennepin and Ramsey Medical Societies

On the cover: Dr. Terril Hart discusses caring for the Native American Community and health care services in underserved communities.

Article begins on page 10.

November/December 2006

1

LETTERS

I

appreciate that signed articles may not reect the ofďŹ cial position of HMS and RMS. I would like to submit my thoughts as a considerate response to “Physicians Values and Clinical Decision Making,â€? July/Aug. 2006.

I’m not sure why HMS and RMS need ethical reminders from the AMA. The authors of this article raise a number of ethical concerns that are not conclusively settled in medicine or elsewhere or by their article.

The certainty of their conclusions should remind us of the postulates of Emil Durkheim, father of sociology, who said that society can tolerate only so much deviancy before what was previously thought deviant is now considered normal.

Their reference to values is confusing. “Doctors values,� “patient values.� Can we project Taliban values, Al-Quaida values, or that there is no acceptable “value�? The author’s secular progressive values would preclude any suggestion of absolute or transcendent values. It appears that secular values are really opinions or preferences rather than norms or standards.

Whether one is a homophobe or a homophile, it is a given that people have rights

wrong� (?Churchill). I believe it was Freud that cautioned his students “try not to treat sick people.�

If a patient presents to a doctor and relates that each morning he religiously eats the editorial page of the New York Times, should the doctor accept his behavior and, in the interest of diversity and not being “judgmental,� suggest he should alternate with the editorial page of the Wall Street Journal?

I suspect most people would accept that the NYT has credibility, but I’m not sure about its nutritional value. “Counseling gay patients to change‌.is poor public health policy.â€? This concerns a subgroup that has a 20-year deďŹ cit in life expectancy and a disproportionate incidence of HIV, Hepatitis C and STDs. Could this be the objective for the pursuit of happiness? When I left practice in 1989 there had been eight reports of transmission of HIV to physicians/nurses due to needle stick injury.

OSHA/NIOSH recently reported that 800,000 needle stick injuries occur per year.

What would be a “good public policy?�

as human beings not because of their behavior. I take it that the pejorative references to “religious ideology, Leviticus and threats of punishment in the after life� preclude any moral basis for discussion of homosexual behavior.

Even secularists would have to grant that life is fuller because of an appreciation of natural law. Nature does not provide any normal outlet for expression of homosexual behavior. Heterosexual behavior is complimented by nature. The vagina has an acid pH resisting bacterial growth and provides lubrication to facilitate coitus. The anal rectal pH is alkaline to promote bacterial growth and there are no lubricant glands to support sexual activity. “Safe sex,� or otherwise, is foreign and damaging to these tissues.

The authors are a bit liberal with HIV statistics. The last time I looked, HIV in this country was predominantly homosexual.

We do not compare our TB statistics with third world countries, why HIV? It’s a bit of a stretch to compare homosexual behavior with being left-handed. Where are the Mendelian ratios?

As for the American Psychiatric Association, “wrong is wrong even if everybody is

Thomas W. Votel, M.D., FACOEM drvotel@ergodyne.com

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The Journal of the Hennepin and Ramsey Medical Societies

Reducing the Harm of Influenza The Compelling Case for Universal Pediatric Influenza Vaccination

A

ACCORDING TO THE Centers for Disease Control, an estimated 36,000 people in this country die each year as a result of influenza.1,2 This has nothing to do with “avian flu,” but due to the yearly wave of influenza A and/or B that spreads across this country. The dangers of this virus are particularly acute beginning in the late fall and concluding in late winter/ early spring. This number of deaths seems to be fairly consistent, in spite of expanding efforts to vaccinate and protect those individuals most at risk for complications and mortality from influenza. The most vulnerable are children under 2, adults over 65 and those individuals with various long-term health conditions.1 36,000 deaths per year is on the order of magnitude of other significant health issues that we spend a lot of time and resources trying to reduce. Motor vehicle accidents cause 43,000 deaths per year,3 and deaths related to secondhand smoke are estimated at 38,000 non-smokers per year.4 Influenza is also the disease with the highest number of potentially vaccine-preventable deaths in this country. By contrast, there were about 100 deaths per year attributable to varicella when universal vaccination was begun for that disease.5 There are a number of suggestions as to why the current vaccination strategy has not been effective up to this point: • The traditional trivalent inactivated influenza vaccine (TIV) may not be as effective in protecting those populations most at risk, especially those over 65.1,6 • Antigenic drift in the influenza virus has caused strains not covered by that year’s TIV to be the chief cause of infection in a number of communities.1,6,7,8

BY PETER DEHNEL, M.D.

MetroDoctors

The vaccine supply for 2006-2007 is likely to be better than in the past few years, with an estimated 120 million doses of the vaccine available.9 There is also an expanded inclusion of children up to 60 months of age, as well as all household contacts of anyone who is at risk. In spite of these recommendations, there will still be significant segments of the population who are not recommended to receive routine vaccination, including most school-aged children and teens.1,6

• There have been supply issues in recent years, which have led to regional unavailability at the prime time of recommended influenza vaccination, and no means to “go back” and vaccinate those who missed out in the initial round of injections.1,6 • This history of vaccine supply interruptions and unavailability has led some providers to be hesitant to actively promote vaccination efforts.9 • Household contacts of those at most risk have frequently not been vaccinated, especially in those years of perceived shortage.1,6 • Relatively low rates of vaccination among health care workers, resulting in vulnerable populations coming in contact with workers who are either clinically or sub-clinically infected.1,6 • The largest pool of individuals in any community who are likely to be infected with influenza — school-aged children and teens — have not traditionally been included in the recommended groups to receive TIV.10,11,12,13,14

The Journal of the Hennepin and Ramsey Medical Societies

Universal Pediatric Vaccination One approach very likely to be successful in reducing the total harm caused by influenza, especially deaths in individuals over 65, is universal vaccination of children from 6 months of age to the completion of college. This prediction is based on: • Epidemiology of influenza-related infection.

• Literature-based comparisons of communities vaccinated and not vaccinated.

• Japan’s previous experience with universal pediatric vaccination.

• Indirect evidence from pediatric PCV-7 vaccination.

Epidemiology of influenza-related infection 11,12,13,15,16

The highest attack rates of influenza in any given year are in children. School-aged children and pre-school children attending day care are likely to have rates of infection in the 35 percent to 50 percent range. These children serve as the “point of entry” into their homes, where household contacts — parents, siblings,

(Continued on page 4)

November/December 2006

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Reducing the Harm of Influenza (Continued from page 3)

grandparents and other relatives — are at risk of becoming infected themselves. Adults from these home settings, who either have clinical or sub-clinical infections, can then bring them into their workplaces where they expose others to influenza. This can be especially troublesome if the adult works in a health care setting with individuals who have chronic medical conditions or are over 65 years of age.

If “antigenic drift” of the influenza virus has occurred, this will add additional risk because of the decreased effectiveness of TIV in these communities.

Literature-based comparisons of groups vaccinated and not vaccinated 12,15 There have been recent comparisons in the literature between those communities where children are vaccinated with those communities serving as “controls.” Vaccinated communities typically show significantly less influenza-related illness in all age groups, with reductions measured up to 67 percent. When comparisons are made at the household level, reductions of up to 80 percent are experienced in those homes where children are immunized.

Significant benefit is seen at the community

level when 59 percent or more of the children are vaccinated.

vaccination reducing morbidity and mortality in those over 65.

The Japanese Experience 17 Following a particularly devastating Asian influenza epidemic in 1957-1958, Japan embarked on a childhood influenza immunization program. This program was in effect from 1962 to 1994, and was mandatory between 1977 and 1987. It is estimated that during this time, 37,000 to 49,000 deaths were prevented each year in Japan, or about one death prevented for each 420 children immunized.

Influenza Vaccination Strategies In order for universal pediatric vaccination to successfully go forward, a number of barriers must be overcome in the current environment: • Recognition that pediatric vaccination benefits all age groups. It is likely to significantly reduce morbidity and mortality of those over 65 and under 2 years of age, as well as those with significant underlying health conditions.11,12,15,16 • Reliable availability of influenza vaccine for the pediatric population, with access to that vaccine not impeded by financial barriers.2 • Universal insurance coverage of live attenuated influenza vaccine (LAIV). There is significant evidence to show that LAIV is more effective than TIV, and that LAIV has some additional protective benefit in the event of “antigenic drift” of the influenza virus. The intra-nasal administration of the vaccine overcomes the fear of injections, a substantial barrier for children who are going to receive a “flu vaccine.” This barrier alone contributes to the non-vaccination of a large number of school-aged children and teens.1,7,10,11,12,19,21 • LAIV is a very safe vaccine, as evidenced by the small number of reports to the national Vaccine Adverse Events Reporting System (VAERS).24 • Strong clinician and clinic staff endorsement of universal vaccination as an important step of protection not only for the child, but also the siblings, the parents, the grandparents and the community as a whole.2 • Media support for universal influenza vaccination, downplaying perceived fears and dangers of vaccination and fully informing the public of the benefits to all members of the community.20 • Adequate clinic-based and communitybased resources to ensure every child and teen can be immunized in a timely manner.2,13,16 • Influenza “point of care testing” to determine which children with a febrile illness

Indirect evidence from pediatric PCV-7 vaccination 18 Routine heptavalent pneumococcal conjugate (PCV-7) vaccination of children under 5 years, and especially children less than 2 years was established in 2000. Since that time, there has been a significant decrease in children having invasive pneumococcal disease. A remarkable secondary benefit of this vaccination program is that there has been a significant reduction in the number of infections caused by vaccine-related strains of pneumococcus in senior citizens. This group has not received the vaccine, but apparently has benefited by vaccination of young children. This further supports the experience of pediatric influenza

The MN Dept of Health is doing a demonstration project in Minnesota on the universal influenza vaccination.

Following is a summary: “The overall aim of this project is to assess the ability of school-based immunization programs to deliver influenza immunization to schoolchildren. All schoolchildren K-12 in three Minnesota counties will be offered live, attenuated influenza vaccine (LAIV). Children with contraindications to LAIV will be encouraged to receive inactivated influenza vaccine at their private physician’s office. This project will establish the feasibility of vaccinating schoolchildren against influenza for herd immunity-based approaches to protecting high-risk persons against morbidity and mortality from influenza.”

4

November/December 2006

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The Journal of the Hennepin and Ramsey Medical Societies

during the typical influenza season actually have influenza.1,22,23 Conclusions • Influenza still causes a lot of morbidity and mortality — far more than it should given its vaccine-preventable nature and our current state of medical knowledge.

• Universal pediatric immunization against influenza should be promoted as an important intervention to reduce the morbidity and mortality of influenza in all age groups, especially senior citizens.

• Both LAIV and TIV should be readily available in ample quantities, with financial and insurance barriers being eliminated to the fullest extent possible.

• Clinicians and office staff need to be strong supporters of this initiative, and the media can help by endorsing the process and minimizing the reporting of unsubstantiated or exaggerated complications and risks.

Burden in Children. Pediatrics 2002;110(6):1246-1252.

11. Luce BR, Zangwill KM, Palmer CS, et al. Cost-effectiveness Analysis of an Intranasal Influenza Vaccine for the Prevention of Influenza in Healthy Children. Pediatrics 2001;108(2):e24(1-8), accessed online 8/10/2006.

12. White T, Lavoie S, Nettleman MD. Potential Cost Savings Attributable to Influenza Vaccination of Schoolaged Children. Pediatrics 1999;103(6):e73(1-5), accessed online 6/27/2006.

13. Block S. Role of Influenza Vaccine for Healthy Children in the US. Pediatr Drugs 2004;6(4):199-209.

14. Neuzil KM, Hohlbein C, Zhu Y. Illness Among Schoolchildren During the Influenza Season. Arch Pediatr Adolesc Med 2002;156:986-991.

15. Hurwitz ES, Haber M, Chang A, et al. Effectiveness of Influenza Vaccination of Day Care Children in Reducing Influenza-related Morbidity Among Household Contacts.

JAMA 2000;284(13):1677-1682.

16. Kempe A, Daley MF, Barrow J, et al. Implementation of Universal Influenza Immunization Recommendations for Healthy Young Children: Results of a Randomized, Controlled Trial with Registry-based Recall. Pediatrics 2005;115(1):146-154.

17. Reichert TA, Sugaya N, Fedson DS, et al. The Japanese Experience with Vaccinating Schoolchildren Against Influenza. N Engl J Med 2001;344(12):889-896.

18. Centers for Disease Control and Prevention. Direct and Indirect Effects of Routine Vaccination of Children with 7-Valent Pneumococcal Conjugate Vaccine on Incidence of Invasive Pneumococcal Disease – United States, 1998-2003.

MMWR Weekly 2005;54(36):893-897.

19. Treanor JJ, Kotloff K, Betts RF, et al. Evaluation of Trivalent, Live, Cold-adapted and Inactivates Influenza Vaccines in the Prevention of Virus Infection and Illness Following Challenge of Adults with Wild-type Influenza A (H1N1), A (H3N2) and B Viruses. Vaccine 2000;18:899-906.

20. Daley MF, Crane LA, Chandramouli V, et al. Influenza Among Healthy Young Children: Changes in Parental Attitudes and Predictors of Immunization During the 2003 to 2004 Influenza Season. Pediatrics 2006;117(2):e268-e277, accessed on 8/10/2006.

21. MacNeil JS. New Cold-adapted FluMist more Effective than Shots. Pediatr News 2006;40(6):1&6.

22. Barclay L, Lie D. Point-of-care Influenza Testing in Children may Reduce Overall Testing. Medscape 7/10/2006. Accessed 7/20/2006 at www.medscape.com/ viewarticle/540316.

23. O’Brien MA, Uyeki TM, Shay DK, et al. Incidence of Outpatient Visits and Hospitalizations Related to Influenza in Infants and Young Children. Pediatrics 2004;113(3):585-593.

24. Izurieta HS, Haber P, Wise RP, et al. Adverse Events Reported Following Live, Cold-adapted, Intranasal Influenza Vaccine. JAMA 2005;294(21):2720-2725.

Peter Dehnel, M.D., is medical director, Children’s Physician Network.

References 1. Centers for Disease Control and Prevention. Prevention and Control of Influenza. MMWR 2006; 55(RR-10):1-39.

2. Szilagyi PG, Iwane MK, Schaffer S, et al. Potential Burden of Universal Influenza Vaccination of Young Children on Visits to Primary Care Practices. Pediatrics 2003; 112(4):821-828.

3. National Transportation Safety Board Press Release.

Transportation Fatalities Decrease in 2004. September 9, 2005. Accessed at: www.ntsb.gov/pressrel/2005 on 8/8/2006.

