3septoct99 by Advocates for Better Health

Sept/October 1999

Doctors MetroDoctors THE BULLETIN OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

Advocating for Medicare Equity Medicare Monthly Reimbursement Levels in Selected Counties United States per Capita Cost 1999

$100 $200 $300 $400 $500 $600 $700 $800

Blue Earth, MN

$380

Anoka, MN

$411

Hennepin, MN

$422

National Average

$484

Long Beach, CA

$648

New York, NY

$742

Dade, FL

$779 Source: Health Care Financing Administration

Doctors MetroDoctors THE BULLETIN OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

Physician Advisor Thomas B. Dunkel, M.D. Physician Advisor Richard J. Morris, M.D. Editor Nancy K. Bauer Assistant Editor Doreen Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Managing Editor Sheila A. Hatcher Advertising Manager Dustin J. Rossow Cover Design by Susan Reed MetroDoctors (ISSN 1079-4808) is published bimonthly by the Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of HMS or RMS. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. E-mail: nbauer@mnmed.org. For advertising rates and space reservations, contact Dustin J. Rossow, 4200 Parklawn Ave., #103, Edina, MN 55435; phone: (612) 8313280; fax: (612) 831-3260; e-mail: djrossow@aol.com. MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available.

CONTENTS VOLUME 1, NO. 3

SEPTEMBER/OCTOBER 1999

FEATURE: MEDICARE REIMBURSEMENT

Inequities Prevail Among Reimbursement Rates

COLLEAGUE INTERVIEW

David L. Swanson, M.D.

HCFA Proposes Medicare Changes

Physician’s Unions — Panacea, Placebo, or Paradox?

Two States Have Laws to Assist Physicians with Collective Bargaining

RISK MANAGEMENT

When Attorneys Call Physicians

Minnesota Poison Control System Seeks Stable Funding

COMMUNITY SERVICE

Honduras After Mitch

What to do About Colon Cancer Screening Will Flexible Sigmoidoscopy Become Unavailable?

Center for Health and Medical Affairs Physician Leadership College

Metropolitan Visiting Nurses Association Helps Community

NOTEWORTHY RAMSEY MEDICAL SOCIETY

24 25 26 27

President’s Message RMS Receives Award of Excellence RMS News RMS Alliance HENNEPIN MEDICAL SOCIETY

29 31 32

Chairman’s Report HMS News HMS Alliance

On the cover: Medicare reimbursement rates vary widely from state to state and county to county. See related articles beginning on page 2.

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September/October 1999

FEATURE STORY Inequities Prevail Among

Medicare Reimbursement Reimbursement Rates

Peter Wyckoff

“The result of the current system is that seniors living in high-cost states are richly rewarded, while seniors living in low-cost states are penalized.”

For 5,500 seniors in Anoka County, the clock is ticking. On January 1, 2000, their health care provider no longer wants them as customers. They’ve been told to move on, take their Medicare payments with them, and find somewhere else to go for services. There’s just one problem: Only two not-for-profit health maintenance organizations (HMOs) offer Medicare services to seniors living in Minnesota. The reason is simple. Hospitals, health plans and other providers in the state receive dramatically less money in per-patient Medicare reimbursements than many of their counterparts elsewhere. For example, the current Medicare reimbursement rate is $422.01 in Minneapolis compared with about $742.00 in New York and more than $779.00 in Miami. “(The health plans) are losing their shirts because the payment premiums are inadequate,” says Susan Foote, University of Minnesota School of Public Health professor. The reason is tied to the federal government’s complex, and historically-dated, Medicare reimbursement funding formula. According to the Fairness in Medicare Coalition (Fairness 2000), an organization with hospital and health plan members nationwide, the problems in Medicare funding date back to its origin. When the U.S. Congress created Medicare in 1965, it based the program on the prevailing health care delivery model of the day: fee-for-service. Under this system, patients visited doctors, physicians set the prices, and the government paid the bills. Subsequent changes in Medicare policy centered on altering the payment formula. By the 1980s, with costs threatening to spiral out of control, the government began to allow seniors to spend their Medicare premiums on HMOs. Like private insurance, HMOs receive premium payments from thousands of people, thereby spreading the risk of too many things going wrong with too many people at the same time. There remained two questions: How much should the government reimburse Medicare HMOs for every new patient? And should the level of reimbursement take local economic differences into account? The ultimate decision, to reimburse HMOs at a rate of 95 percent of what Medicare was already spending on a per capita basis in each county, seemed logical. But the resulting disparities in health care coverage for seniors defy common sense. Thanks to Minnesota’s long history of health care delivery experimentation — dozens of multi-disciplinary group practices emerged as early as the 1960s — costs are lower here. A good thing, yes? Not when it comes to Medicare. Because the government reimburses Medicare HMOs at 95 percent of the local cost, a Minnesota HMO delivering services in Anoka County received just $411.10 in 1999. That same HMO operating in Blue Earth County, in the southeast corner of

BY TODD MELBY

September/October 1999

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Minnesota, received only $379.84 back from the feds. Compare that to the $647.70 per patient reimbursement an HMO gets for doing business in Los Angeles County, California, and the inequities begin to emerge. Los Angeles County isn’t even the biggest offender. Reimbursement rates are even higher in New York, N.Y. and Dade County, Fla., where Miami is located. According to the Health Care Finance Agency (HCFA) — the federal government agency responsible for implementing Medicare — New York providers receive about $742 per beneficiary and Dade County HMOs get a whopping $779 per patient. Regional cost differences don’t account for the huge disparity in dollars. Studies show that cost differences vary by only about 15 percent, but that seems to have had little effect on Medicare cost reimbursements to physicians, hospitals and HMOs, which vary by as much as 211 percent. Those differences have an impact on services. While a Long Beach, Calif. (in Los Angeles County) senior pays the national Medicare premium of $45.50 in 1999 to become a member of United HealthCare, she gets a big bang for her buck. As a health care consumer, she’ll receive physician and specialist (Continued on page 4)

“Minnesota Comments on Medicare from Attorney General Mike Hatch Everyday, I get calls from citizens voicing their concerns about the inequities in the Medicare Plus Choice reimbursement rate system. As Attorney General, I am committed to doing whatever I can to bring about fairness to the system. The present Medicare reimbursement structure is irrational — the federal government uses HMOs to contain costs, yet it is the efficient HMOs, and consequently their enrollees, that suffer. Unfairly, it is the inefficient HMOs and their enrollees that reap the rewards of the higher reimbursement rates. In order to effectuate Congress’ intent, it should be the efficient HMOs, like Minnesota’s, and their enrollees, that benefit for keeping costs down. No one has felt the effects of the inequities more than Minnesota’s seniors. Minnesota seniors are being punished while seniors in inefficient states, like New York and Florida, get all of the benefits. In these big states with the high reimbursement rates, HMOs do not charge their Medicare Plus Choice enrollees a premium or a co-payment. Furthermore, in order to keep the high reimbursement rates coming in, the HMOs entice their members with free prescription drugs, eyeglasses and rides to the clinic. At the same time, Minnesota seniors do not receive any additional benefits and must pay a monthly premium, as well as co-payments for basic things such as office visits to their primary care providers. Unjustly, our seniors are forced to suffer. I continue to hear horror stories of seniors who cannot afford to pay for their prescription drugs. Some of these seniors are being forced to make the decision between keeping shelter over their head or food on their plates and buying their prescription drugs. This cannot be tolerated. Along with the Senior Federation and the Fairness Coalition, my office is working hard at finding a way to address the disparities in the Medicare reimbursement rate structure. One way or another, we will bring about change to this extraordinarily unfair system. ✦

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seniors are being punished while seniors in inefficient states, like New York and Florida, get all of the benefits.”

September/October 1999

(Continued from page 3)

visits at a low rate of $3.00 per visit, outpatient prescription drugs at a cost of $5.00 for generics and $15.00 for brands ($3,500 annual maximum), and free hospital visits. Also available: two dental exams (with $5.00 co-pay), hearing aids (with co-pay), routine eye exams (with co-pay), and eye glasses and contacts. What does an Anoka County, Minnesota senior get for that same Medicare premium of $45.50? As a member of Medica - Senior Care Complete, physician and specialist visits jump to $15.00 per visit, hospital visits are covered (same as in Long Beach), but there the similarities end. There is no coverage for out-patient prescription drugs, preventive dental coverage, hearing aids, or eye glasses and contacts. There is, however, some coverage to have one’s hearing checked and one’s eyes examined. Need help for any shortcomings though, and you’re on your own. Anne Robinson should know. The 89year-old Minneapolis woman reaches deep into pension and Social Security funds to pay for her health care expenditures. In addition to a Medicare premium, Robinson spends about $113 monthly for supplemental insurance from a local HMO. And it doesn’t stop there. Neither Medicare nor the HMO covers the cost of the five over-the-counter and prescription drugs Robinson must take to fight arthritis and the effects of aging. That’s another $120 a month or so. “I can make it (financially),” Robinson says. “But it hurts.” Adrienne Hyde, 65, also worries about keeping up with medical costs. After a car accident more than a decade ago, Hyde has been unable to work full-time. She depends on Social Security and a part-time job to stay afloat. For health care, Hyde relies on Medicare and private insurance. Funds from the 10-hour per week job is enough for the $140 monthly premium on the insurance. It doesn’t offer medication coverage either. “It’s a little scary,” Hyde says. “When I need prescription drugs, the cost is really high. It’s like $50 or more.” 4

September/October 1999

Such scenarios aren’t just a Minnesota phenomenon. Seniors in Iowa, Maine, New Hampshire, North Dakota, South Dakota, Washington and Wisconsin are also facing the same health care crisis. “The result of the current system is that seniors living in high-cost states are richly rewarded, while seniors living in lowcost states are penalized,” says Peter Wyckoff, Minnesota Senior Federation metro region executive director. Foote, the U of M professor, agrees. “It’s a very arbitrary way of calculating premiums that’s not directly tied to quality,” she says. “The government pricing system is highly flawed and has led to serious inequities in a program that’s really important to people.” To obtain necessary coverage, many Minnesota seniors are forced to pay an additional $70 for services Medicare doesn’t cover. The current situation irks Kate Stahl, executive vice president of the Minnesota Senior Federation. “This is an issue that’s doing real harm to our members,” Stahl says. “It’s a hidden and menacing problem that many people don’t see and don’t understand. And if it’s going to be solved, Medicare beneficiaries and those concerned about a just health care system will need to step forward.” The Senior Federation, and others, are attempting to do just that. The group has formed the Medicare Justice Coalition, a grassroots organization with 300-plus members, whose mission is to urge Congress to enact fair Medicare reimbursement rates, increase fee-for-service reimbursement and equalize Medicare benefits. That kind of pressure — citizen phone calls, letters, and e-mails — contributed to a slight alteration in the Medicare reimbursement formula in 1997, the year Congress passed the Balanced Budget Act. The new law gives a higher percentage of cost-of-living increases to underfunded counties (such as Anoka County, Minnesota) than Medicare-rich counties (such as Dade County, Florida). But it doesn’t solve all inequities. “The Balance Budget Act offered some improvement to seniors,” says Jack Davis, CEO of the Hennepin Medical SoMetroDoctors

Kate Stahl

ciety. “But the disparity is still too great. It penalizes our local citizens.” The halls of the U.S. Capitol aren’t the only place the Senior Federation intends to fight. It has also authorized a local law firm to file a class action lawsuit against the federal government claiming the funding formula unfairly rewards some seniors at the expense of others. Edward A.L. Spenny, M.D., HMS chair, is concerned. “The Hennepin and Ramsey Medical Societies are supporting the class action lawsuit and have contributed $10,000 to support this effort. We join other local organizations in this initiative.” Attorney General Mike Hatch also promises involvement. “The importance of this issue cannot be understated,” Hatch said in a May 1999 speech. “(My) office will be lending support to the Minnesota Senior Federation’s Medicare Justice Campaign. With Minnesota’s growing senior population and medical costs which continue to soar, the time to take action is now.” The timing of the lawsuit remains uncertain, but the issues surrounding the need for legal action remain clear. “The real scandal in all this is the way the system is set up,” Foote says. “If health plans could provide a mandated, basic medical benefit package and get proper reimbursement from the government, more people would have access to care.”✦ Todd Melby is a freelance writer. The Bulletin of the Hennepin and Ramsey Medical Societies

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September/October 1999

COLLEAGUE INTERVIEW

David L. Swanson, M.D.