Crutchfield Dermatology “Remarkable patient satisfaction from quality, service, convenience and excellent results” “Exceptional care for all skin problems”

4. Centers for Disease Control and Prevention. Annual Smoking-Attributable Mortality, Years of Potential Life Lost and Productivity Losses – United States, 1997-2001.

MMWR Weekly 2005;54(25):625-628.

Charles E. Crutchfield III, M.D.

5. Centers for Disease Control and Prevention. Decline in Annual Incidence of Varicella – Selected States, 1990-2001.

MMWR 2003;52(37):884-885.

Board Certified Dermatologist

6. Centers for Disease Control and Prevention. Prevention and Control of Influenza. MMWR 2005; 54(RR-8):1-42.

&

Psoriasis Acne Specialist

7. Nichol KL, Mendelman PM, Mallon KP, et al. Effectiveness of Live, Attenuated Intranasal Influenza Virus Vaccine in Healthy, Working Adults. JAMA 1999; 282(2):137-144.

8. Belsbe RB, Gruber WC, Mendelman PM, et al. Efficacy of Vaccination with Live Attenuate, Cold-adapted, Trivalent, Intranasal Influenza Virus Vaccine against a Variant (A/Sydney) not Contained in the Vaccine. J Pediatr 2000; 136(2):168-175.

Your Patients will Look Good & Feel Great with Beautiful Skin

9. Elliott VS. New Challenge for Officials: Maximizing Takers for Increased Flu Shot Supply. Amednews.com.

7/10/2006. Accessed at www.ama-assn.org/amednews/ 2006/07/10/hll20710.htm on 8/8/2006.

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Appointments 651-209-3600 Prompt Appointments via Physician Requests

10. Committee on Infectious Disease, American Academy of Pediatrics. Policy Statement: Reduction of the Influenza

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

November/December 2006

5

FEATURE STORY

Gubernatorial Candidates Respond to Questionnaire on Health Care Issues

Editor’s Note: Republican Party candidate Governor Tim Pawlenty, DFL candidate Attorney General Mike Hatch, Independence Party candidate Peter Hutchinson, and Green Party candidate Ken Pentel were invited to respond to a questionnaire on health care issues. The questions were designed to provide our MetroDoctors readership with valuable insight into their positions on topics that are important to practicing physicians and their patients.

The following responses were received.

Mike Hatch What is your position on universal health care?

We must cover all Minnesotans; it is a moral, economic imperative in the global economy. That said, I do not favor an amendment to the state constitution making health coverage a right. We must stem the meteoric rise of health care costs and improve accessibility for all Minnesotans. Over the last four years, health premiums and out-of-pocket expenses have soared. Fewer employers offer health insurance and 77,000 more Minnesotans are uninsured. The cost of health care is the largest tax on business and the most common cause of family bankruptcy. This is unconscionable.

In order to rein in spiraling health care costs, we must address the prescription drug problem. Prescription drugs are among the fastest growing segments of health costs, increasing at double-digit rates over the past decade. Unlike most industrialized countries, which have laws to hold down the cost of prescription drugs, the United States has laws to protect the industry from competition. Instead of simply importing Canadian drugs, we should import the entire Canadian drug negotiation system. The State should negotiate prices for prescription drug medication on behalf of all Minnesota consumers. By representing a large block of purchasers, the State can substantially lower the price of prescription drugs for all Minnesotans.

I will also enact reforms to make it easier for small businesses to provide health insurance for their employees. An employer who buys group health insurance coverage should not have to assume the cost of catastrophic care. An employer should be able to buy group coverage for healthy employees and, for employees with a catastrophic injury or illness, buy a subsidized policy, perhaps through the Minnesota Comprehensive Health Association. By reapportioning the cost of catastrophic health care throughout society, we can alleviate the undue burden now faced by small to mid-size businesses.

As Attorney General, I exposed massive waste in our HMOs, secured coverage for 6

November/December 2006

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

mental health treatment, and reached agreements with all 126 Minnesota hospitals to stop overcharging the uninsured. As Governor, I will continue to make our health care system more accountable, efďŹ cient and accessible.

What is your position on a comprehensive statewide smoking ban for all workplaces, including bars and restaurants?

As Governor, if a bill reaches my desk that the Legislature has enacted which bans smoking in all workplaces, I would sign it.

What is your position on diverting Health Care Access Fund monies for spending on non-health care expenditures included in the Minnesota State budget?

This is wrong. I oppose diverting Health Care Access Fund monies away from health care. Governor Pawlenty wanted to un-dedicate the Health Care Access Fund so it would be treated as general fund monies. In the end, about $400,000,000 was diverted to the general fund with a commitment to use bonus federal funds to replace $100,000,000 of it. The Governor did not follow through on his commitment, and this money was not recovered. I believe the Health Care Access Fund should remain dedicated and should be used to give access to health care for the uninsured. I will never use it for general fund expenditures.

Do you have positions on other health care issues that you would like to review for our readers?

Since the Health Care Access Fund has had surplus funds since the last legislative session, I believe the ďŹ rst priority for use of the funds should be to restore cuts made to MinnesotaCare in 2003 by Governor Pawlenty. Cutting the health coverage of over 36,000 working Minnesotans is no way to solve the health care crisis. Business, local governments, health care providers, and individuals have all been struggling to ensure that more people have coverage because it is the moral thing to do and fewer people with coverage end up costing more in the long run. Those who lost coverage because of these cuts should be reinstated — no one should go without health care while there is a surplus in this fund.

Additionally, please read through our comprehensive health care position papers on our Web site, www.hatch2006.org, for a more detailed discussion of the health care crisis in our state and nation.

Peter Hutchinson What is your position on universal health care?

Peter Hutchinson and his Lt. Governor, Dr. Maureen Reed have developed a proposal for comprehensive reform to our health care system. In their plan, universal coverage is mandated, with an enhanced sliding fee for those who cannot afford it on their own. However, everyone would be required to pay something for their health coverage and everyone would be required to carry basic health insurance.

(Continued on page 8)

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November/December 2006

7

Gubernatorial Candidates (Continued from page 7)

What is your position on a comprehensive statewide smoking ban for all workplaces, including bars and restaurants?

Peter Hutchinson and Maureen Reed support it.

What is your position on diverting Health Care Access Fund monies for spending on non-health care expenditures included in the Minnesota State budget?

The transfer of these dollars into the general fund simply continued the current administration’s fiscal dishonesty. Our fiscal principles are simple: voters should understand where their tax dollars are coming from and what they are used for.

Budgets should be balanced — without the smoke and mirrors of accounting shifts — and special funds should not be raided for general fund purposes. Our comprehensive reform plan offers a dollar-for-dollar replacement for the Access Fee with an expanded tobacco tax.

Ken Pentel What is your position on universal health care?

I will establish a single payer health care system that is universal. This would eliminate the multi-payers, advertising and marketing. A state hospital board would be established to distribute technologies and expertise fairly in Minnesota. And we would have set fees on a menu for hospitals, doctors and drugs.

All Minnesotans would have a health card; go into the doctor or hospital following their procedure then their card would be swiped. The bill would be covered by the State. Simple and easy.

We would pay for the system from the savings in overhead and administrative costs, as well as a progressive income tax and pollution tax.

What is your position on a comprehensive statewide smoking ban for all workplaces, including bars and restaurants?

We should do everything to prevent people from smoking. I 8

November/December 2006

Do you have any positions on other health care issues that you would like to review for our readers?

Yes. Hutchinson/Reed is the only team to offer a complete and comprehensive reform of the health care system that ensures affordability, as well as high quality and access. You can get the full details on our Web site: www.TeamMN.com.

Here’s an overview of our plan: 1. Cut the cost of administration and bureaucracy in half by 2010.

2. Improve the quality of care and reduce its cost — particularly the burden of chronic disease — by 2010.

3. Assure that every Minnesotan gets affordable, quality basic health care when they need it. Require basic health care insurance coverage for all residents. Expect all Minnesotans to have the minimum basic coverage and make it possible for them to buy more extensive coverage if they choose.

4. Make it rewarding for consumers to take greater responsibility for their health and control of decisions about their care.

5. Make detailed information on health care quality and cost readily available to everyone.

6. Implement the public health measures most beneficial to improving our health. support advertising and educational programs produced by, and marketed to young people that lead us toward this goal.

I support a statewide ban on smoke-free workplaces and would leave it to citizens in each county to vote on a referendum if local businesses also should be smoke-free.

What is your position on diverting Health Care Access Fund monies for spending on non-health care expenditures included in the Minnesota State budget?

The health care provider tax should be used for its original intent and not be funneled to the general fund.

Do you have positions on other health care issues that you would like to review for our readers?

My approach for health care is not just the pathway we choose once someone is injured or ill, we need to look at health holistically.

The health of the earth cannot be separated from the health of the people of the earth.

For example: If we do not prevent persistent toxic poisoning in the environment, poisons that deplete the immune system, then we are just chasing our tails on health care.

Also, rewarding healthy food production, eating habits and physical fitness will be one of my goals as Governor.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

PHYSICIAN'S SOAP BOX

Let the War Begin

T

he first shot was fired at the annual meeting of the Minnesota Medical Association this year when the delegates adopted the resolution that the Minnesota Medical Association would advocate for an increase in the excise tax on beer, wine and spirits by the equivalent of $.10 a drink (approximately $240 million per year) and that these increased funds should be used for prevention, treatment, and public safety services related to the use and abuse of alcohol.

This resounding resolution heralds the message that it will now be unacceptable for the alcohol-beverage industry to only pay $26.0 million per year in alcohol sales taxes to cover $4.5 billion per year in state health care costs and lost productivity secondary to the use of their product. This economic burden of alcohol use amounts to over $900 for every person in the state of Minnesota.

The time has come for alcohol users to pay their fair share of these costs.

There have been only two increases in the state’s liquor tax in the past 35 years — in 1971 and 1987. According to the Center for Science in the Public Interest, Minnesota’s liquor tax ranked 33rd in the nation in 2004, tied with Idaho. The 1987 Minnesota tax on a 12-oz beer, the alcoholic beverage of choice, was 1.4 cents.

Because of a percent loss in value of 40 percent in 1987, when the last alcohol excise tax increase occurred, the deflated tax rate per 12-oz serving of beer is now $0.0084. This is outrageously unacceptable to maintain this status quo of taxation.

The alcohol-beverage industry has done a superb job of keeping under the awareness radar of the people of Minnesota, the lack of appropriate state taxation on alcohol. Minnesota politicians have been bemoaning that they cannot find fair funding sources to support necessary public programs when they should be considering alcohol as this fair source of untapped revenue.

A 2004 survey by Robert Wood Johnson showed that most Americans did not know the current alcohol-tax rate in their state, but once they were informed of their state’s current rates, they fully supported an increase.

The upper Midwest has the nation’s highest binge drinking rates (49 to 55 percent) among young adults ages 18 to 25. In

Minnesota, 16.0 percent of 9th graders, 31.7 percent of 12th graders, and 45 percent of University of Minnesota students age 18 to 24 are binge drinking.

A narrowed focus approach emphasizing education and awareness for the prevention of underage drinking has made little impact on decreasing underage drinking rates. Evidenced-based strategies for combating underage drinking have shown that increasing taxes on alcoholic beverages and restricting alcohol advertising to underage and young consumers effectively leads to a reduction in the levels and frequency of drinking and heavy drinking among them.

They are more price-sensitive. (Center for Science in the Public Interest) According to the Minnesota Department of Public Safety, more than 471,000 Minnesotans, one in eight drivers, have a DWI conviction. There were 36,870 DWI arrests last year, the most DWIs issued in 15 years. This number represented an 8 percent increase from the previous year 2004 (34,199). There was a 6 percent increase from the prior year, 2003 (32,193). The estimated economic cost of alcohol-related crashes in 2005 was $310,055,700.

The price-insensitive, heavy and addicted drinkers should rightly pay the most in alcohol taxes since their drinking imposes the greatest public health and safety costs to society. Twenty percent of drinkers consume 85 percent of all alcoholic beverages. The alcohol excise tax, therefore, is a true “user fee.”

The previously mentioned adopted resolution further has the Minnesota Medical Association considering alcohol abuse, particularly among underage drinkers, as one of its public health priority issues. They well emphasize that smoking, obesity and alcohol make up the number one, two, and three public health preventable causes of death — the Big Three.

BY CARL BURKLAND, M.D.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

November/December 2006

9

COLLEAGUE INTERVIEW

Terril H. Hart, M.D.

Terril H. Hart, M.D. is the chief executive officer, Indian Health Board of Minnesota, a 30-year old community health clinic offering medical, dental, mental health and outreach services to a diverse community.

Prior to this position Dr. Hart served as the Vice President Medical Affairs and Chief Medical Officer at Children’s Hospitals and Clinics of the Twin Cities (1997-2001), a pediatrician and managing partner at Wayzata Children’s Clinic (1981-1997), and Coordinator of Medical Affairs, Methodist Hospital, St. Louis Park, MN (1978-1981). Dr. Hart is a co-founder of Wayzata Children’s Clinic.

Questions were provided by Drs. Macaran A. Baird, Todd D. Brandt, Peter J. Dehnel, Dale Dobrin, and Janet Zander.

Q A

What challenges do you see in serving the Native American community — limited resources, poverty, unique health issues, etc?

American Indian cultures, and I emphasize the plural, have a 200-year history of learning to be suspicious and distrustful of what has become the majority culture in the United States. In part, that is what led to the creation of the Indian Health Board by Indians in the community, in order to have a source of care they could trust. In the past, as IHB evolved to care for all peoples, events have periodically shaken that trust.

Regaining it has been the single greatest challenge in being able to serve the Native American community. I feel and hope we are making good progress.

How does traditional western medicine interface with Native American medicine?

I would call it “conventional” western medicine, and I do not see any conflict. In fact, I have found that Indian views of healing and wellness have much to teach western medicine. Traditionally, Native Americans have a much broader view of health, and find spirituality, family involvement, social support systems, ceremony, herbalists and other modalities may be important to a person’s healing and wellness. I have never heard a traditional healer say hostile things about conventional western medical modalities. I have heard invitations from them to participate cooperatively in the healing process.

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November/December 2006

What are the current challenges and opportunities for primary care providers, especially in underserved communities?

Will there be primary care, anywhere? A recent paper in the New England Journal carried the question as a title: “Will Primary Care Survive?” That’s the challenge. In a time of shortage in these specialties, how will safety net clinics like IHB attract skilled physicians and nurse practitioners from more lucrative practices? As for underserved communities, that’s a great environment in which to practice. The needs are high and match what we all trained for. Patients are just as appreciative of kind and capable care as in any practice setting.