Editor’s Note: “Colleague Interview” provides HMS and RMS members with an opportunity to ask questions of their colleagues who are in unique roles. The content for this issue of Colleague Interview was jointly produced by David L. Swanson, M.D., internist/dermatologist practicing in North Minneapolis, and Janet Silversmith, Director Health Economics and Policy Analysis at the Minnesota Medical Association and staffs the Geographic Coalition. Although there is little activity on this topic occurring at the national level at this time, Dr. Swanson and Ms. Silversmith continue to monitor the work of the Geographic Coalition closely.

Q A

What is the Geographic Coalition? The Geographic Coalition is a non-partisan coalition of state medical associations whose members are committed to achieving a more equitable Medicare reimbursement system by reducing the geographic variation in fee-for-service and managed care payment rates.

Who Belongs to the Coalition? The Geographic Coalition consists of the following 24 state medical associations representing more than 160,000 physicians: Alabama, Arizona, Colorado, Idaho, Indiana, Iowa, Kansas, Maine, Minnesota, Missouri, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Oregon, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Wisconsin, and Wyoming. In addition, Louisiana is a contributing supporter of the Coalition, but is not a formal Coalition member.

Why was the Coalition established? The Geographic Coalition was originally created in 1989 in response to Medicare’s development and implementation of the RBRVS fee-for-service reimbursement system. Prior to the establishment of RBRVS, Minnesota had three different geographic practice localities for the purpose of establishing fee-for-service reimbursement rates. As a result of the cooperation of Minnesota physicians from across the state, a single payment locality was established within Minnesota for services provided to benefi6

September/October 1999

ciaries covered under Medicare’s fee-for-service system — clearly the dominant form of coverage at that time. This means that all physicians in Minnesota receive the same payment for services provided to Medicare beneficiaries covered under the fee-for-service system. The Coalition was re-established in 1995 during Congressional Medicare reform deliberations to again address the geographic disparities in both Medicare’s fee-for-service system (210 payment localities existed across the country and variation in payment within each locality existed) and Medicare’s HMO reimbursement system (a growing segment of Medicare enrollees and a significant source of payment variation). In 1996, the Coalition was formalized to develop advocacy materials to generate statelevel, grassroots support to impact Medicare reform, focusing primarily on the managed care payment rates.

Who Created the Coalition? The Minnesota Medical Association (MMA), together with the Utah Medical Association, was the Coalition’s founder. The MMA manages the Coalition and it is coordinated by Janet Silversmith, the MMA’s Director of Health Economics & Policy Analysis.

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What are the Coalition’s Objectives? The Coalition adopted the following policy positions in 1997 to guide its activities and advocacy (it is important to note that many of these provisions were enacted into law by Congress in 1997): • The Geographic Coalition does not advocate one type of delivery system over another (i.e., fee-for-service vs. managed care); • The Geographic Coalition supports Congressional reform proposals that maintain the solvency of the Medicare program, while maintaining legitimate choices for Medicare enrollees; To address fee-for-service variation, the Coalition supports a requirement that HCFA, as part of its five-year review of relative value units, evaluate the fee-for-service payment areas to ensure that demographic or other economic changes have not inappropriately altered market areas; • The Geographic Coalition supports incorporation of a health status measure in Medicare’s risk adjustment methodology; • The Geographic Coalition supports efforts to improve the method by which the managed care payment base rate is calculated (options could include lower rates for new enrollees, or new methods of estimating expected costs); • The Geographic Coalition supports, as a first step, the development of a managed care payment floor that will begin to redistribute dollars more equitably; ideally, the Coalition encourages adoption of policies that would eliminate the direct link between local fee-for-service spending and the AAPCC rates through the blending of national and local rates to develop rates that reflect variation in input costs, not practice patterns; and, • The Geographic Coalition supports efforts to reduce the volatility of rates by consolidating counties into larger payment areas (such as metropolitan statistical areas) that are more reflective of natural market areas.

Dr. Swanson, in your estimation, what areas of patient care have been most affected? Uneqivocally pharmaceuticals. The high cost and poor coverage for pharmaceuticals places a tremendous burden on many of my patients, who simply have to forego adequate therapy because of an absence of financial resources and their fixed incomes.

means of controlling program expenditures, the legislation establishing the risk contract program required the AAPCC rates to be set at 95 percent of the costs Medicare would have incurred for HMO enrollees if they had remained in fee-for-service. HMOs were allowed to keep all profits in excess of the AAPCC rate up to the level earned on their non-Medicare business; if estimated profits from the Medicare risk contract exceeded estimated profits on the non-Medicare business, the excess dollars had to be passed on to the enrollees in the form of either reduced co-payments or deductibles, additional benefits, or refunded to HCFA. There were four primary steps employed by HCFA in calculating the risk contract payment rate. First, HCFA calculated the United States per capita cost (USPCC), a national estimate of per capita costs utilizing three years of Medicare historical spending data. Separate costs were calculated for Part A and Part B services for the aged, the disabled, and for persons with end stage renal disease (ESRD). This “base rate” takes into account both payments and utilization of services. Second, HCFA adjusted the USPCC for geographic differences in Medicare fee-for-service expenditures (using a five-year moving average of fee-for-service claims data) to derive county-specific average per-beneficiary costs. Third, the county rate was multiplied by 0.95 to develop the county adjusted average per capita cost (AAPCC). The final step was to risk adjust the AAPCC rate to account for the demographic characteristics of HMO enrollees. The AAPCC rates reflected the county-level differences in the prices of local medical services and in the utilization of those services by resident beneficiaries. If there are barriers to care for fee-for-service beneficiaries (e.g., lack of physicians in a rural area), the low utilization will be reflected in the AAPCC rates for that county. If beneficiaries in a county utilize a large quantity of services (e.g., increased demand, excess capacity), the high utilization will be reflected in high AAPCC rates.

Are your Medicare patients aware of the geographic disparity between the resources made available in Minnesota for Medicare patients and patients in states with higher AAPCC? Unfortunately, I think my patients are generally unaware of the disparity. This certainly is not an issue that Medicare openly communicates to its subscribers, so unless a patient has a discussion about Medicare payments with a friend or relative in other parts of the country (or receives mailings from the Senior Federation on this topic), I don’t think they would know of the variances.

Why are the Medicare managed care rates so problematic? The short answer is because they are a reflection of historical fee-for-service, county-level payment and utilization. As early as 1972 Congress recognized the potential for HMOs to save the Medicare program money. Efforts to encourage HMO participation and beneficiary enrollment in HMOs expanded significantly in the mid-1980s. The rate calculated by the Health Care Financing Administration (HCFA) and paid to Medicare HMOs (called risk contracting HMOs) was called the adjusted average per capita cost (AAPCC). Because Congress saw the use of HMOs as a

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Why didn’t the AMA advocate on this issue instead of the Coalition? If you look at the Coalition’s members, there are numerous states not included, many of whom have large populations, have a large delegation at the AMA, and have large Congressional delegations. There is no question that many states benefit under the current financing mechanism and few are eager to redistribute those dollars to other states and other benefi(Continued on page 8)

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(Continued from page 7)

ciaries. Nevertheless, the AMA recently adopted policy supporting a reduction in the wide variation in Medicare managed care payment rates. Thanks in part to the educational efforts of the Geographic Coalition, which has held several meetings during AMA Annual and Interim Meetings, more and more individuals are becoming aware of the inadequacies in the payment formula. In addition, the inequity in rates is found both across states and within states.

Has there been any improvement? Yes, some. In 1997 Congress adopted a series of changes in the Medicare program, including changes in the way Medicare pays participating managed care plans. Under the changes, “risk contracts” and the “AAPCC” are gone. Instead, a new Medicare Part C (Medicare+Choice) program was created to offer beneficiaries a choice between traditional Medicare feefor-service or a Medicare+Choice plan. At the time, the financing change was significant — the AAPCC formula was replaced with a new Medicare+Choice capitation payment methodology equal to the greatest of: 1) blended capitation (90 percent county and 10 percent national in 1998; by 2003, 50 percent national and 50 percent local); 2) floor of $367 in 1998; 3) a minimum percentage increase — two percent in 1998 over 1997 rates. Payment updates would be based on national average per capita fee-for-service spending (rather than county-level spending) minus a percentage point (.8 in 1998; .5 through 2002). A minimum two percent annual increase was guaranteed.

What was the impact of the changes in Minnesota? In 1998, Minnesota counties saw substantial increases — from the minimum two percent increase to a 61.5 percent increase in one county (up to the $367 floor). However, many of these counties did not currently have HMOs offering Medicare beneficiaries coverage, so the increases, while significant, did not mean substantial change for individuals living there. Many of the rates were not yet high enough to entice HMOs to enter the county. In addition, the rate increases in 1999 were limited due to a technical flaw in the legislation that required implementation of the two percent minimum increase before the blending of rates. This lower than anticipated growth in rates for 1999 resulted in many managed care plans dropping out of the program and/or raising premiums. Although it is difficult to sympathize with a loss of additional free benefits for Seniors in some counties in the country, the changes and reduction in benefits were very real to those individuals. The proposed rates for 2000 appear somewhat improved. Minnesota counties will see rate increases from 5.7 percent to 11.4 percent. The real issue, however, is whether these rates are high enough to encourage health plan participation and physician participation with those plans.

September/October 1999

Janet Silversmith

What impact, if any, has this disparity had on your medical decision making or clinical autonomy? The greatest impact on my ability to practice medicine is when I find myself having to create a therapeutic plan that occasionally uses alternative regimens in keeping with the patient’s financial resources. They simply can’t afford what would be considered standard care in other parts of the country.

Other groups are also interested in this issue; who else is trying to address this problem? There is another Coalition, the Fairness Coalition, that was developed in about 1995 to address the managed care payment rate variation. The Coalition is primarily comprised of health plans and hospital systems. Membership in the Coalition draws from similar geographic areas as the MMA’s Geographic Coalition. Staff from the Geographic Coalition and the Fairness Coalition have met numerous times to discuss areas of mutual agreement and opportunities for collaboration. Despite the similar goals, to date, the Geographic Coalition has decided to maintain its independence so as not to confuse the issues unique to physicians attempting to serve patients in both the fee-for-service and managed care systems. Of note, both the Hennepin and Ramsey medical societies participate in the Justice Coalition as described in the feature article of MetroDoctors on page two. ✦

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HCFA Proposes Medicare Changes Modifications in Medicare Practice Expense Payments The Health Care Finance Administration (HCFA) has proposed the year 2000 Medicare fee schedule with changes in the distribution of the resource-based practice expense payments. Payments for practice expense total about $20 billion per year from Medicare to physicians and other providers. The overall effect of the proposal indicates that HCFA is continuing to reduce payments to hospital-based physicians and increase payments to office-based physicians. For example, cardiologists received a nine percent reduction in 1998 and they will receive a two percent re-

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duction under the new proposal. Anesthesiologists will have to deal with an eight percent reduction by the year 2002, which was unexpected. More information about the HCFA proposal will be available after the AMA completes its review of the proposal from HCFA and releases its analysis. New Method for Reimbursing Professional Liability Costs A new method for reimbursing physicians for the cost of professional liability insurance by Medicare has been proposed by the Health Care Finance Administration which would shift from a historical charge-based approach to a resource-

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based system. The professional liability component of the Medicare fee schedule is the smallest and the last component to move from historical charges to resource-based. There are three components included in the cost to provide the 7,000 physician services covered by Medicare. They are the physicianâ&#x20AC;&#x2122;s expertise, the expenses for staff and equipment, and the cost of buying professional liability insurance. HCFA adopted the original resourcebased relative value system developed by Harvard University in 1992. The relative value units for professional liability are based on the actual premiums paid by 20 specialties and on Medicare payment data. The range for premiums in 1995 was $7,765 for psychiatrists to $57,679 for neurosurgeons. When you compare the changes in practice expense allocations to the change to resourcebased professional liability insurance costs, the proposed change in professional liability insurance cost reimbursement is minor. For example, cardiac and orthopedic surgeons will receive a 1 percent reduction, while ER physicians will receive a 2.7 percent increase.â&#x153;Ś

September/October 1999

Physicians’ Unions — Panacea, Placebo, or Paradox? Editor’s Note: The AMA House of Delegates meeting in June in Chicago authorized the AMA to proceed with organizing a national negotiating organization for physicians. The authors, Michael Zeiler, J.D., and Harry Wernecke, BBA-IR, MHA, are consultants who have a combined 70 years experience in labor relations and union avoidance. The information they provide the reader presents the con side of unionization for physicians. The next issue of MetroDoctors will discuss the pro side of physician unionization.