How could the rest of us at Hennepin Medical Society and Ramsey Medical Society work to improve health care and services in underserved communities/communities of color?

There’s a bit of a bully pulpit held by the medical societies. If they used that to more widely publicize the facts of health disparities, that might help. For Minnesota as a whole, health statistics look relatively good. We have one of the country’s lowest uninsured rates or routinely are named the healthiest or second healthiest state in the Union. That tends to mask the awful health status in some underserved communities. It’s the tale of the girl with the curl right in the middle of her forehead. Where we are good, such as with the insured population or those with some affluence, we’re very, very good, but where we are bad, such as health levels in the American Indian communities, we’re awful. Truly awful.

I would also like to see universal coverage, and HMS and RMS might campaign for that. I don’t mean a government system, or even a single payor model. But until everyone has coverage, the financial pressures on health centers like ours will not relent.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Childhood obesity rates are soaring. How do we reach out to the Native American community to stem the tide of childhood obesity within that community?

I’m not an expert on childhood obesity, and don’t have anything wellfounded to say. My common sense and pediatric bones say keep the TV and electronic games turned off most of the time, avoid fast food like the plague as well as similar products in the grocery store, see that children get adequate sleep and get their bodies moving when they’re awake.

What are the main health threats to Native American children in Minnesota?

We’re planning to open career paths for American Indians, children and adults, into professional health care careers. One of the challenges will be to break down barriers. Loss of the Title VII hurts that strategy, but will not stop it.

Do you have any suggestions for how to continue this program with other sources of funding?

It’s possible some of the tribe might have an interest. I haven’t discussed it with anyone. Additionally, ideas could be sought from graduates of the program.

(Continued on page 12)

Native American children in Minnesota are threatened by forces tending to pull apart their families and distance them from traditional Indian ways. Those forces include poverty, a crystal meth epidemic, ignorance on the part of dominant culture about Indian history in America, and poor funding for health care for urban residents.

You have experience as a practicing physician and as an administrator. How have your administrative duties helped you as a physician, and your physician responsibilities helped you as an administrator?

Many physicians have traditionally regarded “administrators” with suspicion, or viewed them, best case, as superfluous. I take the view that we physicians have been blind to the contribution modern management can bring to health care. In fact, I think our major deficits in the health care system are management deficits. I’m not casting aspersions on managers or executives. We haven’t let them in. Look at the Leapfrog Group’s “Safe Practices” standards. Staffing all intensive care units 24/7 with trained intensivists is a management move. Creating a rapid response team is a management activity. Installing electronic health records, e-prescribing capability, putting in a PACS system, those are all management. My management experience has helped me understand that.

Conversely, it’s very easy inside an organization, large or small, to forget about patients. I don’t mean forgetting their presence, but rather having a deep understanding of what it feels like to be a patient, and what it feels like to be working directly to care for them.

The federal Title VII funding is ending that has been supporting the efforts in Duluth to create a “pipeline” for American Indians to enter health careers, especially as physicians. If this program (the Center on American Indian and Minority Health) is significantly reduced due to this change in federal support, what will be the impact upon health care delivery for American Indians in Minnesota?

I’m working with other leaders of Indian organizations in this community to build and enrich its viability. We’re involved in long-term planning for many areas, one of which is workforce development. Health care is the largest component of our economy and one of the fastest growing.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

November/December 2006

11

Colleague Interview (Continued from page 11)

Knowing that you have served in a variety of capacities, what has been your most satisfying role?

Nothing has been more satisfying than taking care of children in a pediatric practice. It was my desire since childhood. I put what we have accomplished at the Indian Health Board as a very close second. But I hesitate to rank these things, they differ so much. The experience on the Boards of PHP, Medica and Allina had a large influence on me, and I learned much from some very bright, talented people. At Children’s I had a large operational responsibility, such as I had never faced before, and I gained valuable experience. I’m grateful for all of it.

For the possible medical leaders of the future, could you mention some of the key steps that accelerated your interest in medical leadership activities?

Founding a practice, as my friend Dr. Mitch Einzig and I did with the Wayzata Children’s Clinic, probably started it off. We knew how to be pediatricians, but didn’t know how to run a business. It was OJT during that time, but we figured out most of it. After I reached my dream, namely to be a pediatrician, I had a “do I want more?” question rattling my brain, and took a risk.

I took a job at Methodist Hospital as what would now be called a VPMA. When I decided to explore a switch from practice to management, I started taking some seminars with the American College of Physician Executives. I liked the learning, and started answering headhunter ads. So maybe the take-aways are to stay open to learning and take a few risks. One can almost always make another decision.

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As with others in the positions you have held over the years, you have seen controversy and conflict in various organizations and among their leaders. What “words of wisdom” do you have looking back on these experiences regarding organizations that are resilient vs. those which needed “revolution” to “right the ship”?

The true value systems of organizations determine their fate. I’ve seen it in companies great and small. By true, I mean how they really operate, not just what they say or put into print. Those values, for good or ill, seem to persist long after the latest fad in management has faded. At the extreme, bad values take down large organizations like WorldCom or Enron, in the middle it makes them stumble, like to goings on at Hewlett Packard, or helps them thrive through the decades, like the Red Cross or Proctor & Gamble or SunnyFresh Foods right here in Minnesota. SunnyFresh just won its second Malcolm Baldrige national Quality Award.

In the same context, how did you manage to maintain your personal balance during times of upheaval?

A lot of my balance I ascribe to luck. It is lucky DNA for my personality, and I grew up in a happy home with parents who loved each other and me and my brother, too. I’ve already come to realize that most controversies, at least in the workplace, aren’t personal. I knew that for sure when I first came to the Indian Health Board, since almost no one in the community knew me. So in spite of the turmoil, I was optimistic that we had a good purpose and good values. I tried to lay to the work we had to do and not spend much energy worrying about the personal attacks. We do our best to manage for quality here. I believe that will always win out.

What are your thoughts about the current structure of Allina and its mandated separation from Medica?

The atmosphere in health care, when Allina was formed in 1994, was that HillaryCare was eminent, and the country would turn into a mass of ISNs. That’s Integrated Service Networks, for recent graduates. Minnesota went out even further on that diving board, for a time. When both those efforts disappeared, I think the rationale for integrated companies like the original Allina went away also. I’m fairly certain that dividing the health plan from the delivery system would have happened as a business decision instead of the political one which actually occurred. I no longer have any direct information about either Allina or Medica, but both seem to be doing well. I know that Dick Pettingill has Allina on a path to win a Baldrige in health care, and I applaud that loudly.

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November/December 2006

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

What Does the Surgeon General’s Report on Secondhand Smoke Mean for Physicians?

T

THE U.S. SURGEON GENERAL’S Report on secondhand smoke (SHS) had a clear message for policy makers — make indoor public gathering spots smoke-free as soon as possible. But it had an equally clear mandate for physicians — talk to your patients early and often about limiting their exposure to SHS. Physicians routinely warn our allergic patients to stay away from allergens. We tell our diabetic patients not to frequent candy stores. Now there are compelling reasons to warn patients with heart disease, asthma and other lung diseases to avoid even brief visits to smoke-filled restaurants, bars, workplaces and residences.

The Surgeon General doesn’t jump to conclusions lightly. In 18 instances of this most recent report, the Surgeon General concluded that the available evidence is “inadequate to infer the presence or absence of a causal relationship (which encompasses evidence that is sparse, of poor quality, or conflicting). In at least 20 other instances, the Report concluded that the evidence is “suggestive, but not sufficient to infer a causal relationship.”

To be sure, the Surgeon General demands rigorous scientific evidence before it comes to a conclusion. Twenty-two of the top experts in the world waded through a huge volume of available peer reviewed research to reach the conclusions reflected in this Report. Their draft was then reviewed by 40 peer reviewers. A revised draft was then sent to 30 scientists and experts who reviewed it for scientific soundness.

For those who want more detail than is offered in this relatively brief summary, the nearly 700-page report and an extensive

B Y A N N E M . M U R R AY, M . D . , M S C .

MetroDoctors

searchable database of original research are available at www.cdc.gov/Tobacco/sgr/sgr_ 2006/index.htm. The database provides access to the scientific data behind the conclusions, and the methodology behind the data.

But this article will provide a thumbnail sketch of some of the Report’s main conclusions, and discuss their relevance to physicians.

Good News While the report has more bad news than good, it is important to note that there is some very good news imbedded in the Report.

Smoke-free Policies Work. The Bush Administration’s Surgeon General concludes “smokefree environments are the most economic and effective approach for providing protection from exposure to SHS.” It also notes that the number of smoke-free environments available to citizens is growing steadily. This is certainly the case in Minnesota, where the cities of Minneapolis, St. Paul, Bloomington and Golden Valley, have in recent years, enacted strong laws to limit SHS exposure in restaurants and bars.

Research has found that such polices not only reduce non-smokers’ exposures to SHS, but also lead smokers to quit or smoke less.

Smoke-free Policies Economically Harmless.

Contrary to the claims of pro-smoke forces, peer-reviewed studies show that smoke-free policies have not had an adverse economic impact on the overall hospitality industry.

Exposure to SHS Being Reduced. Research shows we are making a bit of progress in limiting Americans’ exposure to the carcinogens and toxins in SHS, in large part because the majority of American workers are now covered by

The Journal of the Hennepin and Ramsey Medical Societies

smoke-free policies. Among non-smokers aged 4 and older, nicotine exposure has declined from 88 percent in 1988-1991 to 43 percent in 2001-2002. Exposure levels are measured by sampling for blood continine, a metabolite of nicotine.

Bad News Along with this good news, however, there is plenty of very troubling news in the report.

SHS is Dangerous. More than 50 carcinogens have been identified in sidestream smoke (i.e. the smoke given off the burning end of cigarettes) and secondhand smoke (i.e. the smoke exhaled by smokers). The exposure of nonsmokers to SHS causes a significant increase in the urinary levels of metabolites of tobaccospecific lung carcinogens. Beyond the cancer threat, the evidence is also sufficient to infer that SHS exposure has a prothrombotic effect and causes endothelial cell dysfunctions.

SHS Causes Cardiovascular Deaths. The Surgeon General concluded that the evidence is “sufficient to infer a causal relationship” between SHS exposure and increased risks of coronary heart disease morbidity among both men and women. The pooled relative risks from meta-analyses indicate a 25 to 30 percent increase in the risk of coronary heart disease from exposure to SHS. An estimated 46,000 die from coronary heart disease related to SHS smoke exposure every year.

SHS Causes Lung Cancer Deaths. The Report concluded that the evidence is sufficient to infer a causal relationship between SHS exposure and lung cancer among lifetime non-smokers.

For people who live with a smoker, the pooled (Continued on page 14)

November/December 2006

13

Surgeon General’s Report (Continued from page 13)

function during childhood among children exposed after birth.

evidence indicates a 20 to 30 percent increase in the risk of suffering from lung cancer. Approximately 3,000 Americans die from SHSrelated lung cancer every year.

SHS Causes Diseases Impacting Children.

Among other things, the Report also found sufďŹ cient data to infer a causal relationship between SHS exposure and: 1) sudden infant death syndrome; 2) reductions in birth weight; 3) lower respiratory illnesses among infants and children exposed to parental smoking; 4) middle ear disease among children exposed to parental smoking, including chronic middle ear effusion and acute and recurrent otitis media; 5) phlegm, wheeze and breathlessness among school age children exposed to parental smoking; 6) ever having asthma among school age children exposed to parental smoking; 7) onset of wheeze illnesses in early childhood among children with parental smoking; 8) persistent adverse lung function across childhood among children with mothers who smoke during pregnancy; and 9) lower level of lung

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Exposure to SHS Remains. Though exposure to SHS has been reduced overall, there is much more work to do. About six of every 10 nonsmokers have biologic evidence of exposure to SHS. Moreover, the level of exposure varies signiďŹ cantly by ethnicity, gender and income. For instance, the median cotinine levels in children are more than twice as high as adults. The cotinine levels for non-Hispanic blacks are more than twice as high as non-Hispanic whites and Mexican Americans. Exposure also tends to be higher for lower income people.

SHS Hot Zones Remain. Homes and workplaces are the leading locations for exposure to secondhand smoke. Approximately 30 percent of indoor workers in the United States are not covered by smoke-free workplace policies.

Those who work in smoky environments, such as bars, restaurants, casinos, gaming halls and vehicles, are particularly exposed to the dangerous substances in SHS. Ventilation and Sectioning InsufďŹ cient. Research indicates that separating citizens into smoking and non-smoking sections does not adequately protect patients. Similarly, relying on air cleaning and mechanical air exchange systems does not provide enough protection.

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November/December 2006

So What?

So what are physicians supposed to do about it? There are two primary ways physicians can reduce the health impact of secondhand smoke on patients: 1) Actively support public policies that create more smoke-free environments; and 2) Talk to patients about the need to avoid SHS whenever possible.

Erroneous claims made during debates about smoke-free policies often confuse patients so much that they don’t take adequate steps to protect themselves. Health education is badly needed on this subject, and physicians are strongly positioned to be primary educators. Public opinion research continually shows that physicians are among the most trusted sources in any given community on health care issues. Physicians can help both policymakers and patients understand the importance of limiting exposure to secondhand smoke.

MetroDoctors

Smokers should be told in no uncertain terms that the best way to protect their loved ones is to quit smoking. Until they attain that ultimate goal, smokers should be counseled to keep their homes and vehicles completely smoke free. Non-smokers should be advised to avoid even brief exposure to smoky indoor settings, such as SHS-contaminated restaurants, bars, workplaces and residences.

While all patients will beneďŹ t from such a discussion, some types of patients need the warnings more than others. Arguably, heart patients are at the top of the priority list.

Patients with a pre-existing cardiovascular condition, in particular, should be aware that breathing secondhand smoke for even a short time could have immediate adverse effects on the cardiovascular system. According to the Surgeon General, “brief exposure to secondhand smoke can cause blood platelets to become stickier, damage the lining of blood vessels, decrease coronary ow velocity reserves, and reduce heart rate variability, potentially increasing the risk of a heart attack.“ People who smoke and have children at home, or are pregnant, should also be hearing from physicians. As the report says, “home is now becoming the predominant location for exposure of children and adults to secondhand smoke.â€? Because smoke-free laws and regulations almost never apply to private residences, physicians should be particularly active in counseling patients about the need to reduce SHS exposure levels at home.