Physicians are “fed up” with a lot of things these days. Among those who have listed physician’s frustrations is Dr. Barbara LeTourneau, vice president of medical affairs for Mercy/Unity Hospitals, and Ann Fleischauer, vice president of physician communications at Allina. They listed “What Physicians Want” in an article for healthcare executives with the intent of helping executives understand where doctors are coming from, so they can better balance what they call the “heart of medicine,” the profession, with the “enterprise of medicine,” the business. Dr. LeTourneau’s call for balance stands out in a sea of articles, and talk, which express anger and frustration. Anger and frustration in the work place have historically led to talk about unions, and so it has with physicians. We suspect that physicians’ talk about unions isn’t for a union as much as it is against management. We say that because unless you have worked closely with unions, you don’t know what “union” really means. You may think that “union” just means getting together to have a voice and some power to deal with your problems and frustrations. This is only partially true, and yet it means much more than that. So what does “union” really mean? A union is a specific form of legal entity which operates in specific ways delineated in the National Labor Relations Act (NLRA) of 1935 and its amendments through the years. The law is administered by the National Labor Relations Board (NLRB) through its 32 regional offices across the country. But the NLRA has no application to non-employee physician groups negotiating trade agreements with Managed Care Organizations or to any other commercial non-employee relationships. This law applies only to the employment relationship and even then not all employees are eligible BY MICHAEL ZEILER AND HARRY WERNECKE

September/October 1999

for coverage under the act. For example, if you perform supervisory or management functions you are not eligible for union representation. If you are eligible to join a union, there must be an NLRB defined “bargaining unit,” and in most cases an election supervised by the NLRB. If the majority of eligible voters who vote choose the union, it is “certified” as the “exclusive representative” of that whole group of employees. If fewer than a majority of eligible persons vote, a minority of that group could force a union on the majority. Because of the publicity received by unusual settlements, there is a widespread assumption that unions can “get” almost anything. In fact, there is no requirement than anybody “get” anything. The law requires only that the employer and the union “meet and discuss” the terms and conditions of employment “in good faith.” There is no requirement that these terms and conditions be improved or even maintained. There is not even a time limit on the discussions — they could go on indefinitely, as could the status quo. If, when they “meet and discuss” the terms and conditions, they feel they are not making sufficient progress, union members may use the economic weapon of a strike to convince the employer of the strength of their feelings. However, when meeting and discussing, it is important for physicians to know that patient related issues, often mentioned as the source of their anger and frustration, are with few exceptions, not mandatory topics of bargaining. Rather, these are “permissive” topics, and the employer is not required to even discuss them, much less make any concessions regarding them. Needless to say, neither party may insist upon permissive topics to the point of an impasse or strike. Then there is the matter of union rules. If you like your hospital medical staff by-laws and rules and regulations, you’ll love the constitution and by-laws of the international union1. Here is found genuine, static, self-perpetuating bureaucracy! They explain where the power really is, (it’s with the international union) and who pays for it, (you do) and under what circumstances you might expect additional assessments, or fines (yes, there can be). You may be accustomed to going into an administrator’s office with a few angry words and see him jump into action. Well, under a union contract, he may well shove a form in your face and tell you to fill it out. Or, he could refuse to see you, referring you instead to your off-site union representative. What we have here is a formal grievance procedure, which can be tedious indeed, with written complaints, written responses, a number of steps (usually equal to the layers of management), and no requirement of resolution. In this situation, contracts often call for outside arbitration MetroDoctors

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with lawyers, witnesses, and endless testimony, including yours. Or the end could be a lawsuit, with resolution by a judge — definitely an outsider. Do physicians strike? Sure they do and have, and to believe that this won’t happen again in the future defies reason and probability. This is because, lets face it, the only real economic power of a union is the power to strike. What’s wrong with collective bargaining, as defined by the NLRA? It is intentionally an adversarial process, designed in and for a 1930s industrial economy. It is a win-lose process, which is diametrically opposed to the win-win models of collaboration which are so popular, and effective, today. This win-lose thinking continues today. In the Electromation decision the NLRB decided that employee “action committees,” or teams, even in non-union workplaces, were illegal labor organizations because they were set-up and operated with management support, rather than being under control of an external union. When strictly construed, this decision would negatively affect the practices of 3⁄4ths of American Industry. Is this what the “union solution” would mean for the practice of medicine? What does the marketplace say about the effectiveness and desirability of unions today? A decade ago 35 percent of all workers in America were represented by unions. Today a little less than 10 percent of private sector workers are union members. Over the same period union overhead quintupled despite the obvious plummeting revenues. This forced unions to take the same actions they scorned in corporate America — mergers, acquisitions, downsizing, and layoffs. Unions are in dire need of more members — that is — more revenues. Like the robber who robbed banks

because “that’s where the money is,” six major AFL-CIO unions have targeted healthcare as an industry, and physicians in particular. The unions see that only 4.4 percent of America’s 680,000 physicians are members of unions, the majority of these are salaried employees. They see this as a great marketing opportunity. So, here we have a reactive, adversarial model for dealing with industrial age issues of the 1930s, cast in stone by the National Labor Relations Act of 1935, being suggested for the solution of professional problems in an information age, when successful models today are proactive and collaborative. While we understand the anger that brings up the “U” word, isn’t it ironic that the group historically seen by society as the epitome of the professional, now, and alone in the society, wants to turn to a methodology of 1930s mentality long ignored by the newer information age professions? ✦ 1

Almost all unions in the United States are sponsored by national organizations which call themselves “international unions”. An international union and its staff provide the organizational structure, the expertise, and the controlling leadership on which the local unions depend.

Michael Zeiler, JD, is president of Professional Labor Relations Services, Inc., a national firm based in Mill Valley, CA. He has 25 years experience in labor relations for Fortune 100 companies and healthcare employers. Harry Wernecke, BBA-IR, MHA, is midwest director for PLRS. He has 45 years experience in industrial relations, hospital administration, and consulting. He lives in Roseville.

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The Bulletin of the Hennepin and Ramsey Medical Societies

September/October 1999

Two States Have Laws to Assist Physicians With Collective Bargaining

Another article in this issue discusses the talk of unions that has accompanied the apparently increasing dissatisfaction with managed care plans among physicians. In at least two states, Washington and Texas, this talk has led to the passage of laws, while California is reported to have 50 pieces of pending legislation intended to remove or neutralize the various alleged impediments to medical practice. On June 20, 1999 Texas Governor George W. Bush signed into law an act that permits physicians to be engaged in “collective negotiation” under state supervision. The Texas law is based on a Washington state law originally passed in 1993 and largely repealed in 1995, except that the portion relating to collective bargaining for physicians was retained. The Washington State Medical Association (WSMA) started a non-profit corporation to work on behalf of physicians to improve health care carrier contracts. Physicians must sign up for the “Representation Services,” the actions of which are very closely supervised by a state agency. The law does not require health plans or carriers to negotiate anything; it is a voluntary and non-binding law. So far, the health plans and carriers have come to the table to discuss issues with the WSMA Representation Services (WSMARS), which is pleased with progress to date and optimistic about the future. For employed physicians, (employed by employers not owned and controlled by physicians) who wish to form a bargaining unit and affiliate with a union, WSMA-RS created a new and independent division called the Washington Association of Medical Practitioners (WAMP). Both the Washington and Texas laws prohibit activities that would constitute violations of state or federal antitrust laws (such as acting in concert in response to a report of the provider’s representative) or allow a boycott. Both state’s laws regulate the negotiating process very closely. For example, physicians cannot negotiate directly with a health plan or carrier. Instead, a representative must be designated, and this third party must be approved and authorized by a state agency as the sole representative of the physicians. The third party must prepare, and file with the state agency, a general plan of operation including procedures which assure compliance with the law. Then, before engaging in any negotiations, the representative must place BY HARRY WERNECKE AND MICHAEL ZEILER

September/October 1999

in writing a report of the proposed subject matter of the negotiations, and the efficiencies and benefits expected to be achieved. This entire report, or plan, must be approved by the state agency before the health plans or insurance carriers can be contacted. And if any new information becomes available that would change the original subject matter, this too, must be submitted to and approved by the state agency. Before reporting the results back to the physicians, the planned communications must be placed in writing and furnished to the state agency for approval. In the case of Texas, the state agency must seek the advice of the attorney general before approving or disapproving the communications. If the activity is not approved, the state agency will present a written explanation of the “deficiencies” along with suggestions for “remedial measures” that could “correct” the deficiencies. Both states require that the provider’s representative shall not represent more than 30 percent of the market of practicing providers for services of a particular type or specialty in the service area of a health plan with less than five percent of the market. Of course, there are timelines for the various steps in the process. As you can see, every time anyone turns around, this action must be approved by the state agency. The process is clearly not run by physicians. On the other hand, physicians need not participate in the bureaucratic details (except for the waiting), and if the entire process is constructive and improves the lot of physicians, or makes life somehow better for patients, perhaps it’s worth the effort. It is interesting that physicians, sick and tired of the bureaucracy of health plans and insurance carriers, talk of turning to another bureaucracy, that of a union, to solve their problems. Similarly, we see the Washington and Texas laws as a variation on the same theme; that is, away from the adversarial bureaucracy, to a regulatory governmental bureaucracy. We wonder if the decisions of the latest bureaucracy will be any more understanding of the physician’s viewpoint than previous ones. Perhaps it is time to re-examine the period when physicians relinquished health care to insurance executives and other money “types,” and to consider what other courses of action might have been taken. Perhaps it isn’t too late to restructure what we have done, and this time do it better for both physicians and the patients we serve. We will undertake that re-examination in a future article. ✦ MetroDoctors

The Bulletin of the Hennepin and Ramsey Medical Societies

RISK MANAGEMENT

When Attorneys Call Physicians

You may have the type of practice where you deal with attorneys all the time as you conduct independent medical examinations or testify as an expert witness. Or a call from an attorney may be a rare occurrence, prompting some anxiety. Whatever your situation, there are some basic guidelines to keep in mind when attorneys call. Different types of calls There are many different reasons why an attorney would contact a physician. Calls about patients involved in automobile accident litigation, concerns about another physician’s care and treatment, questions about a report issued on a worker’s compensation patient, are all reasons attorneys may need to call physicians. In almost all cases, you must have permission from your patient before you discuss anything with their attorney. Worker’s compensation cases, in most states, do not require separate authorization from the patient. If you are in doubt, the safest route is to obtain permission first. Typically, it is your choice whether you speak with an attorney about a patient’s care. If you do, however, there are some risks to consider that vary depending upon the type of question asked. Questions about care a prior treating physician rendered to your current patient You have assumed care of a patient who had an adverse outcome with a prior treating physician. Perhaps that physician made treatment decisions you would not have chosen. Or BY MIDWEST MEDICAL I N S U R A N C E C O M PA N Y R I S K MANAGEMENT COMMITTEE

MetroDoctors

the other physician’s diagnosis is inconsistent with yours. The patient may also relate a medical history or course of prior treatment that creates questions about the physician’s care. When an attorney calls for your opinion on prior care, most often the attorney is seeking your opinion on negligence. Without coming right out and asking, the attorney may be hoping for you to make a statement that the other physician’s care breached the standard of medical care for that particular condition. Many physicians have been candid with patient’s attorneys and criticized care rendered by another physician, only to find themselves named as an expert witness in a malpractice lawsuit against that colleague. Another possibility is that you will find yourself named in the malpractice suit, right alongside the physician whose care you criticized. Risk Management Tip: Before criticizing care rendered by another physician, make sure you have actually reviewed the medical records, gathered all of the pertinent information and concluded that the care was a breach of accepted medical standards. Consider, too, whether you are prepared to testify in court against that physician in a malpractice claim. Questions about your care of a current patient If an attorney wants to discuss your care and treatment of a patient, you should first know why. If you have concerns that this patient may sue you for malpractice, contact your malpractice liability carrier before you discuss anything with the patient’s attorney. You may not have received any indication that the patient is unhappy and do not have any reason to think you are being sued. In that case, it is prudent to ask why the inquiring attorney represents your pa-

The Bulletin of the Hennepin and Ramsey Medical Societies

tient — is this a claim against you, against another physician, against an employer, or against another party in an accident? Once you know the reason the patient has an attorney, you may then decide whether or not you wish to discuss the patient’s care. Risk Management Tip: Ask why an attorney wants to discuss your care and treatment of a patient before agreeing to talk. Contact your malpractice insurer if you have any concerns that the patient may sue you, before agreeing to talk with the attorney. Questions about a patient involved in other litigation Attorneys of patients involved in personal injury litigation for worker’s compensation or motor vehicle accidents often contact the treating physician to discuss their client’s care and prognosis. Discussing your care of these patients with their attorneys poses no particular risks as long as you have your patient’s permission. These are the most common reasons attorneys call physicians and some practical cautionary advice. If you have concerns, however, about why an attorney wants to talk with you, you should always contact your liability carrier’s risk management staff to discuss the situation. ✦ Midwest Medical Insurance Company is a physician-owned malpractice insurer covering physicians, clinics, and hospitals in Minnesota, Illinois, Iowa, Nebraska, North Dakota, South Dakota and Wisconsin. For more information, call 1-800-328-5532.

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September/October 1999

Minnesota Poison Control System Seeks Stable Funding Service rated high by callers, but experiencing crisis-level budget problems

The Minnesota Poison Control System (MPCS) offers comprehensive, 24-hour-a-day, 365-daya-year poison control telephone information services in every county in Minnesota through a single toll-free phone number (1-800-POISON-1; in numerals it’s 1-800-764-7661). With this system, most poison emergencies can be handled in the home, based on advice provided by telephone. Without it, most would have to be handled in doctors’ offices or hospital emergency departments. “Without” is a potential situation for Minnesota and many regional or state poison

control centers around the country. Like Minnesota’s, many centers are running at deficits. Until this spring, MPCS was jointly managed and staffed by Hennepin County Medical Center (Hennepin Regional Poison Center) and Regions Hospital under contract with the State of Minnesota. Together, the two hospitals contributed $1.5 million a year to support MPCS even though in today’s changing health care economy, both hospitals are facing serious financial challenges. This past spring, Regions announced it was

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September/October 1999

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discontinuing its service to MPCS at the end of its contract June 30 in order to stem its own losses, and soon afterward Hennepin Regional Poison Center announced it was unable to continue its share of the subsidy. Since July 1, Hennepin alone has provided services statewide as it seeks funding to stay in operation. In 1998 this state-mandated system handled 53,000 poison exposure calls and 24,000 calls seeking poison and drug information. Most calls — 61 percent — came from the metro area. (In 1998, over 16,000 calls came from Hennepin County and over 6,400 from Ramsey County). Over half the poison exposure calls were for children under the age of five. “The system is saving money, and decreasing morbidity and mortality,” said Louis Ling, M.D., Medical Director of the Hennepin Regional Poison Center. “It’s nationally certified by the American Association of Poison Control Centers.” Pharmacists, certified by AAPCC with specialized training in toxicology and poison control, answer the phones. Board-certified medical toxicologists are available for consultation at all times. In 1998, more than 500,000 pieces of printed material and stickers were distributed statewide. MPCS also provides on-site toxicology instruction for pharmacy students, nurses, medical students and residents, and offers public and professional educational programs. The Minnesota Department of Health has been working on a short-term plan to keep the system operating, and a long-term plan to assure sustained funding for this service. MDH provides just under a quarter of the system’s $2 million annual budget. “There’s no doubt in my mind that this system is absolutely crucial,” said MDH Deputy Commissioner Julie Brunner. “It’s tremendously

The Bulletin of the Hennepin and Ramsey Medical Societies

effective for the people who call in, and it saves very real dollars for the state’s health care infrastructure.” If the Minnesota Poison Control Center were to shut down, the result would be “chaos,” according to experts who run the system. “The 77,000 calls will have to go somewhere,” said Debbie Anderson, Pharm.D., who directs the Hennepin Regional Poison Center. “Most of them will go to 911, doctors’ offices and hospital emergency rooms. And their specialized knowledge on poisonings is limited,” she added. “These are the people who rely on the Minnesota State Poison Control System for their information.” Morbidity and mortality are sure to go up, she said, and walk-ins to clinics and emergency rooms would increase dramatically. About 74 percent of the poison cases in 1997 were managed at the site of exposure — that is, at the home, school, workplace or other site for the caller — and just 13 percent were referred to a health care facility. Less than seven percent of the calls came from a health care facility where the patient was already being treated or was enroute. In either event, whether the caller was a lay person or a medical professional calling on behalf of a patient, the Minnesota Poison Control System was involved in providing poison information and treatment advice. Members of the public who recently used Hennepin Regional Poison Center services ranked the system highly. More than 95 percent of callers polled in a 1999 survey gave high ratings to the poison specialist they spoke with and the information they received. A national study in 1997 found that every dollar spent on poison centers saves an estimated $7 in unnecessary health care costs, mainly by eliminating the need for emergency department care for cases that can be managed safely at home. For Minnesota health plans, purchasers, and risk-bearing providers, this represents almost $12 million saved in 1998. The funding plan for the Minnesota Poison Control System is two-pronged. For the short term, MDH and MPCS are working together closely to find funds from private and other sources to keep MPCS operating until a permanent funding source can be established by the legislature. “We’re looking for private funding from MetroDoctors

foundations and other sources to cover the next six to nine months,” she said. “That will help the Poison Control System over this temporary financial hump. Beyond that, we’re considering other options, including legislation, that will assure this service continues to be available to all Minnesotans.” Debbie Anderson said that Minnesota physicians can help keep MPCS in operation by rallying their lobbying groups around a funding plan to present to the next legislative session. The Minnesota Medical Association Foundation will give $10,000 on a one-time basis, and reports that the East Central Medical Society has given $1,000. Paul S. Sanders, M.D. and Chief Executive Officer of MMA, invites donations from MMA component societies and specialty societies. To participate, contact Dr. Sanders at the MMA at (612) 378-1875. In more than a decade, there actually has been some decrease in state or federal funding for the Center, while costs of running the system continue to increase. In the past, HCMC and Regions have provided subsidies for the service exceeding $1 million a year.

The current sources of government funding are: • $ 380,000 — state general fund (decreased from $400,000 in 1992) • $137,700 — federal block grant (decreased from $150,000 in 1995) • $50,000 — 911 funds (added in 1993) • $567,700 — total for 1998 “Hennepin Regional Poison Center wants to provide this service,” Anderson said. “It fits with our role as a public teaching hospital. And, as a teaching hospital, we have other resources we can draw on, like the expertise in other fields, and our hyperbaric chamber for carbon monoxide poisoning.” She added, “It’s a matter of having the compensation for the services. The Hennepin Regional Poison Center has been providing these services since 1972. We’ve also developed the expertise and credentials to obtain the national certification from AAPCC. This is not the kind of thing that can be shut down for a short time, then started up again,” she said. ✦

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September/October 1999

COMMUNITY SERVICE

Honduras After Mitch

Kenia was due to deliver a baby when Mitch hit. The nurse midwife had arranged for this 36-year-old mother of two to have a repeat Cesarian Section at the Social Security (the charity) Hospital in Tegucigalpa. When she finally arrived, the hospital was closed with mud and water up through the third floor. After a long and expensive trip to LaCeiba, the surgical delivery was completed and she had a new healthy baby boy. When she eventually arrived at her “home” in a small village about three hours North of Tegucigalpa, her home and the land beneath it had been carried down the mountain. She and her three children are now homeless and trying to live with relatives, none of whom have the space or resources for long term support. She saw Dr. Beth Eiken of the International Health Services (IHS), a Minnesotabased voluntary health care service, in late February for a continuing wound infection from her surgery, but more importantly for symptoms of a post-traumatic stress syndrome. She has continuous worries about trying to keep her children alive and healthy and can’t sleep because of “crackling” sounds that she hears at night. Honduras was named by the Christopher Columbus expedition for its “deep waters.” The young men of Uhi, which is a small peninsula projecting into the Caribbean coast of Honduras provide frank testimony to the effects of these “deep waters.” Dr. Peter Wodrich, of St. Paul, was among the IHS team stationed at Uhi which is a very isolated community which required that Dr. Wodrich and his colleagues carry all their food and water 45 minutes through knee deep water from a boat landing to the village. The medical problems at Uhi were related more to poverty, isolation and exploitation than Mitch.

Entrepreneur lobster fishing crews hire the young men of Uhi to dive into these deep waters hunting for lobsters. Decompression sickness or “the bends” is a serious illness caused by diving too deeply, and resurfacing too rapidly which results in air getting into the blood stream and causing destructive emboli in various places. In Type I decompression illness there are joint pains, itching, and unusual sensations in the muscles. In the more serious Type II there are changes that affect the brain, can cause seizures and affect the spinal cord causing paralysis. One of Dr. Wodrich’s patients was a 22-year-old man who had been paralyzed from lobster diving at age 14 and is confined to a donated wheelchair for the rest of his life. The ground on Uhi is quite firm so he was able to get around quite well because he had the use of his upper extremities, but he had large pressure ulcers on

his knees and back that were open, infected, foul smelling and weeping. A catheter drained his urine to the base of the wheelchair. Dr. Wodrich noted many of the young men in this community suffering from Type I decompression sickness and others with the more serious Type II. The men are coaxed onto the boats with promises of high salary, approximating a yearly income (which is only several hundred dollars) and their sensibilities are numbed by cocaine and alcohol so that they will dive three and four times to depths of 120-125 feet. If a diver develops symptoms of the decompression sickness they are not allowed to return to the mainland for treatment in a hyperbaric chamber until the all important lobster hunt has been completed when it is too late to affect the illness. It is difficult to imagine the callous disregard for suffering that can be inflicted upon so many young

B Y D O N A L D S . A S P, M . D . A s s i s t a n t M e d i c a l D i r e c t o r, International Health Service

September/October 1999

Dr. Joseph Tombers prepares to cross the Caratasca with a boat full of supplies.

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The Bulletin of the Hennepin and Ramsey Medical Societies

men for profit, but this continues to occur. Reportedly, the primary purchasers of these lobsters are American fast-food chains. Joe Tombers, M.D., Gastroenterologist from Minneapolis has served with the IHS Team for several years and this year went with the Kruta River team along with Marianne Serkland, M.D., a St. Cloud Cardiologist and Co-Medical Director of IHS to this small village in the Mosquito Coast, near the very Eastern tip of Honduras. The Kruta team left Puerto Lempira, the only small “city” in the Mosquito Coast, in small boat loads. Joe was in a wooden boat powered by a fifteen horsepower engine which also carried the supplies. The team got off to a shaky start with a several hour delay in a swamp in rain and fog while their native guides struggled to find the location of the river. In this remote village with no plumbing or electricity, the team held clinics in Kruta and in the neighboring village of Tikaraya. This is a part of Honduras that has changed little since the time of Columbus. It’s very isolated with no access by road and the only airstrip is in Puerto Lempira. On occasion, patients are transferred

Dr. Donald Asp (left) treats a girl in septic shock.

MetroDoctors

Dr. Steve Earl talks to his patient — a policeman with his gun.

to Puerto Lempira and flown to larger hospitals by volunteer pilots from the Wings of Hope. The majority of the citizens of Kruta speak only their native Indian dialect with only a very few speaking Spanish and even fewer speaking English so that the translation issue becomes quite problematic. Everything needed by the team was brought in including medical supplies, food and all medicines. The team carried filtering equipment to produce water for their own use. West metro Obstetrician, Robert Rosenberg, M.D. and Family Physician, Steve Earl, M.D. served in the Yocon in the mountains of Central Honduras. Both physicians worked principally in primary care, but Dr. Rosenberg found several occasions where his local anesthetic surgical skills were important. Yocon is in the process of building a hospital and hopes to develop an ongoing system of health care delivery in this remote mountain community. The cement blocks are made locally and construction is started in what Dr. Rosenberg feels will be a successful project. Graduate medical students in Honduras have a service obligation to the nation for their medical education.The

The Bulletin of the Hennepin and Ramsey Medical Societies

community hopes that they can staff the facility utilizing these young physicians, plus some permanent physicians supplemented by visiting physicians from other nations. Individuals within IHS are supporting this community in their building project. George Nemanich M.D., was both surgeon and teacher at Coxen’s Hole, which is on one of the offshore Caribbean Islands. IHS provides two or three surgical teams each year and in addition to being a surgical referral source, arranges for young Honduran surgeons to work and learn with the U.S. surgeon. Dr. Nemanich completed 40 surgical cases with his student during the two week trip. George’s wife, Ann Nemanich, collected 1,600 glasses from the Lion’s Club and distributed them among several teams and fitted over 400 local inhabitants with their first pair of glasses. According to George, Ann was the most popular member of the team with long lines waiting for the opportunity to see clearly once again or to be able to resume reading. The five plus day hurricane that stalled over Honduras caused untold damages to the infrastructure of the nation. More than a hundred bridges were destroyed, close to two million people were homeless, more than 7,000 deaths have been documented and approximately 8,000 additional individuals are missing and (Continued on page 18)

September/October 1999

(Continued from page 17)

assumed dead. Fifteen villages were totally destroyed. Medical teams from around the world have been offering support and care for the Honduran citizens. The first to arrive were a team of physicians from Cuba who met the immediate needs of many victims. Shortly thereafter, Mexico offered both medical and financial support. The U.S. Corp of Engineers constructed a critically important Bailey Bridge in downtown Tegucigalpa which allowed the city to reconnect to the Western communities of Honduras. This bridge was recently dedicated by President Clinton. The Minnesota based IHS Team is one of several that have arrived from the United States. This IHS Team of 111 health care workers, including physicians, dentists, nurses, pharmacists and other health care volunteers spent two weeks in remote areas of Honduras and brought along all their own medical, surgical and pharmaceutical supplies. Of the medical and surgical team about half worked in the Mosquito Coast area; one surgical team was set-up in the off shore islands and the remain-

Dr. Robert Rosenberg in the Yucon with a new mother and her baby.

ing teams were in the inner mountainous regions. The entire IHS group saw more than 10,000 patients for medical, dental and surgical services. The majority of medical problems, while very serious, were more related to poverty than Mitch. As noted by Maria Zuniga, Director of the Center for Health, Information, and Services, “The disaster didn’t bring new diseases. It just exacerbated what was already here and made the critical health situation of the poor, more visible.” “Nothing new blew in with the storm. It left the same old health problems. They are just easier to see now.” With 70 percent of the crops destroyed and nearly two million homeless, the recovery will be long and painful. Carlos Flores Facusse, the Honduran president stated that, “In 72 hours, we lost what we had built, little by little, in 50 years.” Honduras, which is about the size of Ohio, has rugged hills and mountains covering three-fourths of its surface. Of the remaining rich bottom land, three-fourths is controlled by foreign fruit companies (it is the original Banana Republic).