What about smokers’ rights? Reagan Administration Surgeon General Dr. C. Everett Koop put it well: “The right of smokers to smoke ends where their behavior affects the health and well being of others.� Two decades later, the Bush Administration Surgeon General makes essentially the same point more succinctly, by repeatedly referring to SHS exposure as “involuntary smoking.�

The rancorous debate around secondhand smoke in Minnesota’s State Capitol, city halls and county courthouses often sheds more heat than light, but physicians can change that by arming themselves with the ďŹ ndings of this new Report and speaking out to policymakers, as well as their patients.

Anne M. Murray, M.D., MSC., is with the chronic disease research group at Hennepin County Medical Center.

The Journal of the Hennepin and Ramsey Medical Societies

Minute Clinic Offers Patient-Centered Care as Complement to Twin Cities Primary Care Providers

Editor’s Note: Since entering onto the scene in the year 2000, the number and variety of retail (storebased) health clinics is growing exponentially across the country. They are considered one of the “Fast 50” innovations by the magazine Fast Company. Starting as a partnership with Cub Foods in St. Paul, QuickMedex (name later changed to MinuteClinic) established this model of health care delivery. There are now at least nine companies across the nation in partnership with large retailers including Wal-Mart, Target, Rite Aid, Osco Drug, and CVS Pharmacy.

Including this article in MetroDoctors is neither an endorsement nor recommendation of this care delivery model. It is an acknowledgement that all physicians need to be very aware of this rapidly expanding method of meeting the perceived needs of our patients.

The American Medical Association (www.ama-assn.org) and the American Academy of Family Physicians (www.aafp.org) have both developed principles regarding policies and operations of these clinics. Meanwhile, in their September 2006 policy statement, the American Academy of Pediatrics (www.aap.org) “opposes retail-based clinics (RBCs) as an appropriate source of medical care for infants, children and adolescents, and strongly discourages their use, as the AAP is committed to the medical home model.”

Peter Dehnel, M.D.

F

FOR THE LAST SIX YEARS the Twin Cities

has been the incubator for one of the fastest growing trends in health care delivery in America — the emergence of retail-based health care centers pioneered by Minneapolis-based MinuteClinic, Inc. With 21 health care centers in retail and office locations throughout the metropolitan area, MinuteClinics, which are staffed by certified family nurse practitioners and physician assistants, have provided treatment for more than 330,000 patient visits this decade in the Twin Cities.

We’ve learned that patients appreciate the choice and convenience offered by our walk-in clinics that offer high quality care for common family illnesses and other basic services seven days a week with no appointment required.

It’s that demand for patient-centric health care

BY JAMES WOODBURN, M.D.

MetroDoctors

that has led MinuteClinic to open a total of 95 health care centers in 13 states around the country with plans for an additional 150 to 200 clinics by the end of the year. MinuteClinic is a subsidiary of CVS Corporation.

In the Twin Cities, MinuteClinics can be found at CVS/pharmacy and Cub Foods stores and in several retail and office building locations as well as corporate headquarters.

Our mission is to provide exceptionally high quality health care as a convenient complement to primary care when a patient cannot be seen in their medical home. As a result, MinuteClinic’s growth has come with the support of physicians in the Twin Cities and other metro areas throughout the United States. In fact, physicians have become one of our primary sources of referrals, especially when patient care is needed on evenings and weekends or at times when busy appointment schedules can’t be changed.

The Journal of the Hennepin and Ramsey Medical Societies

In turn, MinuteClinic has become an important source of referrals to primary care practices for patients without a medical home.

About 30 percent of our patients tell us they are without a primary care physician. In those instances, we provide the patient with a list of practices in their neighborhood who are accepting new patients.

Urgent care centers and emergency rooms have also benefited by referring less critical patients to our locations during peak periods, just as we refer patients with more serious conditions to their doors.

What is MinuteClinic?

To understand how MinuteClinic can be an adjunct to a primary care practice, it’s important to know what we do and do not treat.

We offer diagnosis and treatment of a limited number of acute illnesses, such as strep pharyngitis, otitis media, sinusitis, uncomplicated female urinary tract infections and conjunctivitis. In addition, MinuteClinic provides care for a number of seasonal conditions that include allergies, poison ivy, and minor sunburn. MinuteClinic also offers common vaccinations, such as flu shots, tetanus, pneumonia, MMR and Hepatitis A & B. Our services are posted on electronic message boards outside each of our locations and they can also be found on the web at www.minuteclinic.com. We believe in pricing transparency, so prices are always included with our list of services. In Minneapolis, the average price for service is between $49 and $59, but costs vary depending on the treatment we provide.

Individuals with illnesses outside MinuteClinic’s scope of services or who exhibit signs of a chronic condition are referred to their physician or, if necessary, the nearest urgent (Continued on page 16)

November/December 2006

15

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MinuteClinic (Continued from page 15)

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care center or emergency room. Patients who can’t be treated are not charged for their visit.

MinuteClinic only serves patients over the age of 18 months.

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Quality Care Every MinuteClinic patient assessment and treatment follows evidenced-based clinical practice guidelines from the Institute for Clinical Systems Improvement (ICSI.org) as well as the American Academy of Family Physicians and the American Academy of Pediatrics.

These guidelines are deeply embedded in the MinuteClinic electronic medical record (EMR) system to assist the careful adherence to the protocols for the care we provide.

MinuteClinic nurse practitioners and physician assistants use our custom built EMR that guides diagnosis, treatment and billing.

At the conclusion of each visit, the software generates educational material, an invoice and a prescription for the patient when clinically appropriate, as well as a diagnostic record for the patient to keep and share as they choose.

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November/December 2006

13765 Nicollet Ave. S. Burnsville, MN 55337

MetroDoctors

The medical record is also sent to the patientâ&#x20AC;&#x2122;s primary care providerâ&#x20AC;&#x2122;s ofďŹ ce.

We also have local Medical Directors who support our clinics. Our physicians are licensed, actively practicing in primary care, board certiďŹ ed in family or emergency medicine and experienced in collaborations with nurse practitioners or physician assistants. In addition, we have local managers of operations who are full-time nurse practitioners and who provide day-to-day operational management.

In the six years that MinuteClinic has been in operation, we have achieved a 93 percent excellent rating in our patient satisfaction surveys.

MinuteClinic has achieved accreditation from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the national evaluation and certifying agency for nearly 15,000 health care organizations and programs in the United States, including hospitals, hospice services, nursing homes, laboratories, rehabilitation centers and behavioral health care organizations. Weâ&#x20AC;&#x2122;re the ďŹ rst retail health care provider to achieve this accreditation.

To ensure that we continue to operate with the highest quality of care, MinuteClinic has formed a National Clinical Quality Advisory Council, an eight-member panel that brings together nationally recognized health care leaders from a variety of specialties and backgrounds to contribute strategic creativity, clinical guidance and quality improvement ideas.

Members on the Quality Advisory Council include Dr. Kristan Nichol, professor of medicine at the University of Minnesota and chief of medicine at the VA Medical Center in Minneapolis; Dr. Mark Paller, professor of medicine and vice president for research at the University of Minnesota Academic Health Center; Dr. Andrew Eisenberg, who serves as the AAFP representative to the council; and Dr. Michael Fleming, family physician and former past president of the AAFP. As we look to the future in the rapidly changing world of health care delivery, we would appreciate your comments and suggestions as to how MinuteClinic can be an even better adjunct to primary care providers in the metropolitan area. Please visit our Web site www.minuteclinic.com and feel free to e-mail me at woody.woodburn@minuteclinic.com.

James Woodburn, M.D., is the chief medical ofďŹ cer for MinuteClinic, Inc.

The Journal of the Hennepin and Ramsey Medical Societies

Minimally Invasive Spinal Fusion: Big Solutions Through Small Incisions

O

ONLY A DECADE AGO, patients having spinal fusion surgery could expect to be hospitalized for several days and take as much as a year before being able to return to normal activities. Continued expansion of minimally invasive techniques are changing the face and perception of spinal fusion surgery. While initial procedures were limited to decompressions and disc removal alone, recent advances have allowed lumbar interbody fusion to be achieved through minimal access techniques.

The minimally invasive transforaminal lumbar interbody fusion (TLIF) procedure first described by Foley, et al. has generated enthusiasm as a viable method of achieving fusion.1 Conventional posterior lumbar fusion is associated with significant muscle stripping and retraction that can adversely affect both short- and long-term patient outcomes. In contrast, minimally invasive lumbar fusion is performed via a muscle-dilating approach and significantly diminishes the extent of operative soft-tissue injury. This has translated to a reduction in intraoperative blood loss, postoperative pain intensity, narcotic use and duration of hospital stay. More importantly, excellent fusion rates and patient satisfaction have been achieved.

Back and leg pain is a significant cause of lost productivity, disability and emergency room visits resulting in millions of missed work hours and billions of treatment dollars.

According to the U.S. Bureau of Labor Statistics there were 303,750 work-related back injuries in 2003. In addition, normal aging can lead to back pain, leg pain and disability, which may require surgery after all conservative measures are exhausted. The result is over 200,000 lumbar fusions being performed B Y S T E FA N O M . S I N I C R O P I , M . D .

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yearly in the U.S. alone and these numbers will continue to grow. This has led to a search for better, less invasive methods of treating this growing segment of the population. Minimally invasive spinal fusion techniques now give the spine surgeon the technology to treat complex spine problems through small muscle-sparing incisions and provide cost-saving opportunities to the health care system. Rouben reported an average cost-savings of $24,336 per case over open inter-body fusion procedures.2 He adds that if all inter-body fusions were done in a minimally invasive fashion then the savings would be $753 million annually. This number would expand to over $5.2 billion annually if all lumbar fusions were done using this technique.

Rationale for Use of Minimally Invasive Fusion Techniques Posterior lumbar fusion is a well accepted technique of stabilizing the unstable or painful motion segment. First described by Hibbs in 1911 for the treatment of tuberculosis of the spine3, it has become the staple of surgical treatment for various degenerative, traumatic, infectious, and oncologic disorders of the lumbar spine. Posterolateral lumbar fusion procedures have been associated with significant morbidity related to extensive dissection

The Journal of the Hennepin and Ramsey Medical Societies

of muscle and other soft tissues. This in turn can result in atrophy and pain syndromes. A popular term coined to describe successful fusions with poor outcomes is “fusion disease,” which may be partially the result of this chronic dennervation. Stevens et al. compared maximum intramuscular pressure generated by a minimally invasive retractor to a standard open retractor.4 A statistically significant difference in reduction in pressure with the minimally invasive retractor was found. MRI was utilized to compare patients at six months after undergoing traditional or minimally invasive approaches, finding dramatically less muscle edema in the minimally invasive group. They concluded that less muscle damage occurs with minimally invasive approaches. Several other critical studies have supported the findings that open surgical procedures can result in muscle atrophy, dennervation and dysfunction.5,6,7 Evolution of Posterior Interbody Fusion to a Minimal Access Approach Posterior Lumbar Interbody Fusion(PLIF) was popularized by Cloward over 50 years ago, affording the advantage of fusing the space between the vertebral bodies from a posterior approach8, achieving circumferential fusion through a single incision. Many surgeons now prefer the TLIF (Transforaminal Lumbar Interbody Fusion) approach for lumbar arthrodesis described by Harms and Rollinger.9 These procedures have yielded high fusion rates by taking advantage of large interbody fusion surface area, copious blood supply of cancellous bone, and placement of the interbody graft in compression. Osteoinductive recombinant bone morphogenic protein (rhBMP-2) can be (Continued on page 18)

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Spinal Fusion (Continued from page 17)

used within the interbody cage to help yield faster and more robust interbody arthrodesis.

As clinical researchers explored less invasive ways to achieve the same surgical goals with minimally invasive approaches, the percutaneous spinal fusion evolved. Recent innovations in tubular retractors, originally developed for the minimally invasive microdiscectomy procedure10, combined with refinement of percutaneous pedicle screw instrumentation enabled performance of minimal access spinal fusion. This evolution allowed the goals of traditional surgery to be accomplished with minimal paraspinal trauma, thus maintaining normal midline musculoskeletal structures.

Which Patients Should be Considered for Minimally Invasive Spinal Fusion Recurrent disc herniations, especially after previous discectomy can be difficult to treat.

The typical post-discectomy patient will report that they were initially happy with relief of radicular pain, but with time have had new or

increased mechanical back pain and return of leg symptoms. They are considered outstanding candidates for the minimally invasive TLIF procedure as it can be a definitive treatment for back and leg pain. Correlation of symptoms with radiographs, MRI, discograms, and selective injections is utilized for preoperative planning and selection of levels. The minimally invasive TLIF is usually performed on the same side as the original surgery because the lateral approach avoids midline scarring.

Spondylolisthesis associated with persistent mechanical low-back and radicular pain, is an excellent indication for minimally invasive spinal fusion. The ipsilateral exiting and traversing nerve roots can be decompressed through the excellent visualization afforded by the fiberoptically illuminated tubular retractors. Two methods can achieve contralateral decompression in cases of bilateral radiculopathy. The first is indirect decompression through graft placement and disc space distraction. This achieves increase in height of the contralateral foramen through distraction and slip reduction. If stenosis is severe on the opposite side,

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then a minimally invasive decompression can be performed on both sides using a tubular retractor. Usually this approach is limited to Grade I or II spondylolisthesis. Higher grade slips are technically demanding, requiring wide bilateral decompression and therefore an open traditional approach is recommended.

Discogenic back pain is a great source of disability and squandered productivity in industrialized nations. An aggressive non-operative approach including physical therapy, injections, pain control, massage, acupuncture and meditation should be attempted. Many patients can do well with these and return to work. There is a subset however, that become depressed, addicted to pain medications, and are unable to function at work or home despite exhaustive trials with conservative modalities.

These patients are good candidates for a minimally invasive fusion if one or two discs are identified as the pain generator.

Other indications include spinal stenosis with instability and trauma.

Overweight patients are also excellent candidates for this procedure provided that the procedure is technically feasible. Many of these patients are not good candidates for open surgery because of their increased risk of infection or other complications. Many times they are asked to lose weight, however, cannot because of their pain. Minimally invasive surgery gives the spine surgeon an attractive option at surgically managing their problem so that they can resume activities to improve the quality of their life.

Brief Technique Overview A detailed discussion of the procedure is beyond the scope of this article. The four basic portions of the procedure involve: (1) placement of the screws and rods in a percutaneous fashion; (2) performing the decompression through a tubular retractor; (3) disc space removal and preparation; and (4) placement of the interbody cage. Flouroscopic guidance and neuromonitoring are used to ensure accurate screw placement. The disc space and cage can be filled with bone and rhbmp-2 (Infuse™ — Medtronic Sofamor Danek) to enhance the fusion. Final images are taken

The Journal of the Hennepin and Ramsey Medical Societies

to ensure accurate screw and cage placement.