Ann Nemanich, wife of Dr. George Nemanich, collected eyeglasses for the Hondurans. This man is all smiles after receiving his glasses; he could hardly see without them.

September/October 1999

MetroDoctors

There is extreme disparity between the rich and the poor and overall it is among the poorest nations in the Western hemisphere. Noemi Espinoza, Executive President of the Christian Commission for Capital Development in Honduras characterized the challenge of rebuilding most clearly when she said, “We have to learn from this disaster. We have to change the way power is distributed and exercised so that the poor and forgotten can participate in rebuilding their lives — not just be spectators while international assistance is used to rebuild an economy only for the wealthy. The poor possess a tremendous capability to solve their own problems. Our task is to accompany them. If they are not the ones to rebuild their community, to participate in making decisions about their lives, then we have no future as a country.” The International Health Service is a volunteer organization which receives support from a number of hospitals and their foundations including North Memorial, Fairview and HealthEast, some private donations and equipment from some health care product vendors, but is financed in large part by its volunteers. Drs. Eiken and Wodrich are family practice residents in the Universities’ program at St. Joseph’s Hospital in St. Paul and their participation was funded by the HealthEast Foundation. ✦

The Bulletin of the Hennepin and Ramsey Medical Societies

What to do About Colon Cancer Screening? Will Flexible Sigmoidoscopy Become Unavailable?

Editor’s Note: A St. Paul internist group is experiencing a limit in their ability to provide this service due to specialists no longer performing sigmoidoscopies at the hospital and the hospital’s decision to close their unit. Give us your feedback. Are you experiencing similar limitations in this or other areas and, if so, what have you done to retain the ability to deliver the service to your patients?

Over the last several months we, at St. Paul Internists, have been trying to decide what to do about screening our patients for colon cancer using flexible sigmoidoscopy. The endoscopy suite where we have been doing them is closing and another available site is not forthcoming. The history of doing flexible sigmoidoscopy in our group is straightforward; the direction to take now is not as clear. We are a group of ten internists in St. Paul. Up until a few years ago we were doing flexible sigmoidoscopies in our office in a special procedure room equipped with a bathroom. OSHA requirements then demanded that, given the use of glutaraldehyde, we obtain a hood for cleaning the scope. This was going to be expensive and require structural changes to make sure we had adequate venting. We decided to continue doing the procedure at the HealthEast endoscopy center in our building. Although personally less convenient, we did not have to deal with training personnel, scope breakdowns and maintaining facility procedures. The HealthEast endoscopy center has been used by a variety of family practitioners and internists for flexible sigmoidoscopy. The bulk of its use, however, is from gastroenterologists and colorectal surgeons doing endoscopy and B Y E I L E E N O ’ S H A U G H N E S S Y, M . D . President, St. Paul Internists

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colonoscopy. The GI physicians and colorectal surgeons are now in the process of finishing their own endoscopy center north of downtown St. Paul. The bulk of their nonemergent procedures will then be done at their own facility. The reality of reimbursement is such that the money received for endoscopy and colonoscopy essentially subsidized the use of the facility for sigmoidoscopy. Keeping a center open for just flexible sigmoidoscopy does not make sense. The dilemma for us is whether to return to the practice of doing them in our office. Looking at the economics and support procedures necessary to do this begs the question whether it is worthwhile. The University of Pennsylvania and the Philadelphia Veterans Affairs Medical Center looked at this issue (Annals of Internal Medicine, March 16, 1999). They concluded Medicare reimbursement covered the cost of flexible sigmoidoscopy without biopsy. If a biopsy was done, the expense was greater than payment. This was based on a physician doing at least 75 per year and the procedure taking no longer than 21 minutes. Their cost estimate did not include staff time for such things as checking in patients or cleaning the scope. It also did not include cost of scope repair. The Medicare physician payment for doing a flexible sigmoidoscopy in our office is $103.91. If done at an outside facility it is $52.36. The University of Pennsylvania data also pointed out the average hourly revenue for outpatient care was $136.49 by AMA calculations and $171.53 for Medicare. Facility convenience and efficient use of a physician’s time is also a factor. Other important statistics included: cost of new scope $5,600 with average life expectancy of five years; cost per day of cleaning solution $4.17; average hourly wage of medical assistant $11. Looking at doing the procedure in our of-

The Bulletin of the Hennepin and Ramsey Medical Societies

fice also required us to look at equipment issues, cleaning protocol, and staff time. There is now a cleaning solution called Sporox. It does not require a hood. The scope has to be thoroughly cleaned and then soaked in this solution for 30 minutes. There have also been many questions raised about the risk of spreading infections from poorly handled disinfection. It is recommended to limit the number of personnel doing the cleaning so standards can be perfected and maintained. Staff time is also needed for checking people in, evaluating vitals, preparing the patient for the procedure and also handling problems such as poor prep or vasovagal reactions. We discussed the possibility of abandoning the procedure and referring the colon cancer screening to the gastroenterologists and colorectal surgeons. Per the American Cancer Society guidelines, a person at average risk can also be screened by colonoscopy every ten years or double contrast barium enema every 5-10 years. We are concerned, however, that our patients would not get the screening done. We believe a reluctant patient is more likely to agree to screening if their usual physician will be doing it. It is also questionable whether the specialists could handle the volume of screening procedures if the internists and family physicians quit doing them. As a group, we have discussed all of the above issues and decided to start doing flexible sigmoidoscopies in our office again. We would prefer a convenient endoscopy center but, given the realities of reimbursement, this is not going to happen. We want to continue to ensure our patients are getting the screening they need. We also have young physicians who want to maintain their skills. We will monitor our procedures, costs, and payment schedules and see how it goes. ✦ September/October 1999

Center for Health and Medical Affairs Physician Leadership College

For the past twelve years, the Center for Health and Medical Affairs (CHMA) has offered introductory health care management education through the Certificate Program in Management for Physicians and the Mini-MBA in Health Care Management. Six years ago, in response to demand for graduate-level executive outpatient-focused education, the Graduate School of Business began offering the MBA in Medical Group Management. Today, the “Leadership College” addresses the need for advanced leadership education for physicians. The Center for Health and Medical Affairs continues its tradition of offering exceptional programs for health care administrators with another exciting initiative: Physician Leadership College. This collaborative effort of the University of St. Thomas and the Minnesota Medical Association is an 18-month program designed for seasoned physician leaders. Several years of planning and development were brought to fruition at the Gainey Conference Center this May as the inaugural leadership college cohort began their first Module. The Leadership College re-evaluates the traditional format for delivering physician education. This program provides a neutral academic setting for multiple stakeholders to convene, study and explore solutions to contemporary health and medical issues. Unlike the traditional CME offering which stresses episodic, individual training most often focusing on clinical issues, the Leadership College offers ongoing systematic programming in a cohort-style learning environment. The curriculum is a mixture of skills-based and knowledge-based education with the sufficient rigor and relevancy needed to greatly enhance the leadership abilities of our students. The cur-

riculum is comprised of ten modules of varying lengths. The backbone of the Leadership College is the personalized, ongoing, one-on-one aspect of the mentoring system. Each participant, by the end of the first module, will participate in the selection of a mentor/coach who will be available to him or her throughout the length of the program. St. Thomas selects mentors based on history in the marketplace, ability to model and demonstrate leadership skills, as well as ability to teach in the program. The faculty and mentors associated with the Leadership College are committed to facilitating a program whereby participants will come to understand both the science and art of leadership as well as be able to enhance their own leadership capabilities. The development of Leadership College,

from concept to reality, is a significant accomplishment for the CHMA team. The Center for Health and Medical Affairs is committed to enhancing the quality of health and medical care through the delivery of management and leadership education within an ethical framework. Mark Arnesen, M.D., is one of the physicians participating as a member of Cohort 1, Leadership College. He offers the following insights and ideas about leadership: “In my past and present leadership activities, I have learned the difficulty of implementing change, as well as the need for fundamental change in the system. I have also seen the difficult ethical challenges we all face and the need for a strong ethical framework as we look at new and perhaps radically different models for delivering care. “I would not care to lead without the elective support of my physician colleagues. I am strongly committed to the ‘pluralism’ our medical staff embodies. I feel the competitive marketplace has made our private medical staff second to none, and I would like to find a way to preserve it. Working at what I see is the best hospital in the Midwest gives me a sense of pride and hope. I think the commitment to our patients and improving our quality of service to them is the key to our survival. Finally, I know that adherence to a strong ethical framework is the only way we can ‘keep our souls’ as we face the challenges ahead.” ✦

“Physicians must be at the table of leaders, designing and implementing the new health care system. We must have the leadership training and experience to be contributing members of the team. The aim of the Leadership College is to educate doctors to maximally contribute to these efforts. From past experience it is clear that physicians must play leadership roles in developing the new health care system. It is very exciting to be part of the team that is adding yet another offering toward the goal of creating a community of physicians capable of leading tomorrow’s health care organizations.” Brian Campion, M.D., faculty

BY THOMAS GILLIAM AND MARY SCHMIDT

September/October 1999

MetroDoctors

The Bulletin of the Hennepin and Ramsey Medical Societies

Ramsey and Hennepin Medical Societies offer the

2000 Winter Medical Conference Mexican Riviera Saturday, February 26-March 4, 2000

Gala Resort Playacar The Riveria Maya is a protected area with many remembrances of the fascinating Mayan civilization. Beyond the new Gala Resort Playacar is a temple at Tulum where kings and priests vacationed more than 1,000 years ago. Even within the Resort grounds there are some amazing remains from the Mayan culture. Strategically located a short driving distance from the beautiful 250 acre ecological theme park Xcaret, the resort enjoys a gorgeous stretch of pristine coast-line. At Xcaret visitors may don life jackets and leisurely float with the cool water currents through a series of caves and streams. There is also a “Dolphinarium”, botanical garden museum and riding stables.

ALL INCLUSIVE RATES (AIR AND HOTEL) $1,849* per physician/single $1,149* per spouse/guest, double occupancy $1,069* for children 12-15 years old $829* for children 7-11 years old $349* for children under 7 years old (children under 2 years old are free) * Please add $69.00 per air seat for departure tax and fees.

(This does not include the conference registration.)

ABOUT THE RESORT The Gala Resort Playacar is a deluxe, all-inclusive resort located on a glorious sandy beach, a short distance from the village of Playa del Carmen and the ferry dock to Cozumel. Each of the 300 deluxe rooms feature airconditioning, satellite color TV, telephone, mini-bar with mineral water, soft drinks and beer, safety box, hair dryer, and a balcony with garden, partial or full ocean view. The hotel features four swimming pools (one is “Adults only”), four lighted tennis courts, gym with steam room and nautilus exercise equipment, volleyball and basketball courts, water sports center (scuba diving, snorkeling, windsurfing, kayaking and sailing), discotheque, indoor/outdoor theater, and children’s “Galaxy Kids Club”. Available at an extra cost is the game arcade, massages and beauty parlor, golf, deep sea fishing, excursions (Arqueological Sites Tulum, Ecological Park Xcaret), and wave runners.

Space is Limited: Register early to guarantee your reservation.

Call Becky at Hobbit Travel (612-338-8452 ext. 2) or RMS/HMS (612-362-3704) MetroDoctors

The Bulletin of the Hennepin and Ramsey Medical Societies

September/October 1999

levels, chronic asthma, chronic head lice and other health problems.

Metropolitan Visiting Nurses Association Helps Community Agency Information The Metropolitan Visiting Nurses Association (MVNA) is a non profit nursing agency that provides home health care and public health services in the Twin Cities metro area. Since 1902, MVNA staff have served people in need of nursing care, public health nursing services and community education. MVNA employs 140 permanent full-time employees who are primarily field staff — Public Health Certified Nurses, RNs, LPNs, Home Health Aides, Homemakers and Interpreters. Masters prepared Clinical Nursing Managers supervise nursing field staff and para-professionals. MVNA staff performs nearly 75,000 home care visits each year to individuals and families in the metro area. MVNA is proactive in the development of programs that ensure healthier, safer environments, lifestyles and life-choices for individuals and families in the Twin Cities area. MVNA provides charity nursing care to Twin Cities residents. MVNA is a member of the Minnesota Home Care Association. Who We Serve MVNA nursing staff primarily serve individuals and families from high-risk populations in Minneapolis and St. Paul although our radius of service extends to the nine county metro area. Theses clients are disadvantaged, high risk and low income. Many of the individuals, children and families we serve, require specially needed support because of social issues, poverty, emotional/behavioral problems or are at-risk for abuse and neglect. They are referred for public health interventions, or nursing and paraprofessional services with diagnoses that range from postpartum depression to chronic health conditions. In 1998, MVNA staff served approximately 4,000 children birth to 17 years and nearly 5,000 adults through nearly 75,000 home 22

September/October 1999

visits. Startlingly, more than 70 percent of MVNA clients/client families referred for home care services rely on Public Health, Medical Assistance or charity care — 50 percent of the home visits our staff make are provided free of charge. As well, more than 60 percent of MVNA clients residing in Minneapolis are living at or below 200 percent of Federal Poverty guidelines. Overview of Therapeutic Home Visiting Services A comprehensive effort is made to serve metro area adults and elderly who are acute or chronically ill. The greatest number of our clients live in the inner-city and have very minimal resources. They are often isolated and have needs well beyond acute intervention for their illness. Services include: Skilled Nursing; Home Health Aide; Homemaker; Therapies; IV Services; Block Nurse Program — neighborhood home health care for the elderly; and Hospice Care. Home Health Care to Ill Children and Public Health Nursing Many of the services provided by staff involve work with moms and their children. These services include: special intervention efforts for drug-addicted moms and babies through the Project Child Program; nursing and family health aide assessment; role modeling and support for families identified as at risk for abuse and neglect and living in the Zaneway Corridor in Brooklyn Park through the Zaneway Program; support for unwed moms (of all ages) before and after pregnancy; nursing support for families who have children in the NICU (Neo-natal Intensive Care Unit); and for women and children at battered women’s shelters. MVNA also provides early health screenings for children, refugee assistance, home safety assessments for children who are at risk from high blood lead MetroDoctors

Other Services • Day Care Consultation services to Minneapolis and Suburban Hennepin County Day Care Centers and Family Child Care Providers. • Public Health Nursing to the Way To Grow Programs. • Flu Shot Clinics, Immunizations. • Cholesterol and Blood Pressure Clinics for Corporate Clients. Community Involvement In addition to the very tangible services we provide to the children and families, elderly and disabled whom we serve each day, are the ancillary services we offer that other home care agencies do not. For example: MVNA has developed a holiday “gift -giving” program that benefits our most needy clients; in 1998, more than 400 gifts were donated as well as contributions which totaled over $1,000. In addition, each year we solicit area Target Stores, Cub Foods, Rainbow Foods, TJ Maxx and Walmart stores for donations. Year in and year out, we write grants to support the work we do — some monies support general operating expenses while others are restricted to support for programs that benefit at-risk children and youth. ✦

MVNA Gala Charity Benefit Friday, November 19, 1999 6:30-10:00 p.m. University Club — St. Paul Featured Speaker: Dr. Patch Adams, the founder and director of Gesundheit Institute, a free health facility in operation for the past 22 years. Dinner and Cocktails Semi-formal attire Tickets: $100 each Table Sponsorships are available: $2,500 each

The Bulletin of the Hennepin and Ramsey Medical Societies

NOTEWORTHY

U.S. House of Representatives to Consider Health Care Quality and Choice Act of 1999 in September House Speaker Dennis Hastert, (R-IL), has indicated that the House will take up the bill, known as the Coburn-Shadegg bill, when the House returns in September from the August recess. The Coburn-Shadegg bill was developed in response to the Bipartisan Consensus Managed Care Improvement Act of 1999, H.R. 2723, also known as the Norwood-Dingell bill, introduced and sponsored by 45 Democrats and 20 Republicans. Because the Coburn-Shadegg bill had not been introduced at the time MetroDoctors was going to press, the specific language of the bill was not available. The AMA indicated that it would evaluate the bill when it was introduced in September. At press time, many of the provisions appeared to be similar, however, the devil is always in the details. Both bills included a right to sue health insurers for damages over delayed or denied benefits. Both bills also included language for an external appeals process; guaranteed coverage for emergency services; direct access to specialists; and a point-of-service option that allows patients to go outside the network of providers. A major sticking point in the CoburnShadegg bill was the lack of a “whistleblower” provision. The Norwood-Dingell bill included a ban that would prevent a health plan from retaliating against physicians and nurses who raise concerns about the quality of their patient’s medical care. Speaker Hastert indicated that a separate bill would be considered that would include the access issue, a provision for HealthMarts, tax deductions, and Medical Savings Accounts. That language was not available at press time. Many of the provisions in both bills were

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included in patient protection legislation passed by the 1998 Minnesota Legislature and included in Minnesota statutes. The major feature of both bills under consideration in the House that will be watched closely by Minnesota physicians is the right to sue health insurers for damages caused by delayed or denied benefits.

about its finances, provider network, premiums and other items. The legislature created this category as a way to increase health care competition. CCHC was envisioned as an alternative for rising health insurance premiums for small-medium sized employers. Dr. E. John English, an Apple Valley physician served as its chairman. ✦

Classifieds

Accountable Provider Network Fails

IMPROVE YOUR CASH FLOW. CPA with extensive fee-for-service and capitated experience in Minnesota and California can help you manage your clinic finances. Available for special projects or temporary/part-time position. (612)996-6516.

The Minnesota Health Department denied an application by Community Coordinated Health Care (CCHC) to form Minnesota’s first Accountable Provider Network, citing that CCHC had not provided information

FOR SALE. X-ray, heavy duty file cabinets, five shelf; physical therapy wall and overhead frame; Cybex II; microfiche equipment. Make offer. Allen at (651)455-6514. Leave Message.✦

The Bulletin of the Hennepin and Ramsey Medical Societies

AUTO LEASING Boulevard Leasing offers many advantages to the physician or group practice. • • • •

Selection of any car, van or truck, foreign or domestic. Tailormade leases, not a “program” that must be adapted. Fair, competitive prices. Small, local firm with responsive, personal service.

Boulevard Leasing Nancy Kapps President 2817 Anthony Lane S., #104 St. Anthony, Minnesota 55418

(612) 781-8449

Endorsed by Ramsey Medical Society

September/October 1999

P R E S I D E N T ’ S M E S SA G E LY L E J . S W E N S O N , M . D .

RMS-Officers

President Lyle J. Swenson, M.D. President-Elect John R. Gates, M.D. Past President Thomas B. Dunkel, M.D. Secretary Robert C. Moravec, M.D. Treasurer Peter H. Kelly, M.D. RMS-Board Members

Kimberly A. Anderson, M.D. John R. Balfanz, M.D. James A. Brockberg, M.D. Charles E. Crutchfield, M.D. Peter J. Daly, M.D. Aimee George, Medical Student Michael Gonzalez-Campoy, M.D. James J. Jordan, M.D. F. Donald Kapps, M.D. Charlene E. McEvoy, M.D. Joseph L. Rigatuso, M.D. Thomas E. Rolewicz, M.D. Jamie D. Santilli, M.D. Paul M. Spilseth, M.D. Jon V. Thomas, M.D. Randy S. Twito, M.D. Russell C. Welch, M.D. Phua Xiong, M.D., Resident Physician RMS-Ex-Officio Board Members

Blanton Bessinger, M.D., MMA House of Delegates Speaker Chad Boult, M.D., Council on Professionalsim & Ethics Chair Kenneth W. Crabb, M.D., AMA Alternate Delegate Duchess Harris, Alliance Co-President Neal R. Holtan, M.D., Community Health Council Chair Nicki Hyser, Alliance Co-President Frank J. Indihar, M.D., AMA Delegate William Jacott, M.D., U of MN Representative C. Randall Nelms, M.D., AMA Specialty Delegate Robert W. Reif, M.D., Sr. Physicians Assoc. President William M. Rupp, M.D., Joint Contract Review Program Chair Melanie Sullivan, Clinic Administrator Kent S. Wilson, M.D., MMA Past President RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive Officer Doreen Hines, Assistant Director

At the American Medical Association’s Annual Meeting in June, the AMA’s House of Delegates went on record supporting the formation of an AMA-sponsored physicians’ union for employed physicians, and an AMA-sponsored union for resident and fellow physicians. The House of Delegates also resolved to “vigorously support anti-trust relief for physicians and medical groups” by supporting the Quality Health Care Coalition Act of 1999 introduced by Representatives Tom Campbell of California and John Conyers of Michigan, and called on AMA leadership to be prepared to form a national organization for self-employed physicians to collectively bargain with large health plans. The idea of physician unionization is certainly not a new one. It has been estimated that six percent of physicians are already members of unions, including physicians-in-training. Your own Ramsey Medical Society has explored and formally discussed unionization within the last year, and has brought in authorities to speak on this issue. Why has the AMA, which has not supported unionization in the past, now shown support for unionization and the ability of independent physicians to bargain collectively? Despite AMA leadership’s recent statements opposing unionization, the rank and file of the House of Delegates have seen the need for drastic action to try to level the field with large health insurance companies and managed care plans. Because of current anti-trust laws and regulations, physicians are prevented from collectively negotiating the terms and conditions of contracts with large health plans. The health plans have anti-trust exemptions under the McCarron-Ferguson Act, enabling them to develop tremendous power and control over patients and physicians. The disparity and imbalance between the power of ever-larger health care plans and physicians has finally caused enough physicians in the AMA House of Delegates to support unionization and collective bargaining as a means to allow more equal negotiating positions, and to support legislation

MetroDoctors The Bulletin1999 of the Hennepin and Ramsey Medical Societies 24 September/October

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in an attempt to achieve this balance. There are many aspects to this effort that merit consideration. Can unionization be a part of the profession of medicine? Will it cause physicians to lose sight of the ideals of their profession? A unique feature of our profession is that we, as physicians, place the highest priority on what is best for our patients, above all else, including financial self-interest. If unionization detracts from this ideal, then it will be bad for physicians and it will be bad for health care. The support for labor unions has suffered in the past from concerns of self-interested control by overly strong leadership, connections with organized crime, and the negative repercussions of strikes. If any of these features begin to be a part of a physicians’ union, it will detract from our profession and it will be bad for health care. Given these potential problems with labor unions, it would seem prudent to make a distinction between traditional labor unions and a physician organization to accomplish our goals of achieving balance in negotiations with large health plans. In addition, whatever form this organization takes, the term “union” should be replaced with a more appropriate descriptive term. What are the chances of significant change in anti-trust laws to allow independent physicians the right to join together for purposes of collective bargaining? One would think that physicians, who are largely Republican, should be able to work toward a solution on this question with a Republican controlled Congress. However, this effort will be strongly opposed by the health insurance industry, the managed care companies, and big business with their millions of dollars put into well developed lobbying organizations; physicians will be at a distinct disadvantage. (Continued on page 25)

September/October 1999 The Bulletin of the Hennepin and Ramsey Medical Societies

RMS Receives Associations Advance America Award of Excellence pensation for the care they deliver to the uninsured patients. 175 physician members of RMS in numerous specialties joined the VSPN to serve the uninsured without compensation. To date over 250 uninsured patients have accessed the program and over 180 uninsured patients have received services from specialists free of charge. In addition, many patients have received hospitalization without charge as a result of the efforts of the physicians advocating for the patient. Now in its ninth year, the prestigious Associations Advance America Award recognizes associations that propel America forward with innovative projects in education, skills training, standards-setting, business and social innovation, knowledge creation, citizenship, and community service. Although association activities have a powerful impact on everyday

Dr. Lyle Swenson (L), president of RMS, and Dr. Tom Dunkel (R), past president of RMS and medical director of VSPN, receive the 1999 Award of Excellence from the American Society of Association Executives for the VSPN program. Dr. Swenson is a cardiologist with St. Paul Cardiology and Dr. Dunkel is an internist with St. Paul Internists.