Incisions range from 1 to 1½ inches for single level fusions and are sealed with fibrin glue for cosmesis.

Clinical Results of Minimally Invasive Spinal Fusion In a landmark study, Schwender, et al. demonstrated excellent results at 22.6 months utilizing a minimally invasive approach in 49 patients.11 All patients reported improvement in back pain and radicular pain following surgery. The mean hospital stay was 1.9 days, and the average estimated blood loss was 140 ml.

Visual analog scale scores and Index improved from 7.2 to 2.1. The Oswestry Disability Index improved from 46 to 21. All patients in the study had a documented radiographic fusion.

They concluded that the procedure was technically feasible and clinical results were excellent.

Isaacs, et al. showed less intraoperative blood loss, hospital stay, and postoperative narcotic use in a series of 20 patients who underwent minimally invasive fusion compared to open procedures for single-level degenerative disease.12 Jang and Lee also reported on 23 patients with significant improvements in postoperative visual analog and Oswestry Disability Index scores.13 They summarized that minimally invasive fusion reduced blood loss and soft tissue injury while yielding significant improvements in function and disability.

Potential Complications Low rates of complications have been reported with this procedure. Screw misplacement can occur, but is rare. In the largest series of minimally invasive spinal fusion patients there were two instances of screw malposition in 49 patients.11 These can be repositioned on an outpatient basis and usually lead to resolution of symptoms. Small cerebrospinal fluid leaks can occur especially in revision settings.

Graft dislodgement and contralateral neuroforaminal compromise can also rarely occur, but respond well to treatment.

Rehabilitation The rehabilitation protocol plays a pivotal role in final patient outcome. Close communication between the surgeon and therapist with regard to protocols and patient progress is essential to ensure optimal results.

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Rehabilitation begins immediately on the day of surgery. The patient is usually discharged from the hospital within 24 to 48 hours of admission. Some patients can be discharged on the day of surgery if cleared by in-hospital therapists. Walking, stretching and isometric exercises are begun targeting the gluteals, hamstrings and quadriceps muscles. Pool exercises are added on the third week and gradually extended to include swimming. Upper extremity resistance exercises are added to increase total body fitness. Walking is transitioned to use of the stationary bike and treadmill. Most patients can return to normal activities by the third month. Return to work is determined by progress in therapy and occupational duties.

Conclusion Minimally invasive spinal fusion has evolved dramatically in the past few years and the results have been impressive. The technique allows complex problems to be addressed through minimal incisions which preserve normal anatomy. Less blood loss, shorter hospital stay and faster recovery make this an attractive option for both the surgeon and patient. With the rapid growth of spinal fusion procedures, minimal access technologies may provide the opportunity to ease the financial burden on the health care system while enhancing patient care and outcomes.

Stefano M. Sinicropi, M.D. is a graduate of Columbia University College of Physicians and Surgeons, and also completed his orthopedic residency at New York Columbia Presbyterian Hospital. After completing the Kenton D. Leatherman Spine Fellowship at the University of Louisville, he joined the Midwest Spine Institute. He is a candidate fellow of the American Academy of Orthopaedic Surgeons. Dr. Sinicropi specializes in minimally invasive surgery, scoliosis, tumors and trauma of the cervical, thoracic and lumbar spine.

Bibliography 1. Foley KT, Holly LT, Schwender JD: Minimally invasive lumbar fusion. Spine 28:S26–S35, 2003) 2. Rouben, DP. Advances in Spine Care Could Save Healthcare System Billions. River City Orthopaedic Surgeons Website.(Research Page) 3. Hibbs RH. An operation for progressive spinal deformities. N Y J Med 1911;93:1013 4. Stevens KJ, Spenciner DB, Griffiths KL, Kim KD, Zwienenberg-Lee M, Alamin T, Bammer R. Comparison of minimally

The Journal of the Hennepin and Ramsey Medical Societies

invasive and conventional open posterolateral fusion using magnetic resonance imaging and retraction pressure studies. J Spinal Disord Tech. 19(2):77-86, 2006.

5. Styf JR, Willen J: The effects of external compression by three different retractors on pressure in the erector spine muscles during and after posterior lumbar spine surgery in humans. Spine 23:354–358, 19982.

6. Gejo R, Matsui H, Kawaguchi Y, et al.: Serial changes in trunk muscle performance after posterior lumbar surgery.

Spine 24:1023–1028, 1999 7. Sihvonen T, Herno A, Paljarvi L, et al.: Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine 18:575–581, 1993 8. Cloward RB: The treatment of ruptured intervertebral discs by vertebral body fusion. I. Indications, operative technique, after care. J Neurosurg 10:154–168, 1953) 9. Harms JG, Rollinger H: Die operative Behandlung der Spondylolisthese durch dorsale Aufrichtung und ventrale Verblockung. Z Orthop 120:343–347, 1982 10. Foley KT, Smith MM: Microendoscopic discectomy. Tech Neurosurg 3:301–307, 1997 11. Schwender JD, Holly LT, Rouben DP, et al.: Minimally invasive transforaminal lumbar interbody fusion (TLIF): technical feasibility and initial results. J Spinal Disord Tech 18 (Suppl 1):S1–S6, 2005 12. Isaacs RE, Podichetty VK, Santiago P, et al.: Minimally invasive microendoscopy-assisted transforaminal interbody fusion with instrumentation. J Neurosurg Spine 3:98–105, 2005 13. Jang JS, Lee SH: Minimally invasive transforaminal lumbar interbody fusion with ipsilateral pedicle screw and contralateral facet screw fixation. J Neurosurg Spine 3:218–223, 2005 References

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November/December 2006

19

2006 MMA House of Delegates HMS and RMS Resolutions Report

Resolution 102, An MMA Physician Finder to Link the Public to MMA Member Practice Web Sites

Submitted by the Hennepin Medical Society and the Ramsey Medical Society.

House Action: Adopted as amended.

RESOLVED, that the Minnesota Medical Association (MMA) encourage its members to provide their practice Web site addresses for use in the Physician Finder and explore the option to advertise the Physician Finder service to the general public and patient support and advocacy organizations.

Resolution 103, The Independent Practice of Medicine

Submitted by the Ramsey Medical Society.

House Action: Referred to the MMA Board of Trustees.

Resolution 103, as submitted, read as follows: RESOLVED, that the Minnesota Medical Association form a task force to explore the reasons why physicians are abandoning the 20

November/December 2006

Resolution 402, Excessive Executive MD Pay

Submitted by the Hennepin Medical Society.

House Action: Referred to the MMA Board of Trustees.

Photo by Scott Smith

The 153rd Annual Meeting of the Minnesota Medical Association was called to order on Thursday, September 20, 2006. Forty-four Hennepin Medical Society members and 32 Ramsey Medical Society members served as delegates presenting a total of 40 resolutions for consideration. The work that was accomplished throughout the two-day meeting determines the policies and agenda of the Minnesota Medical Association for this and future years. Below is a summary of the actions taken on HMS and RMS resolutions only. Please visit www.mmaonline.org for a complete report of the actions.

MMA Board Chair, Michael Ainslie, M.D., HMS member, delivers his address to the House of Delegates.

independent practice of medicine and are moving to an employed medical staff model of medical practice, and to make recommendations to help preserve the ability of physicians to independently engage in the practice of medicine, and be it further RESOLVED, that the Minnesota AMA delegation carry a resolution to the AMA House of Delegates calling on the AMA to study all facets of the problems faced by independent physician-owned medical practices and to report back to the AMA House of Delegates with a series of recommended AMA policies to help preserve the ability of independent, physician-owned medical practices to survive and prosper.

The amendment recommended by the reference committee, but not acted upon by the House, read as follows: RESOLVED, that the Minnesota Medical Association (MMA) recommend that Minnesota-based residency programs incorporate education about the legal, financial, and management aspects of various medical practice models.

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RESOLVED, that the Minnesota Medical Association set as policy that a Minnesota Medical Association member should not accept excessive executive compensation that is not in line with the salary survey of the American College of Physician Executives.

Resolution 403, Pharmacists Refusal to Fill Prescriptions

Submitted by the Hennepin Medical Society and the Ramsey Medical Society.

House Action: Adopted as Amended.

RESOLVED, that the Minnesota Medical Association introduce and support legislation that requires pharmacies to ensure that protocols exist that provide patients with immediate access to emergency contraception in the event of a pharmacistâ&#x20AC;&#x2122;s refusal to ďŹ ll the prescription or request, and be it further RESOLVED, that the Minnesota Medical Association work with the Minnesota Pharmacists Association regarding this issue.

Resolution 404, Maternity Care Carve Outs

Submitted by the Hennepin Medical Society.

House Action: Adopted as Amended.

RESOLVED, that the Minnesota Medical Association support existing state law that prevents health insurance plan discrimination against maternity coverage.

The Journal of the Hennepin and Ramsey Medical Societies

Resolution 406, Improving Health Literacy

Submitted by the Ramsey Medical Society.

House Action: Adopted.

RESOLVED, that the Minnesota Medical Association work with interested parties including the Minnesota Hospital Association and Minnesota Alliance for Patient Safety, to develop a model of an informed consent document (written at an approximate 6th grade reading level) that may be used by Minnesota health care institutions, and be it further RESOLVED, that the Minnesota Medical Association work with the interested parties to implement more readable and understandable informed consent forms throughout Minnesota Health Care facilities so as to improve patient safety and understandability of decisions, and be it further RESOLVED, that the Minnesota Medical Association direct its American Medical Association delegation to submit a similar resolution to the American Medical Association House of Delegates to develop nationwide awareness and efforts through national patient safety organizations, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and other interested parties to improve informed consent forms for patients with low and marginal health literacy.

Resolution 407, Physician Education

Submitted by the Ramsey Medical Society.

House Action: Adopted as Amended.

RESOLVED, that the Minnesota Medical Association endorse the American Medical Association policy on the relationship between physicians and the pharmaceutical, device, and medical equipment industries (E-8.061), and be it further RESOLVED, that the Minnesota Medical Association educate physicians in Minnesota and our patients about the fact that physicians, and pharmaceutical and biotechnology companies must work together to continue to improve patient care, and be it further RESOLVED, that the Minnesota Medical Association establish a dialogue with the Pharmaceutical Research and Manufacturers

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HMS and RMS delegates gather for a joint caucus.

of America (PhRMA) and the Office of the Attorney General to help our Minnesota Medical Association sustain its mission of advocacy on behalf of physicians to help ensure access to all available forms of information for all physicians in the state of Minnesota.

Resolution 408, Health Plan Regulatory Accountability

Submitted by the Ramsey Medical Society.

House Action: Adopted as Amended.

RESOLVED, that the Minnesota Medical Association develop and lobby for legislation that: 1) clarifies the ability of the Board of Medical Practice to hold makers of health plan referral and treatment decisions accountable to the same regulatory review standards as other providers delivering medical services; and 2) defines referral and treatment decisions by health plans as medical practice.

Resolution 414, National All Schedules Prescription Electronic Reporting (NASPER)

Submitted by Alfred V. Anderson, M.D., Delegate.

House Action: Referred to the MMA Board of Trustees.

RESOLVED, that the Minnesota Medical Association educate elected officials about the negative consequences associated with legislation to establish a state controlledsubstance Electronic Reporting System, and be it further RESOLVED, that the Minnesota Medical Association actively oppose legislation to establish a state controlled-substance electronic reporting system as proposed by the National All Schedules Prescription Electronic Reporting

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(NASPER) law passed by Congress in 2005 in the 2007 legislative session.

Resolution 300, Mandatory Health Insurance

Resolution 300 was submitted by the Stearns Benton Medical Society. Resolution 304 was submitted by the Lake Superior Medical Society.

Resolution 308 was submitted by the Hennepin Medical Society and the Ramsey Medical Society.

House Action: Substitute Resolution 300 was Adopted in Lieu of Resolution 300, Resolution 304, and Resolution 308.

RESOLVED, that the Minnesota Medical Association reaffirm policy from the Physicians’ Plan for a Healthy Minnesota that would require, by law, that all residents of Minnesota have health care coverage for an essential set of benefits.

Resolution 305, Mandatory Drivers’ Testing

Submitted by the Hennepin Medical Society and the Ramsey Medical Society.

House Action: Referred to the MMA Board of Trustees.

RESOLVED, that the Minnesota Medical Association support efforts to require that Minnesota drivers 70 years and older renew their drivers license in person and not by mail; drivers 75 years and older be required to take a driving test at least every third year, and those 80 years or older to take a driving test yearly to prove continued competency to drive.

(Continued on page 22)

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Resolutions (Continued from page 21)

Resolution 309, Patient Care Management Fee

Submitted by the Hennepin Medical Society and Ramsey Medical Society.

Resolution 306, Improve Beverage Selection in Vending Machines and Cafeterias in Health Care Facilities

House Action: Not Adopted.

Submitted by the Hennepin Medical Society and the Ramsey Medical Society.

Submitted by the Ramsey Medical Society.

RESOLVED, that the Minnesota Medical Association educate members about payment options of a monthly case management fee for primary care services, which include case management, and ongoing care for patients suffering with chronic illness, and be it further

House Action: Not Adopted.

RESOLVED, that the Minnesota Medical Association recommend removing sugaradded pop (non-diet pop), sports drinks, and sugar-added juices from vending machines in health care facilities and hospital cafeterias, and replacing them with healthier options.

RESOLVED, that the Minnesota Medical Association work in collaboration with the Minnesota Academy of Family Physicians and other specialty organizations, to develop criteria and guidelines for such case management retainer agreements with patients, and be it further

Resolution 307, Health Savings Account (HSA) or Health Reimbursement Account (HRA) Payments for Physician Services

Submitted by the Hennepin Medical Society.

House Action: Referred to the MMA Board of Trustees.

RESOLVED, that the Minnesota Medical Association work with insurance companies to clarify that HMO or PPO contractual allowances are not appropriate for any HSA or HRA payments that are the patient’s responsibility, if the billing and collecting process is not the same and if the payments to the physician are not as timely.

Resolution 311, High Deductible Health Plan (HDHP) Combinations for Medicaid and Other Public Programs: “Medical IRAs” for the Poor

RESOLVED, that the Minnesota Medical Association endorse and introduce legislation in the Minnesota Legislature requiring the successful completion of a crash avoidance course and a more rigorous skills test before issuing a drivers license to anyone age 16 through age 17; and that drivers age 16 through age 17 would not be allowed to have other teenagers in the motor vehicle without the supervision of an adult; and that drivers age 16 through age 17 would be prohibited from driving after 11 p.m.