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The Bulletin of the Hennepin and Ramsey Medical Societies

President’s Message (Cont.) In regard to a physician organization for employed physicians to negotiate with their employers, will the AMA sponsored labor organization become a reality, and will it help these employed physicians? Employed physicians tend to be less apt to join their local and state medical societies, and I suspect are less likely to join the AMA than are independent physicians. Currently, approximately 34 percent of physicians are members of the AMA, and part of the decline in AMA membership is probably due to less participation by employed physicians. It remains to be seen whether employed physicians will support an AMA sponsored labor organization and whether it will make any difference. How will the general public view a physicians’ labor organization? We have already seen efforts to instill fear into the people of this country regarding a possible nation-wide doctor’s strike leading to catastrophic results. This is despite the President-Elect of the AMA, Dr. Randolph Smoak, Jr., stating that the physicians’ labor organization would not affiliate with traditional labor unions and would never go on strike. Another issue that is used to sway public opinion is health care costs. The health insurance industry often uses the ploy of predicting dramatic increases in health care costs, usually leading to quick opposition without any evaluation of the data or exploration of the true ramifications on costs. Even though the final form of the AMA sponsored physicians’ labor organization is not clear yet, and the outcome of legislation to change anti-trust laws is in doubt, it is very clear that there is growing support for these efforts among physicians, and that there will be more vocal and vigorous calls for control of health care to be put back where it belongs — with the patient and their physician. ✦ September/October 1999

Ramsey Medical Society

The Ramsey Medical Society (RMS) has won the Award of Excellence in the 1999 Associations Advance America program, a national competition sponsored by the American Society of Association Executives (ASAE), Washington, D.C. RMS received the award for its Voluntary Specialty Physician Network (VSPN). In June of 1996 RMS joined with MetroEast to organize a program to serve the uninsured in the East Metropolitan area of the Twin Cities of Minneapolis and St. Paul. A Reachout Grant was received from the Robert Wood Johnson Foundation to cover the administrative costs. RMS was charged with recruiting a network of specialists who would volunteer to serve in the VSPN. The specialists would receive referrals from the MetroEast primary care clinics. The specialists receive no com-

life, they often go unnoticed by the general public. “The RMS’s program truly embodies the spirit of the Associations Advance America campaign. It is an honor and an inspiration to showcase this activity as an example of the many contributions associations are making to advance American society,” remarked ASAE President Michael S. Olson, CAE. ✦

RMS NEWS Transfer into RMS (Resident) Kenneth E. Nollet, M.D., Ph.D. Transfer into RMS (Student) Julie A. Paquette University of Minnesota

Applicants for Membership We welcome these new applicants for membership to the Ramsey Medical Society.

Active Alan J. Bank, M.D. University of Missouri, Columbia Internal Medicine/Cardiovascular Disease St. Paul Heart Clinic, P.A. Deanna L. Bass, M.D. Medical College of Wisconsin, Milwaukee Psychiatry University of Minnesota Ricardo H. Castillo, M.D. Univerity of California, Los Angeles Obstetrics&Gynecology/ Reproductive Endocrinology & Infertility Reproductive Medicine and Infertility Associates Catherine A. Crosby-Schmidt, M.D. University of Texas Medical School Pediatrics Central Pediatrics, P.A. Kristin M. Mascotti, M.D. University of Minnesota Pathology Central Regional Pathology Laboratories Michael A. Nemeth, M.D. Indiana University Surgery, General/Laparoscopic/Vascular River Valley Clinic, Woodbury Elisabeth J. Paszkiewicz, M.D. University of Texas Urology Metropolitan Urologic Specialists, P.A.

September/October 1999

Suzanne F. Permuth, M.D. Stanford University Medical School Family Practice Park Nicollet Clinic, Eagan Ivan W. Sletten, M.D. University of Wisconsin, Madison Psychiatry Private practice Barbara Schmidt Steinbrunn, M.D. University of Minnesota Surgery, General Minnesota Surgical Associates, P.A.

In Memoriam CLARENCE J. ROWE, M.D., 83, died on

July 29. He graduated from the University of Minnesota Medical School. He was a full clinical professor at the University of Minnesota. Dr. Rowe was in private practice with Mental Health Consultants, St. Paul. He was vice president of medical affairs at the Wilson Center in Faribault. Dr. Rowe was the founder of the Hamm Memorial Psychiatry Clinic, the Minnesota Psychiatric Society, and the Minnesota Society of Adolescent Psychiatry. HOWARD H. SHEAR, M.D., died in

Resident Asif Bashir, M.D. King Edward Medical College, Pakistan Surgery, General University of Minnesota

June at the age of 74. Dr. Shear retired in 1988 after practicing internal medicine for 25 years. He graduated from the State University of New York Medical School in 1961.

Member News

Jeffrey J. Connaire, M.D. University of Minnesota Medicine/Pediatrics University of Minnesota Mark L. Sczepanski, M.D. University of North Dakota Ophthalmology University of Minnesota

Student Kate Hanson University of Minnesota

Transfer into RMS (Active) Julie A. Saxton, M.D. University of North Dakota Pediatrics Pediatric and Young Adult Medicine, P.A.

MetroDoctors

PHUA XIONG, M.D., was named the 1999 Family Practice Resident of the Year by the Minnesota Academy of Family Practice. Dr. Xiong is in the University of Minnesota’s St. Joseph’s Family Practice Residency Program. The award recognizes a third-year resident for contributions to family medicine in the community, including teaching, leadership and educational activities. Dr. Xiong was recognized in large part for her devotion to providing health care to an underserved population — the Hmong community. According to Donald Asp, M.D., a past RMS and MAFP president, “Dr. Xiong has done a great deal in advancing the health benefits to Hmong immigrants and at the same time improving the communication and care giving skills of her colleagues and faculty at our residency program.” ✦

The Bulletin of the Hennepin and Ramsey Medical Societies

RMS ALLIANCE NEWS DUCHESS HARRIS, Ph.D.

The Top Ten Excuses People Use to Not Join the Alliance 1.) I work. I really like this one because it’s usually said in a tone that implies that this is a unique concept. My response is simple: so do the rest of us. Let’s define work. For some people it is travelling to a place of employment that compensates you financially. For others it is scraping peas out of a high chair. For someone like me, it’s both. Any way you slice it, I’ve yet to meet the Alliance member whose idea of a tough decision is how they can fill their labor-free day. 2.) I’m not a woman. Well, we all can’t be, and that’s what makes life interesting. But for those of you who thought this was a prerequisite for membership: think again. We aren’t doctor’s wives, we are physician’s spouses committed to health care in America. So if you’re male, maybe you should ask your wife if she’d appreciate a little professional support, it might make up for the fact that you aren’t a woman, and volunteering could put you one step closer to compensating for this shortcoming. 3.) I already volunteer. As well you should. What makes the Alliance unique however, is that our focus is on health care. This should be important to you because if you are married to a physician there’s a good possibility that concerns about managed care live in your head rent free. MetroDoctors

4.) My spouse isn’t active in the Medical Society. Well, if I were held accountable for everything Jon did or didn’t do, I might have seen the inside of traffic court a long time ago. Think about it like this…while your spouse is with a patient, you can be learning about Health Insurance Reform. Trust me, she or he will thank you. 5.) My spouse works in both counties. Join Ramsey first…because I said so. (I’ve always wanted to say that, but my son’s not old enough yet.) P.S. — You can belong to both. 6.) WIIFM (What’s in it for me?) O.K. So no one actually says this—but you know you might have thought it once or twice. 7.) I am retired or have small children. Aren’t you fortunate! I’ve never met an Alliance member who wasn’t willing to look at a recent snapshot of a cabin up north or a toothless child. Even if you’re retired, or your spouse is deceased, there are social groups within the Alliance like the Bridge and Book Clubs that would be more than glad to see you coming. If you have small children, bring a portable play pen and have a conversation with a grown up. You’ll have something to think about other than those fictitious people that for some reason go up and down on some bus you’ve never ridden on. 8.) Where do my dues go? Well, if you’ve paid your dues we thank you. In

return you receive information about public health issues and community projects. But better yet, your hard earned money will go to important philanthropic endeavors such as scholarship money for medical students or wigs for chemotherapy patients who have lost their hair. 9.) Time, time, time…I don’t have it. What do you really think we’re asking? If you came and helped set up for our annual yard sale that took place July 24 and 25 (which by the way raised $3,000), you could have previewed a lot of good “previously owned” stuff, and hung out with your friends for two hours. 10.) Life is so hectic—I just wanna have fun. O.K. we’re working on this. I admit that we don’t have a reputation for being as loose as Monica Lewinsky, but we’re not as stiff as Al Gore either. I’ll make a deal with you…pay your dues and we’ll invite you to something that’s as fun as the Deva Ball was, and maybe even less expensive. If you want to feel good at the end of the Millennium, join the Alliance. It’s easier than losing the five pounds or paying off the credit card and we all have to start somewhere. ✦

RMS Members Needed for Community Intern Program Physicians from various specialties are needed to host community interns during the November 9-10, 1999, Community Intern Program. The program operates for two days with physicians hosting community interns for a half day. Community interns are recruited from the business community, the legislature, the legal profession, the clergy, and other fields. Each community intern spends a half day in surgery, the ER, primary care, and one other specialty areas accompanying the physician as patient care is provided. Physician volunteers are needed and you are urged to call the RMS office at 612362-3704 to volunteer.

The Bulletin of the Hennepin and Ramsey Medical Societies

September/October 1999

Ramsey Medical Society

Not being a member of the Alliance is easy. Similar to holding on to those last five pounds and using that credit card that one last time, committing yourself to community service is something that we need to do, but often avoid. As the co-president of the Alliance this year, I find myself in the same position as your financial advisor or personal trainer: you’re glad I have the position, but you hate to see me coming. Why? I’ve heard every excuse, but I’m going to encourage you to do the right thing.

Convenient, money saving services just a click away at www.mnmed.org/mmbr MMBR MINNESOTA MEDICAL BUSINESS RESOURCES O

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MMA & HMS

September/October 1999

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The Bulletin of the Hennepin and Ramsey Medical Societies

CHAIRMAN’S REPORT E D W A R D A . L . S P E N N Y, M . D .

HMS-Officers

HMS-Board Members

Michael Belzer, M.D. Carl E. Burkland, M.D. Penny Chally, Alliance Co-President William Conroy, M.D. Rebecca Finne, Alliance Co-President Daniel F. Greeley, M.D. Raymond A. Hackett, M.D. James P. LaRoy, M.D. Michael Lins, M.D. Edward C. McElfresh, M.D. Joseph F. Rinowski, M.D. Marc F. Swiontkowski M.D. T. Michael Tedford, M.D. R. Douglas Thorsen, M.D. Clark Tungseth, M.D. Joan Williams, M.D. Bret Yonke, Medical Student HMS-Ex-Officio Board Members

Lyle French, M.D., Senior Physicians Association Karen Dickson, M.D., MMA-Trustee John W. Larsen, M.D., MMA-Trustee Robert K. Meiches, M.D., MMA-Trustee Henry T. Smith, M.D., MMA-Trustee Benjamin Whitten, M.D., MMA-Trustee Richard W. Davenport, MMGMA Rep. HMS-Executive Staff

Jack G. Davis, Chief Executive Officer Nancy K. Bauer, Associate Director

MetroDoctors

“First a Physician®” is an expanding theme at the Hennepin Medical Society as individual physicians hold out their professionalism of patient care as their primary goal. Some patients find it hard to believe that their physician may be their first and best advocate. This issue of MetroDoctors is dedicated to the exposition that the Federal Government through Medicare, as a major payer, is preventing a level playing field for seniors in our state. The geographic disparity where future medical reimbursements are tied to past experience has the effect of rewarding the East and West Coast and other geographic areas for its past high costs, and penalizing Minnesota and others for its past efficiencies. This disparity, long an issue with Minnesota organized medicine, is finally being recognized by the public. Hennepin and Ramsey Medical Societies have joined the “Justice Coalition” with other organizations, including the Senior Federation and several Minnesota managed care organizations and individual Medicare subscribers to do legal battle with Washington to correct the disparity. This is one time that doctors, hospitals, health plans, patients and politicians can all stand together and work together to advocate for our Minnesota seniors. “Second a citizen” is an added concept where each of us has a chance to do something in our own backyard to further our profession. The items below are such works in progress: • www.metrodoctors.com — The Web page of the Hennepin and Ramsey Medical Societies is being developed with you in mind. Wherever you practice, you and your partners will want to be a part of this avenue for patients to find you. This will also be an excellent chance for patient health education. • The poison control service for our state is presently being challenged for lack of funding by our state health department and past contributors. Hennepin County Medical Center is presently the only source of emergency information regarding poison control, which is highly regarded and used by most

The Bulletin of the Hennepin and Ramsey Medical Societies

•

of us and by MD’s throughout the state. MMA and our societies are donating funds to keep this service alive and to challenge other state organizations to refinance this important service NOW and in the future. Attorney General Mike Hatch is seeking out medical expertise for the formation of an Advisory Board. Hennepin, Ramsey and MMA will be sending representatives. Hennepin’s members will be Drs. Spenny, Estrin and Lupo. The Annual MMA convention at Brainerd is fast approaching. It is important that you and our delegates to the September 26-28 meeting speak up on issues through the resolution process. There are still openings for you to be a delegate or alternate. Please come. The tentative slate of candidates for MMA officers is as follows: President-Elect: Blanton Bessinger, M.D. Vice President: Kevin Fleming, M.D. Speaker: Gary Hanovich, M.D. Vice Speaker: Rebecca Hafner, M.D. and Robert Milligan, M.D. Secretary: David Estrin, M.D. Treasurer: Noel Peterson, M.D. As an HMS delegate, I hope you will join me in showing our support for our colleagues Dr. Hanovich and Dr. Estrin in this election. A special thank you to Charles Meyer, M.D., who served as the HMS Bulletin physician advisor over the last seven years and welcome to Richard Morris, M.D., the co-physician advisor of our new publication, MetroDoctors, along with Thomas Dunkel, M.D., from RMS. New appointments to the Hennepin Board of Directors include: Dr. Mark Swiontkowski, representing Fairview-University Medical Center; Dr. Michael Tedford, representing (Continued on page 30)

September/October 1999

Hennepin Medical Society

Chair Edward A.L. Spenny, M.D. President David L. Estrin, M.D. President-Elect Virginia R. Lupo, M.D. Secretary Richard M. Gebhart, M.D. Treasurer Michael B. Ainslie, M.D. Immediate Past Chair William F. Schoenwetter, M.D.

Chairman’s Report (Cont.) Abbott-Northwestern Hospital; and Rick Davenport from the Minnesota Medical Group Managers Association. • This fall HMS wants to pursue grassroots meetings with your local legislative representatives. Contact Jack Davis if you’d like to be involved in this process. • A physician dialog with Gordon Sprenger, CEO of Allina, is scheduled for September 13 at 6:00 p.m. Contact Jack or Nancy if you wish to attend. • HMS and RMS are continuing to sponsor joint Community Internship Programs where leaders of the public and business community are invited to spend two days observing physicians doing what they do best. If you have not already volunteered to serve

September/October 1999

as faculty for this program, please consider participating in this one-half day commitment by contacting Nancy Bauer at (612) 623-2893. It’s a terrific way for physicians to “tell their story” to the non-medical decision-makers and it truly reflects “First A Physician®.” The fall offering will be held November 9-10, 1999. • As the first year medical students begin their basic sciences journey, the Hennepin and Ramsey Medical Societies will be in attendance at the medical student welcome picnic August 31 at Como Park. Book bags with the metrodoctors.com logo and mousepads will be distributed as we welcome the students and encourage their participation in organized medicine.

MetroDoctors

• Physicians in all specialties are being sought to participate in the “Shadow A Physician” program, offered to all first and second-year medical students, This program, jointly sponsored by HMS/RMS and the University of Minnesota Alumni Faculty, provides an opportunity to students to intimately explore a field of medicine with a practicing physician in that specialty. Mentoring relationships are encouraged, however, not the primary objective of the program. Most of the students avail themselves of this program during their breaks and vacations from school. If interested in participating as faculty or a mentor, please contact Nancy Bauer at (612) 623-2893. • The 2nd annual Southdale Magical Evening of Giving will be held Sunday, November 21, 1999 from 6-10 p.m. $5 tickets to this shopping event sold by the Hennepin Medical Foundation will again benefit the HMSA/ MMA Alliance HIV/AIDS Education Folder project. Tickets will be available from the HMS office or an Alliance member. Remember to mark your calendar and show your support for the terrific project of our Alliance members. • Congratulations to the Volunteers of St. Mary’s Health Clinics who were recently named recipients of the 1998 Acts of Kindness: Governor’s Volunteer Award. The volunteers were selected because of their exceptional commitment to the people who receive medical assistance at St. Mary’s Health Clinics throughout the Twin Cities Metro area. A number of HMS physicians serve the St. Mary’s Health Clinics by providing free health care for the uninsured and underserved population. • There are hundreds of you out there doing your best job — doing things that are valued and need to be recognized. Let us know how to help you do your work better. Thank you for the privilege of serving as Board Chair of the Hennepin Medical Society. It’s been a positive experience and I thank Drs. Bill Schoenwetter, David Estrin, Virginia Lupo, Mike Ainslie and Rick Gebhardt for their help and support. I would encourage all of you to become active in HMS and continue its 145year history of advocacy and preservation of our profession. ✦

The Bulletin of the Hennepin and Ramsey Medical Societies

HMS NEWS

Election Results President-Elect DAVID L. SWANSON, M.D.

Hennepin Medical Foundation Board of Directors

ALFRED DOSCHERHOLMEN, M.D.,

an internist and hematologist, died August 6 at the age of 83. He was an Associate Professor at the University of Minnesota Medical School. He received his medical degree from Oslo University Medical College in Norway and came to the U.S. in 1949. He completed a residency at Asbury Methodist Hospital and postgraduate training at the University of Minnesota. KEITH W. SEHNERT, M.D., died from a

brain tumor on June 22. He was 73. He graduated from Western Reserve University School of Medicine in Cleveland. His first practice was at the Bell Clinic in York Nebraska. He moved to Minneapolis in the 1970s and worked at a private medical practice doing consultant work for businesses and health care organizations. Dr. Sehnert practiced holistic medicine and was the author of 18 books. ✦

JANIS C. AMATUZIO, M.D. Dr. Amatuzio is board certified in pathology-anatomic/clinical and forensic pathology, and works at Midwest Forensic Pathology P.A. in Coon Rapids. She is also the Anoka County Coroner.

MetroDoctors welcomes letters to the editor. Send yours to: Nancy K. Bauer, Editor MetroDoctors Hennepin & Ramsey Medical Societies Broadway Place East, Suite 325 3433 Broadway St. NE Minneapolis, MN 55413-1761

JAMES J. MEYER, M.D. Dr. Meyer is board certified in urology/urologic surgery and practices at Urologic Physicians in Edina. Dr. Meyer served as the 1994-95 HMS chair. This is his second term on the Foundation Board of Directors. ✦ MetroDoctors

The Bulletin of the Hennepin and Ramsey Medical Societies

Fax: (612) 623-2888

September/October 1999

Hennepin Medical Society

Dr. Swanson is board certified in dermatology and internal medicine and practices at North Clinic, P.A. in Robbinsdale. Dr. Swanson has been active through his associations with the Minnesota Dermatological Society where he has held the offices of Secretary-Treasurer, Vice President and President; Chief of Staff at North Memorial Health Care; and Chairman of the Minnesota Medical Association’s Legislative Committee. His current appointments include Clinical Instructor in the Department of Family Practice and Assistant Clinical Professor, Department of Dermatology at the University of Minnesota.

In Memoriam

HMS ALLIANCE NEWS P E N N Y C H A L LY

I am writing this article after coming back from a wonderful trip canoeing in the Boundary Waters. While there, I saw grandfathers with their grandsons, families with young children, and Scout leaders with their troops not only teaching the skills of camping and canoeing, but also sharing and enjoying a special time and a special place together. It was fun watching the mentoring between the generations. The Hennepin Medical Society Alliance has developed a “sharing and enjoying” relationship with two very special groups. We have a Mentoring/Sponsoring Program with the Hennepin Residency Medical Partners and the Medical Student Partners of the University of Minnesota. We felt that it was an excellent idea to be a connector to each group as a support to partners and families of physicians in training. First, we give a certain sum of money to each group for some of their organizational expenses. In addition, a member of the Alliance will mentor a partner by paying the membership fee and connecting with that person by phone — not only about the Alliance meetings, but as a way to form a personal relationship with that partner. Often “one-to-one times” are set up for a good conversation. The sponsoring of a partner differs from mentoring in that the membership is paid, but the “one-to-one times” are not asked for by the sponsored partner. This summer, an orientation was set up for Residency Partners with an informal panel of spouses of practicing physicians and residents. The event provided a time to meet with mem-

bers of the Hennepin Medical Society Alliance and fellow resident spouses and significant others. It proved to be both entertaining and educational. A summer barbecue and family outing for Alliance and Residency Partners was also held. Both events were successful and will become a regular part of the Alliance year. The Alliance will be involved with the Medical Student Partners as they start their programs in the fall. The important part to note in these relationships is not only the connections made, but the help from the mentored/sponsored partners in volunteering for BodyWorks, a health awareness event for public school 3rd grade students in the Hennepin County area, or for other events in which the Alliance is involved. It is hoped that by providing memberships, meaningful community health related volunteer opportunities, leadership training opportunities, networking opportunities, and peer support, that this program will encourage long time memberships in this Alliance, or other Alliances in other areas of the country. As you read this article, we are in the midst of our membership campaign. We want to encourage all the spouses and partners of the Hennepin Medical Society to join us. We are celebrating our 90th year in 2000 and we were the first Alliance be formed in the country. To find out more about us, visit our Web page. Our Alliance welcomes all levels of participation, whether it be through time or financial contributions. In addition, we would appreciate the talents, knowledge and interest that new mem-

Southdale Magical Evening of Giving Sunday, November 21 6:00-10:00 p.m. Tickets — $5.00 All the stores will be open; discounts and door prizes will be available and entertainment will be found throughout the mall.

September/October 1999

MetroDoctors

bers bring to us, and in turn, we feel as Alliance members that we can make a difference in our community as well as we can offer an opportunity to form lifelong friendships. Events: Opening Event at Dorothy Rogers’ home on Friday, September 17. Joint Meeting with the Ramsey Alliance on Wednesday, October 27. A tour of the new Minneapolis Crisis Nursery in Golden Valley. As part of our SAVE and Child Health month project, we will be bringing needed materials to the Nursery. A lunch and talk by Barbara Knutson, author and illustrator of children’s books will be at the Golden Valley Country Club after the tour. Books will be for sale and autographing. Call the HMS office at 612/6232881 for further information and reservations. Thank you to the Hennepin Medical Foundation for voting to give to our Alliance for the HIV/AIDS folder project, the proceeds from the $5.00 tickets from the Southdale Magical Evening of Giving. This event will be on Sunday evening November 21 from 6:00-10:00 p.m.; all the stores will be open, discounts and door prizes will be available and entertainment will be found throughout the mall. Over $2000 was received last year from the Magical Evening and we hope to be able to sell more this year. We would enjoy having physicians and families call and order tickets for this event. We would also welcome anyone who would like to help us with the event. For more information, call the HMS office. The Board of the Foundation also granted $2,000 to the HMSA (who are serving as the fiscal agent for the MMAA) for the State HIV/ AIDS folder project. ✦ The Bulletin of the Hennepin and Ramsey Medical Societies

CAUTION: Your Patients Are Getting Smarter

This fall, the U of M is opening its doors to the public for a FREE, six-week lecture series taught by the worldâ&#x20AC;&#x2122;s foremost experts in medicine and hot health topics. We invite you to become a student in the Mini Medical School to explore cool science in language you can understand. Best of all, no final exams. Courses will be offered on the Twin Cities Campus from 6:30 - 8:30 p.m. and include: October 13 - Anatomy: The Basics of Building a Body October 20 - Infectious Diseases: Examining Invisible Enemies October 27 - Physiology: The Cycle of the Systems November 3 - Genetics: Jumping into Your Gene Pool November 10 - Cancer: From How it Begins to How it is Treated November 17 - Complementary Care: Merging Science with Ancient Wisdom Graduation Ceremony will follow November 17 lecture.

Space is extremely limited, so call now! Call 1-800-864-0819 to register today. Supported by the Academic Health Center and a Pfizer, Inc. educational grant.