Submitted by the Ramsey Medical Society.

House Action: Referred to the MMA Board of Trustees.

House Action: Adopted as Amended.

Photo by Scott Smith

Submitted by the Ramsey Medical Society.

House Action: Referred to the MMA Board of Trustees.

Resolution 318, Drowsy Driving

Submitted by Mark Mahowald, M.D., Delegate.

Submitted by Macaran A. Baird, M.D., Delegate.

November/December 2006

RESOLVED, that the Minnesota Medical Association involve the component medical societies, the Minnesota Medical Group Management Association (MMGMA), and others in actively organizing seminars and conferences to educate providers and the public about dealing with the emerging high deductible health plan market and variations of high deductible health plans.

Resolution 314, Teenage Drivers’ Licensing

Resolution 312, Physician Telephonic Visit

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House Action: Referred to the MMA Board of Trustees.

RESOLVED, that the Minnesota Medical Association delegation to the AMA submit a resolution asking that the AMA lobby Congress and the CMS to allow physician retainer agreements for Medicare enrollees.

RESOLVED, that the Minnesota Medical Association develop and lobby for a plan to use high deductible health plans (HDHPs) for applicable Medicaid populations and for other public sector programs.

Macaran Baird, M.D. testifying at a Reference Committee.

Resolution 313, Seminars on the Emerging Market of High Deductible Health Plans (HDHPS) For Providers, Employers, and Public

RESOLVED, that the Minnesota Medical Association establish a strategy to encourage health plans to recognize the appropriateness, safety, and compensatory value of telephonic visits provided by their subscriber’s health care team, and likewise examine the use of the Internet as a valuable, reimbursable patient encounter opportunity.

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House Action: Referred to the MMA Board of Trustees.

RESOLVED, that the Minnesota Medical Association encourage physicians to inform patients reporting excessive daytime sleepiness about the connection between sleep deprivation, drowsy driving and fatal accidents, and encourage physicians to document the interaction in the medical record, and be it further RESOLVED, that the Minnesota Medical Association encourage physicians to advise patients involved in a crash related to sleep

The Journal of the Hennepin and Ramsey Medical Societies

Photo by Scott Smith

RESOLVED, that the Minnesota Medical Association advocate for an increase in the excise tax on beer, wine, and spirits by the equivalent of $.10 a drink and that these increased funds be used for prevention, treatment, and public safety services related to alcohol abuse, and be it further

Anne Murray, M.D., provides testimony.

deprivation to stop driving until the underlying condition is identified and treated, and be it further RESOLVED, that the Minnesota Medical Association encourage all drivers education programs to use accurate sleep information in text books and to include warnings about the dangers of sleepiness and driving in the curriculum, and be it further RESOLVED, that the Minnesota Medical Association send a letter to police chiefs and top law enforcement officials calling for increased awareness among rank and file officers about the dangers of sleepiness and driving and calling for officers to learn the signs of sleep-related crashes and to — when the evidence indicates it — report sleepiness as the cause of a crash, and be it further RESOLVED, that the Minnesota Medical Association lobby to have the state of Minnesota fund a study to determine if sleep related accidents are underreported and to adopt a “drowsy driving” highway safety program that includes installing more rumble strips along road ways and more safe rest stops.

Substitute Resolution 201, Alcohol Health Impact Tax

Resolution 201 was submitted by the Hennepin Medical Society. Resolution 210 was submitted

by Carl E. Burkland, M.D., Delegate.

House Action: Substitute Resolution 201 was Adopted in Lieu of Resolution 201 and Resolution 210:

RESOLVED, that the Minnesota Medical Association support that future alcohol excise tax increases keep pace with inflation, and be it further RESOLVED, that the Minnesota Medical Association consider alcohol abuse, particularly among underaged drinkers, one of its public health priority issues.

Resolution 202, Clinic-Level Access to Quality Data Reports Via Electronic Medical Records

Submitted by the Hennepin Medical Society.

House Action: Not Adopted.

RESOLVED, that the Minnesota Medical Association advocate for the use of electronic medical record data to improve the value of quality reporting for patient care by working with health plans, professional medical groups, the Institute for Clinical Systems Improvement (ICSI), and the Minnesota Community Measurement Project to develop quality measures with specified data standards that allow direct reporting from an electronic health record, and be it further RESOLVED, that the Minnesota Medical Association advocate for the use of electronic health records (EHR) to provide data for reporting on disease registries, preventive care screening, and chronic disease management criteria that can be used internally by medical clinics as well as by health plans, and Minnesota Community Measurement as the reportable data, and be it further RESOLVED, that the Minnesota Medical Association support payment to providers for delivery of standardized quality data obtained electronically from the clinical record to health plans and the Minnesota Community Measurement Project and other entities that need this data.

Resolution 203, Electronic Medical Records

Submitted by the Hennepin Medical Society.

House Action: Substitute Resolution 203 was Adopted in Lieu of Resolution 203.

RESOLVED, that the Minnesota Medical Association (MMA) reaffirm policy 290.2483 paragraph D that states: “Payment Systems to Support Quality Practice. The MMA will advocate for the adoption and expansion of payment policies by public and private payers (sometimes referred to as “pay for use”) that will financially reward physician actions to improve their capacity and ability to deliver more efficient, effective care (e.g., the installation of electronic health records, computerized pharmacy-order entry systems, clinical decision-support systems, disease and case management, team-based care, etc.) (BT07/2005).”

Resolution 204, Dysmetabolic Syndrome and Type 2 Diabetes in Children

Submitted by the Hennepin Medical Society.

House Action: Adopted as Amended.

RESOLVED, that the Minnesota Medical Association Obesity Task Force collect and disseminate information about the problem of insulin resistant Type 2 diabetes mellitus in children to the physicians who treat children and be it further RESOLVED, that the Minnesota Medical Association delegation to the American Medical Association submit a resolution asking the American Medical Association to promote the study of the circumstances associated with this new onset of insulin-resistant Type 2 diabetes mellitus in children and recommend methods of prevention and treatment of this new public health threat.

Resolution 205, Generic Rx P4P

Submitted by Lee Beecher, M.D., Delegate.

House Action: Referred to the MMA Board of Trustees.

RESOLVED that the Minnesota Medical Association oppose pay-for-performance con(Continued on page 24)

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November/December 2006

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Resolutions (Continued from page 23)

tract clauses in Minnesota health plan provider and insurance provider agreements that link increased physician or clinic reimbursements to physician prescriptions for generic medications rather than branded products.

Resolution 206, Complete Immunization Data Availability for Children, Infants, Adults, and Geriatric Patients

Submitted by the Hennepin Medical Society.

House Action: Adopted as Amended.

RESOLVED, that the Minnesota Medical Association support statewide immunization data availability, and be it further

RESOLVED, that the Minnesota Medical Association encourage members to choose electronic medical records products that are functionally interoperable with state immunization registries, or include in their vendor contracts a commitment to program for this functionality.

Resolution 207, Generic Rx P4P, Formulary Sunshine, and Medicare Part D Regulation

Resolution 212, Fair Pay for Clinic and Hospital Pay-for-Performance Services

Submitted by the Hennepin Medical Society and Ramsey Medical Society.

Submitted by the Ramsey Medical Society.

House Action: Substitute Resolution 207 was Adopted in Lieu of Resolution 207.

House Action: Adopted as Amended.

RESOLVED, that the Minnesota Medical Association advocate that third-party payers reimburse health care providers for costs related to pay-for-performance data collection and reporting.

RESOLVED, that the Minnesota Medical Association amend existing policy 280.17 to read as follows: The Minnesota Medical Association (MMA) will advocate that health plans and insurance companies make readily available to all enrollees and their physicians allowable

Photo by Scott Smith

RESOLVED, that the Minnesota Medical Association encourage hospitals, health care providers, and long-term care facilities to enter immunization data into the Minnesota Immunization Information Connection database to maintain a complete record of immunizations that can be used by health care

payment amounts and patient co-payments for all covered tests, procedures, and pharmaceuticals in the patient’s insurance contract; such information, as well as information about provider prior authorization requirements, shall be made easily accessible to patients preferably through a Web interface. The MMA will submit a resolution to the American Medical Association (AMA) requesting that the AMA advocate for patient-specific payment disclosure to patients and their treating physicians prior to receiving services.

providers to assure complete immunization and avoid duplication of immunization, and be it further

Minneapolis City Councilmember Gary Schiff, St. Paul City Councilmember Dave Thune, Bloomington Councilmember Steve Elkins, and Golden Valley Mayor, Linda Loomis address the MMA Inaugural Reception emphasizing the successful smoke-free ordinances in their communities. In addition, Councilmember Thune played guitar with his band the “Backstreet Boogie Band” during the reception after the President’s Inaugural Dinner.

From left: RMS members elected to MMA Office: Frank Indihar, M.D., MMA Delegate to the American Medical Association; David Thorson, M.D., MMA East Metro Trustee; Blanton Bessinger, M.D., MMA Alternate Delegate to the American Medical Association; Lyle Swenson, M.D., MMA House Vice Speaker; and Todd Brandt, M.D., MMA East Metro Trustee.

Dianne Fenyk, was acknowledged as President-Elect to the American Medical Association Alliance. She will begin serving her term as AMAA President in June 2007.

The MMA Awards Committee has established a new recognition for our colleagues who have served their communities and our organization through the decades. They recognize physicians in Minnesota Medicine who have practiced medicine and maintained their MMA membership for 10, 20, 30, 40, 50 and 60 years.

The following HMS physicians were in attendance for 50-year recognition: Frederick C. Goetz, M.D.; Eugene C. Ott, M.D.; and John C. Whitacre II, M.D. Not in attendance, but honored were: W. H. Hollinshead, Jr., M.D., RMS-60 Years; Samuel W. Hunter, M.D., RMS-50 Years; Edward B. Kiolbasa, M.D., RMS-50 Years; Guillermo Mateo, M.D., RMS-50 Years; George A. Mann, M.D., HMS-50 Years; and William H. Rock, M.D., HMS-50 Years.

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November/December 2006

Eugene C. Ott, M.D.

MetroDoctors

John C. Whitacre II, M.D.

Frederick C. Goetz, M.D.

The Journal of the Hennepin and Ramsey Medical Societies

Douglas Pryce, M.D., HMS, and J. Kevin Croston, M.D., HMS, each received an MMA Community Service Award.

Photo by Scott Smith

Photo by Scott Smith

Judith Shank, M.D., presents Charles R. Meyer, M.D., HMS, with the Physician Communicator Award, given to a physician who demonstrates exemplary skill in communicating with the public through radio, television, or the newspapers and whose work contributes to a better understanding of medicine and health in Minnesota.

Dr. Meyer serves as the editor-in-chief of Minnesota Medicine.

Daniel Franc, medical student, RMS, and Gretchen Crary, M.D., RMS, pose with their Certificates of Recognition after completing terms on the MMA Board of Trustees.

James Jordan, M.D., RMS President, congratulates Frank Indihar, M.D., RMS, on winning the MMA Distinguished Service Award. The Distinguished Service Award is the highest honor that the MMA gives to physicians. Dr. Indihar is board certified in internal medicine, a Vice President of HealthEast Care System, Inc. and the CEO/Medical Director of Bethesda Hospital.

The award winner was announced at the MMA Inaugural Dinner on September 14th.

Barbara Leone, M.D. was honored with the Minority Meritorious Service Award.

This award is given to physicians who have provided outstanding medical service to minority populations by helping to increase access to care and better understanding of diseases prevalent in minority groups. She is pictured with Juan M. Bowen, M.D., chair of the MMA Minority & Cross Cultural Affairs Committee. Dr. Leone is a family physician at University Family Physicians North Memorial Clinic and was nominated by Charles E. Crutchfield, M.D.

Lisa McGinnis, HMS, received the Medical Student Award for outstanding commitment to the medical profession.

Members in the News JACK M. BERT, M.D. has been elected second vice-president of the Arthroscopy Association of North America (AANA). The AANA is the primary source of continuing medical education for practicing arthroscopists and a conduit for new techniques and information concerning the subspecialty. Dr. Bert is a clinical professor at the University of Minnesota Medical School and practices at Summit Orthopedics with offices in St. Paul, Eagan, Forest Lake, Hastings, Maplewood and Woodbury.

LAURA DEAN, M.D., FACOG, who is a Fellow-at-Large of the American College of Obstetrics and Gynecology’s Executive Board, MetroDoctors

joined President George W. Bush at a health policy forum in Minnetonka, MN on Tuesday, August 29, 2006. The President signed an executive order that day, requiring four federal agencies to provide health-care cost and quality data. The goal of the order is to give health consumers more information in choosing facilities and providers. But medical liability reform was a big topic with the President. Dr. Dean practices obstetrics and gynecology at Stillwater Medical Group.

JEFFREY SCHIFF, M.D. has been named medical director for Minnesota’s state-subsidized health care programs. He will be medical director at the Minnesota Health

The Journal of the Hennepin and Ramsey Medical Societies

Care programs, part of the state’s Department of Human Services (DHS). He will also lead the DHS Health Services Advisory Council.

These two positions were established by the 2005 Minnesota legislature. Dr. Schiff is an emergency medicine pediatrician with Children’s Hospitals and Clinics in St. Paul and will continue to practice part time at Children’s Hospital.

Please send your news items to: Editor, MetroDoctors, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413, fax to (612) 623-2888 or e-mail: dhines@metrodoctors.com for consideration by the editorial board.

November/December 2006

25

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

Time to Talk and Way More RMS-Officers

President James J. Jordan, M.D. President-Elect V. Stuart Cox, M.D. Past President and MMA Trustee Charles G. Terzian, M.D. Treasurer Peter B. Wilton, M.D. RMS-Board Members

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

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

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

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November/December 2006

D

DRIVING HOME RECENTLY from the mental health clinic I direct, I found myself engrossed in a conversation on Minnesota Public Radio.

Dr. John Hallberg, who heads up the Center for Medical Humanities at the University of Minnesota, was describing the importance of putting the person back into the patient. If he had been sitting next to me, we would have had much to talk about.

A family physician, Dr. Hallberg highlighted primary care providers’ concern that insurance companies do not fairly reimburse them for the time it takes to do an intensive history, or to counsel and support patients who face serious and chronic problems such as obesity, diabetes and depression.

Psychiatrists and their patients also face these limitations. According to a recent study reported in the American Journal of Managed Care1, “more than 80 percent of patients had no mental health visits with health care providers during the first four weeks after starting antidepressant therapy, and the average patient had only one or two face-to-face visits for any purpose during that period.” These numbers fall below FDA guidelines for follow-up treatment of patients who have received a prescription for anti-depressants. In addition, these numbers reflect what can happen to comprehensive health care when physicians do not feel as though the financial costs of in-depth treatment outweigh the benefits.

In a nation with only 40,000 psychiatrists, family practice doctors are often the first contact for patients suffering from anxiety, depression, or other major mental illnesses. While busy primary care providers are doing their best, their time constraints and reimbursement restrictions can mean that these physicians are able to treat only the symptoms of mental illness without fully examining what underlies these symptoms and without providing necessary follow-up care.

In short, what these patients — these people — are likely not receiving, is necessary psychotherapy. While this lack of treatment is distressing for a range of conditions, research findings clearly demonstrate the benefits of utilizing psychotherapy in the treatment of depression. Our own research at Hamm Clinic provides MetroDoctors

evidence of the effectiveness of a multi-disciplinary treatment approach — and preliminary data suggest that psychodynamic therapy may be particularly effective with longer-term, lower-grade depression. Comprehensive treatment takes time and it takes a commitment from both patients and their doctors to have an open, well-balanced dialog about the risks and benefits of all available treatments, but it is imperative.

Further, though all physicians face issues of cost, new physicians have particular concerns.

Young primary care providers not only face insufficient time to provide the vital personal dimension of treatment, but also low reimbursement rates. Young psychiatrists also face low reimbursements, as well as cutbacks in psychotherapy time for their patients — despite the fact that many studies confirm the need for psychotherapy to accompany pharmacologic treatment. In effect, at a time when they are paying off medical school loans the size of a home mortgage, these young doctors are penalized when they spend more time with their patients than insurance providers will compensate. This happens despite the fact that time with patients may be essential for physicians to provide thorough and cost-effective treatment in the long run.

I’ve said it before and I will say it again, physicians need to be compensated for the time it takes to get to know the real health needs of their patients. For psychiatrists, that equation may include medication, but it most certainly requires psychotherapy. In fact, the model for mental health delivery supported by the Minnesota Legislature, the Minnesota Medical Association and medical societies reflects the need for this combination of treatment elements. Patients in this country need comprehensive care, which includes sufficient time with their doctors.

I think Doctor Hallberg would agree.

Footnotes: 1) Frequency of Follow-up Care for Adult and Pediatric Patients During Initiation of Antidepressant Therapy. [Online] http://www.ajmc.com/Article.cfm?Menu=1&ID=3169.

August 2006.

The Journal of the Hennepin and Ramsey Medical Societies

RMS IN ACTION SUE SCHETTLE, RMS DIRECTOR

Ramsey County

RMS has been involved in the smoke-free initiatives in Ramsey County for the past few years, and is still an active Ramsey Tobacco Coalition member to date. We are working with our coalition partners in Ramsey County to identify physicians to testify at public hearings and to speak out on behalf of their patients.

Ramsey County enacted an ordinance in 2004 that went into effect in 2005 but had a provision in it that allowed establishments the ability to obtain an exemption if certain criteria were met. It is expected that in early to mid 2007 that the county commissioners will re-address this issue. If you have an interest in becoming directly involved, please contact Roger Johnson at rjohnson@metrodoctors.com to find out more details.

Washington County

RMS is also taking the lead on community assessment and planning in Washington County as it relates to readiness to address smoke-free public policies. Sue Schettle, Director of RMS, is heading up this first phase of our three plus year project in Washington County, which will likely last for up to 18 months. This project is funded by Blue Cross Blue Shield of Minnesota through its Communities for Healthy Air project. To learn more about working in Washington County, please give Sue a call at (612) 623-2889, or e-mail her at sschettle@ metrodoctors.com.

Dakota County

Dakota County Smoke-Free Communities MetroDoctors

Partnership project is also well underway, with project coordinator Julie Johnson and community organizer Diane Tran on board and working hard. The Dakota County Smoke-Free Communities Partnership met in September and addressed a number of different things including the staff reporting on their initial community assessments and next steps.

Visit the Web site www.smokefreedakota.org to learn about ways in which you can become involved in the terrific work that Julie and Diane are doing.

RMS president, met in August and discussed a number of different things including the MMA’s recent work in ranking the health plan tiering systems using transparency criteria that included the methodology used to tier physicians; the criteria for cut-off decisions between tiers; data that determined tiering placements; usefulness of information about cost and quality of referrals, and treatment options; and the relevance of quality measures.

RMS In Action Meetings with elected officials

On Monday, September 11 RMS co-hosted with MMA a breakfast meeting for physicians with DFL Congresswoman Betty McCollum, who represents Minnesota’s Fourth Congressional District. RMS and the MMA also co-hosted physician meetings with other elected officials including a meeting on Thursday, August 10 with Republican Rep-

Janet Silversmith, Director of Health Policy for the MMA, (Back row third from the left) reviewed the MMA report titled “The Tiering of Minnesota Physicians.”

resentative Denny McNamara (57B);

Friday, September 8 with DFL gubernatorial candidate Mike Hatch; Wednesday, August 9 with Republican Congressman Jim Ramstad, who represents Minnesota’s Third Congressional District; and on August 29 with Congressman John Kline, representing Minnesota’s 2nd Congressional District.

MMA Annual Meeting

The Minnesota Medical Association Annual meeting was held September 14 and 15 this year at the Minneapolis Convention Center.

RMS had 33 delegate slots available to the membership and presented a total of 14 resolutions, six of which were jointly sponsored with Hennepin Medical Society. Look for further details on the annual meeting proceedings in this issue of MetroDoctors.

Other RMS Actions The Ramsey Medical Society Board of Directors, led by Dr. James Jordan,

The Journal of the Hennepin and Ramsey Medical Societies

The RMS Board of Directors met in August at United Hospital, St. Paul.

The Ramsey Medical Society Executive Committee, chaired by Dr. Jordan, met in July and August.

The Ramsey Medical Society Foundation Board of Directors, chaired by Dr. Robert Moravec, met in August.

Formerly known as the RCMS, Inc. Board of Directors, now called Minnesota Physician Services, Inc. Board of Directors,

met in August and September. This group is chaired by Dr. Peter Bornstein and is working (Continued on page 28)

November/December 2006

27

Ramsey Medical Society

Smoke-Free Project Updates Ramsey Medical Society (RMS) is pleased to be working on smoke-free public policies in the communities within our service area.

Physicians are very interested in the health of their patients, and are therefore very eager to work toward reducing the harm that is caused by exposure to secondhand smoke. We are excited to talk about three initiatives that RMS is directly involved with.

RMS In Action (Continued from page 27)

to increase the non-dues revenue opportunities for the society. The September meeting focused solely on brainstorming and formulating new ideas of potential growth, which the group will investigate further.

Ramsey Medical Society’s Nominating Committee met in August and reviewed the slate of candidates for various positions that are open on the RMS Board of Directors. They were pleased to nominate Dr. Peter Wilton to be a candidate for president-elect, and Dr. Ron Hansen for secretary-treasurer. Physicians who have agreed to be candidates for Board positions and who have been endorsed by the nominating committee are Drs. Art Beisang, Nick Meyer, Jerome Perra, Lon Peterson and Scott Uttley.

Save the Date

RMS Promotes Connections Mentoring Program Ramsey Medical Society is again partnering with the Hennepin Medical Society and the University of Minnesota to promote their Connections program.

Each November, the Connections Physician-Student Mentoring Program matches physicians with current medical school stu-

dents. Relationships vary depending on what the mentor and mentee want from the relationship, but in many cases, lifelong friendships have resulted. All Twin Cities-area physicians are invited to participate, not just University of Minnesota alumni.

In Memoriam CHRISTOPHER J. BROWN, M.D. died on September 27, 2006 at the age of 70. Dr. Brown graduated from Northwestern University Medical School. He was a board certified ophthalmologist practicing at Lexington Eye Assoc., P.A. until his retirement in 2000. Dr. Brown joined RMS in 1968.

JAMES P. BROWN, M.D. died at the age of 72 on September 3, 2006. Dr. Brown received his medical degree from the University of Minnesota. He completed an ophthalmology residency at the Mayo Clinic. Dr. Brown was one of the founders of St. Paul Eye Clinic and retired in 1997. He joined RMS in 1966.

Meeting With Congresswoman McCollum

“Interviewing Minnesotans About Health Care: They Want Greater Involvement in Decisions”

Speaker: R. Scott Wright, M.D. Candidate for MN Senate Rochester, District 30 Friday, November 17, 2006 7:30 a.m. – 8:30 a.m.

DFL Congresswoman Betty McCollum attended a breakfast meeting at the Louisiana Café in St. Paul on September 11, 2006. RMS physicians and staff from the MMA and RMS attended the meeting and provided the Congresswoman with their perspectives on various health care issues.

United Hospital Heart and Lung Building Conference Hall 225 N. Smith Avenue, St. Paul, MN 55102 Lower Level

Sponsored jointly by the Ramsey Medical Society and the medical staffs of United Hospital and HealthEast Hospitals.

The public is welcome.

CME and CEU credits are available.

Please contact Marge Avoles in Physician Services at (651) 241-8548 with questions about this presentation.

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November/December 2006

(From left) Stuart Cox, M.D., Representative Betty McCollum, James Jordan, M.D., and Chuck Terzian, M.D.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

CHAIR’S REPORT PAUL A. KETTLER, M.D.

Medical Staff Governance

T

THE MEDICAL STAFF’S independence and

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

governance is of critical importance to all physicians. As costs and regulations increase and reimbursement decreases, physicians have become less active in the hospital. Apathy has become the norm with fewer physicians involved in the governance of their medical staffs. The medical staff is independent of the hospital and should work in parallel, not being subordinate to the governing board.

The rights and obligations of each physician of the medical staff in every hospital are outlined in its bylaws. These bylaws are the rules adopted by the medical staff and the governing board of the hospital that define the governance of its members and the regulation of its affairs. When is the last time you’ve physically seen, let alone read, your medical staff’s bylaws? I remember the packet of information I was given when I obtained medical staff membership for the first time. I quickly skimmed these materials and never thought much about it again, as I had many patients and a new practice to attend to.

Much has changed since then with my involvement in medical staff leadership, which eventually led to my involvement in organized medicine. I’ve come to know how important these documents are and have actually read them in their entirety (more than once). The bylaws are our constitution, serving as our contract with one another and the hospital.

There is little in Minnesota statute regarding the hospital medical staff, its governance, independence and rights. Existing statutes confirm the medical staff is responsible for the clinical and scientific work of the hospital.

It will also be called upon to advise regarding problems and policies. The medical staff is responsible to the governing board of the hospital, which has ultimate authority. The medical staff will also formulate and adopt bylaws, rules, regulations, and policies for the proper conduct of its work.1 It is then the

HMS-Board Members

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

Michael B. Ainslie, M.D., MMA Trustee Beth A. Baker, M.D., MMA Trustee Karen K. Dickson, M.D., MMA Trustee David L. Estrin, M.D., AMA Alternate Delegate Eleanor Goodall, Co-Presiding Chair, HMS Alliance Donald M. Jacobs, M.D., MMA Trustee Roger G. Kathol, M.D., MMA Trustee Dawn Lunde, MMGMA Representative Jason Meyers, Medical Student Representative Richard K. Simmons, M.D., Sr. Physicians Association Representative Karin M. Tansek, M.D., MMA Trustee Trish Vaurio, Co-Presiding Chair, HMS Alliance Benjamin H. Whitten, M.D., AMA Alternate Delegate HMS-Executive Staff

Jack G. Davis, Chief Executive Officer Jennifer Anderson, Smoke-Free Project Coordinator Nancy K. Bauer, Assistant Director, and Managing Editor, MetroDoctors Kathy R. Dittmer, Executive Assistant

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

board’s responsibility to assure accountability of the medical staff. The board should not assume a duty or responsibility of the medical staff hastily, unreasonably, or in bad faith.

The bylaws outline the purpose of the medical staff, qualifications for membership, rights and responsibilities, organizational structure, credentialing, corrective action (fair hearing), election of officers, other general provisions, and the process of amendment and adoption. With this in mind, here are a few questions to ponder. Who determines the qualifications for membership? How are exclusive contracts handled in the hospital bylaws? What are your rights of appeal if there is an adverse action on your membership or privileges? Does economic credentialing exist at your hospital?

Does the medical staff have control over its dues and budget? How are the bylaws and its policies amended? These are all questions no one gives much thought about…until one has been personally affected by them. WAKE UP! (I just wanted to make sure I haven’t lost you; this topic has been clinically shown to cause drowsiness and fatigue in lab rats and medical students).

Most bylaws have core content, as described above, and associated policies and manuals. For most medical staffs, an amendment of the bylaws requires a two-thirds vote of the medical executive committee (MEC) before it is brought to the medical staff for discussion and vote. A quorum and two-thirds vote are required for adoption by the medical staff. The amended bylaws are then sent to the governing board for approval. The exact process is outlined in the medical staff bylaws.

The bylaws cannot be amended unilaterally, (Continued on page 30)

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Hennepin Medical Society

HMS-Officers

HMS Chair’s Report (Continued from page 29)

although there have been cases of litigation brought by medical staffs against hospitals across the country surrounding this issue.

Over time the structure and content of the bylaws has changed; more is being pulled out of the bylaws and into policies and manuals (an issue the Joint Commission and Accreditation of Hospital Organizations is currently reviewing). Often these policies and manuals are of great importance as they directly impact the medical staff (i.e. credentials, rules and regulations, corrective action and fair hearing).

However, the critical difference is these policies and manuals do not go through the same amendment process as bylaws, often requiring only the approval of the MEC and governing board. This process bypasses input and voting by the medical staff, increasing the power of the MEC. Do the members of the MEC consistently represent the interests of the medical staff who elected them? Not necessarily. Some agendas are driven from administration or the board through the MEC. Do you trust your MEC, hospital administration, and governing board to do the right thing? Do any physicians on your MEC have conflicts of interest? Are they employed physicians of the hospital? Does that matter? Physicians must have a voice and a vote on these critical issues and not delegate this solely to the MEC. Certainly there are things, such as the operations manual and other less significant policies that can be delegated to the MEC. The key issue is the proper balance of power between the medical staff, the MEC, and the governing board. Once a right or privilege is given up, it is very difficult to get back.

In other parts of the country there have been significant problems surrounding these issues — some resulting in litigation. As a result, California passed legislation that codifies the self-governance principles of hospital medical staffs. This statute does not undermine the authority of the governing bodies, but acknowledges the responsibilities and obligations of the governing board and the medical staff. I find these principles to be essential and would 30

November/December 2006

like to see similar legislation in Minnesota. The six self-governance principles are as follows: • Initiating, developing and adopting medical staff bylaws, rules, regulations, and amendments thereto, subject to the approval of the hospital governing board, which approval shall not be unreasonably withheld.

• Selecting and removing medical staff officers.

• Assessing medical staff dues and utilizing the dues as appropriate for the purposes of the medical staff.

• The ability to retain and be represented by independent legal counsel at the expense of the medical staff.

• Establishing, in medical staff bylaws, rules or regulations, criteria and standards for medical staff membership and privileges, and for enforcing those criteria and standards.

• Establishing in medical staff bylaws, rules or regulations, clinical criteria and standards to oversee and manage quality assurance, utilization review and other medical staff activities including, but not limited to, periodic meetings of the medical staff, its committees and departments, and review and analysis of patient medical records.2 In summary, the relationship between a hospital and its medical staff should be horizontal and balanced, rather than being adversarial or subordinate. It should also promote partnering in high quality patient care. This requires mutual respect and trust to be accomplished. Fortunately, Minnesota has not seen the turmoil other medical staffs have experienced across the country, but it is clear medical staff independence and self-governance is being threatened. As a result, Hennepin and Ramsey Medical Societies have formed a joint task force to examine medical staff governance and independence.

“You may be deceived if you trust too much, but you will live in torment if you do not trust enough.” Frank Crane

In Memoriam DONALD AMATUZIO, M.D., died peacefully at home on August 13, 2006, as a result of end-stage kidney failure. He was 88. He graduated from the University of Minnesota and completed an internship at Mercy Hospital in Chicago. After completing his internship he entered the Navy and served as a physician on the USS Merrimack, and at Naval Hospitals in Japan. After his discharge in 1950, he was called back into duty for the Korean Conflict where he cared for wounded Marines in Japan.

Dr. Amatuzio was a research scientist, and Associate Professor at the University of Minnesota Medical School. He practiced internal medicine in Minneapolis with Dr. Ralph Silas and Dr. Frank Martin. He joined HMS in 1955.

PAUL A. WILLIAMS, M.D., died recently at the age of 78. He graduated from the University of Minnesota Medical School. With his goal to be a pilot he enlisted in the Air Force for his residency as a general practice doctor where he became a flight surgeon during the Korean War at Tripler in Hawaii and at Malden, Missouri. In 1957 he started his medical practice in Columbia Heights and later joined the Silver Lake Clinic for the rest of his medical practice.

He was a founding doctor at Unity Hospital.

Being featured on the show 60 Minutes as one of the last doctors to do house calls was one of the many rewards he received. He also received the Physician of the Year Award from Unity Hospital. In 1989 he became a heart replacement recipient, which ended his career.

Dr. Williams joined HMS in 1957.

FREDERICK CARL WUEST, M.D., age 76, died peacefully surrounded by his family on Aug. 16, 2006. He graduated from New York Medical College. Dr. Wuest was an ophthalmologist and the founder of the Northwest Eye Clinic. He joined HMS in 1964.

(Footnotes) 1) MN statute 4640.0800 2) Document #1218 The CMA-Sponsored Medical Staff Self-Governance Bill: A Primer on SB 1325

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

HMS NEWS

HMS Senior Physicians Association Nancy Bauer Rejoins HMS

Jennifer Anderson Joins HMS Jennifer Anderson has joined the HMS staff as the Smoke Free Project Coordinator for Scott County. As previously reported, HMS received a grant from Blue Cross Blue Shield of Minnesota for a tobacco project for Scott County designed to address the issue of secondhand smoke in the workplace. This is a continuation of the work started in Minneapolis and Hennepin County the last three years.

Jennifer is a native of Mankato, received a Masters Degree in Health and Human Services Administration from St. Mary’s University in 2005, and has worked the last several years as a Health Outreach Coordinator working on the health disparities issues in the Jordan (north Minneapolis) neighborhood. “We are very happy to have Jennifer join us to lead the development of a Scott County collaborative to address the issue of secondhand smoke,” says Jack Davis, HMS CEO. MetroDoctors

Seymour Handler, M.D. Seymour Handler, M.D. was the guest speaker at the Sr. Physicians Luncheon and discussed “Evidence-based medicine — myths and reality,” on September 19. Dr. Richard Burman, president-elect, chaired the meeting with 60 people in attendance.

Next Meeting The next meeting of the Senior Physicians Association is scheduled for Tuesday, November 14, 2006. Jan Malcolm, chief executive officer of the Courage Center, will discuss “My Perspective on Health Care —Through My Vantage Points.” The meeting will take place at Zuhrah Shrine Center; social hour will begin at 11:30; lunch will begin at 12 noon.

If you are interested in joining the Sr. Physicians Association, contact Kathy Dittmer at (612) 623-2885 or kdittmer@metrodoctors. com.

Senior Physicians Association members received a back stage tour of the new Guthrie Theater.

Senior Physicians Association members enjoying lunch at the Guthrie overlooking the river.

Seymour Handler, M.D., (left) and Richard Burman, M.D.

Carl Burkland, M.D., Sets the Stage for an Alcohol Use Initiative Carl Burkland, M.D. delivered passionate testimony at the recent MMA House of Delegates meeting calling on the MMA to take action to increase the excise tax on beer, wine and spirits by $.10/drink and the revenue be used for prevention, treatment and public safety services related to alcohol abuse. He further

The Journal of the Hennepin and Ramsey Medical Societies

encouraged the MMA to consider alcohol abuse, particularly among underaged drinkers, as one of its public health priority issues.

(See related story on page 9.) In support of this issue, Dr. Burkland and Nancy Bauer, HMS Assistant Director, have attended meetings of the FACTS Coalition (Facing Alcohol Costs to Society), an organization founded to educate the public about the disparity between the costs of alcohol-related problems and the relatively small amount of revenue collected

by Minnesota.

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31

Hennepin Medical Society

“She’s back!” Jack Davis is pleased to report that after a four-year absence, Nancy Bauer has rejoined the HMS staff. Prior to her leaving, Nancy had been a valued member of the HMS staff for nearly 12 years. Nancy has been the successful managing editor of MetroDoctors since its inception in 1999, which she maintained on a contract basis during her hiatus. Nancy will continue in the managing editor’s role and assume other responsibilities previously undertaken by Sue Schettle. “Nancy has always been a valued member of the HMS family,” according to Jim Rohde, M.D., Board Chair.

Tour Guthrie Theater On August 31, 60+ members, spouses, and guests participated in the Back Stage tour of the new Guthrie Theater. Members were able to experience one or two of the theaters, walk out on stage, view the trap door, enjoy the panorama from the Endless Bridge, and had lunch overlooking the river.

HMS ALLIANCE NEWS ELEANOR GOODALL

Giving Thanks

L

LIKE MOST OF US, as the calendar page turns

into November, my thoughts move ahead to Thanksgiving. Hopefully, it’s a time of our family being together; a time of turkey, stuffing, mashed potatoes, cranberry sauce, pumpkin pie; and a time of giving thanks.

The first Thanksgiving was marked by Pilgrims giving thanks for the bountiful harvest and a new way of life. The idea spread to other locales, with people expressing thanks for their good fortune, for commemoration of the victory over the British, and so on, until Lincoln proclaimed the last Thursday in November as a national day of Thanksgiving.

Lincoln’s proclamation addresses the blessings of fruitful fields and healthful skies, peace with all nations, law and order, increasing size and population of settlements…and a large measure of freedom.

So, in the year 2006, as part of a medical family, what do we give thanks for? As is the case with most families, it is unlikely that we get to live our lives untouched by sadness or

even tragedy. But, by and large, the positives of our lives far outweigh the negatives. Yes, we have our ups; we have our downs. We have good days; we have bad days. We have times when our children and/or grandchildren are perfect, and times when we have unspeakable thoughts about them. But, in the end, we do have much to be thankful for.

As in Lincoln’s proclamation, we can still be thankful for fruitful fields and healthful skies. Unlike many families throughout the world, we are not forced to go to bed hungry.

For the most part, we breathe pure clear air, free of the pollution that afflicts many other countries. Our water is clean, sweet and safe to drink.

Some would argue that this following list of blessings is somewhat problematic at this time. But still, in the sense of our families living in this beautiful metro area, we can count these as blessings. We do have peace with many nations and hopefully we’re working toward that goal with others. We do have law and order

HMSA Holiday Open House & Brunch Silent Auction Fundraiser for HMSA Philanthropic Projects

Friday, December 8, 2006 10:30 a.m. – 1:30 p.m.

Home of Dr. Patrick & Linda Smith 6212 Fox Meadow Lane, Edina, MN 55436 For more information, contact Kathy Dittmer at HMS at (612) 623-2885, or kdittmer@metrodoctors.com

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November/December 2006

MetroDoctors

and compared to many metropolitan areas, our city is a safe, secure place to live. I’m not sure it’s a blessing, but in my area there is a definite increase in size and population as cornfields are turned into housing developments, schools and retail, industrial, and business establishments.

And, finally, despite the inconvenience of having to take off your shoes and pack your shampoo for airport security, we live in a time of great personal freedom.

In addition to Lincoln’s list, family gatherings, turkey and trimmings, I’m thankful for good friends. Friends who call, friends who come when needed, friends who care. Many of these friends can be found in the Hennepin Medical Society Alliance and many are friends I perhaps would never have met had it not been for the Alliance. Besides the good friends, the Alliance provides me the opportunity to serve others. As medical families, I believe we are all interested in the health and well being of our communities. As members of the Alliance, we have the means and the resources to help build healthy communities and to provide health information to children and their families.

Indeed we have done so for many, many years.

So, I guess I can say that I’m thankful for the Alliance!

As you approach Thanksgiving this year, as you count the blessings of family, friends, personal enjoyment of life, this beautiful city we live in, add the blessings and the sense of fulfillment you receive from the Alliance.

And, finally my special thanks to all of you whose time, effort and talents make the Alliance the wonderful, serving organization that it is.

The Journal of the Hennepin and Ramsey Medical Societies

Hidden Lakes Villa

Elegant Charles Cudd Villa in the Hidden Lakes neighborhood with private tree lined lot and spectacular sunset views. Former model, has hardwood floors, vaulted ceilings, gourmet kitchen w/ stainless appliances, luxurious master. 3 bedrooms, 3 baths. $899,900

Kenwood Crest

Elegant twin home built

by Keith Waters & Associates with quality craftsmanship throughout. All the modern conveniences offered today as well as the charm found in the historic neighborhoods of Kenwood and Lowry Hill. 3 bedrooms, 4 baths. $1,695,000

The Penthouse

Private Retreat

Great Location

Breathtaking Humboldt Loft penthouse with panoramic views of the city, river and new Guthrie. Features brilliant style, 12’ ceilings with glorious floor to ceiling windows, concrete floors, 1500 square foot roof top terrace and more. 2 bedrooms, 3 baths. $2,395,000

Fabulous opportunity to own exceptional 1+ acre lot. Wonderful wooded site offers breathtaking Gray’s Bay views with over 400 ft of lakeshore.

Home with great structure & opportunity to improve or build dream home. 4 bedrooms, 6 baths. $3,495,000

Wonderful family home set on private wooded acreage with pond in desirable neighborhood.

New construction feel with vaulted ceilings, large kitchen, dinette, bright living room and den.

Lower level family room with exercise room and hot tub. Gorgeous yard.

5 bedrooms, 4 baths. $895,000

Fantastic Edina Location Updated gourmet kit with granite, adjoining main floor family room with built-ins and fireplace, spacious master, large lower level amusement room, office, beautiful landscaped yard and more.

4 bedrooms, 4 baths. $1,195,000

Call: Bruce Birkeland

612-925-8405 www.brucebirkeland.com

MEMBERSHIP ADVANTAGES FOR PHYSICIANS AND THEIR PRACTICES C A L L R M S AT 61 2 - 3 6 2 - 37 0 4 F O R D E TA I L S . ɻ

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

ɻ

Stanton Group/Schwarz Williams Companies, Inc. offers RMS and MMA members individual and group benefits (medical, dental, life, disability) as well as human resource support services, executive benefits, retirement programs, COBRA/HIPAA/ERISA compliance, and benefit administration. For more information, contact Jim Fries at 763-591-5822 or visit their website at www.schwarzwilliams.com.

ɻ

SafeAssure Consultants recently partnered with RMS to offer the required OSHA compliance training for our members and their staffs. Medical society members receive a 50-60% discount on services and training. To meet or exceed the Minnesota OSHA and Federal OSHA requirements, talk with SafeAssure at 1-800-920-SAFE or visit their website at www.safeassuremedical.com for more information.

ɻ

IC System is a Minnesota (St. Paul) based company specializing in full-service revenue cycle management solutions for the health care industry. They are now offering RMS members effective, ethical, and cost effective solutions to collecting debts, improving cash flow and reducing costs. For more information and a no-obligation price estimate, please contact I.C. System directly at 1-800-279-3511 and let them know you are a RMS member.

ɻ

Berry Coffee Service is a valued partner of RMS and offers medical society members up to 25% off their wide array of coffee and hot beverage services. If you are interested in trying their service, contact Bob Dilly at 952-937-8697. If you are an existing customer of Berry Coffee Service, be sure that you are receiving the discounted pricing.

Winter Medical Conference 2007 “Caring for the Aging Population”

SUNDAY, MARCH 4-SUNDAY, MARCH 11, 2007

CANTO DEL SOL PLAZA VALLARTA PUERTO VALLARTA, MEXICO TRAVEL

AND LODGING

RATES

(INCLUDES: AIR, HOTEL, MEALS, BEVERAGES, TRANSFERS, TAXES & GRATUITIES) PHYSICIAN/ SPOUSE/GUEST SINGLE DOUBLE $1,549 $899

3RD PERSON 4TH PERSON CHILDREN ADULT ADULT

$1,139 $1,019 $699

SPONSORED BY RAMSEY MEDICAL SOCIETY FOUNDATION ENDORSED BY RAMSEY MEDICAL SOCIETY AND HENNEPIN MEDICAL SOCIETY

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For further conference information call RMS/HMS - 612-362-3704; email: dhines@metrodoctors.com For reservations call Darla at Hobbit Travel 612-349-3922 ext. 3339 or 1-800-294-6992 ext. 3339 or email: darlawilke@hobbittravel.com Visit: www.metrodoctors.com for brochure with additional details on this conference.