8julaug00 by Advocates for Better Health

July/August 2000

Doctors MetroDoctors Are contracts influencing how physicians practice? Options on the horizon

Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 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) 2377363; fax: (612) 831-3260; e-mail: djrossow@aol.com.

CONTENTS VOLUME 2, NO. 4

Seymour Handler, M.D.

Message from the Physician Advisors

FEATURE: ACCOUNTABLE PROVIDER NETWORK

APN Becomes Viable Option for Metro Physicians

Introducing Vivius, Inc.

What Physicians and Practice Administrators Were Not Told

Metropolitan Medical Practice Forum Comments on 2000/2001 BCBS AWARE and Referral BLUE PLUS Agreements

The Integrated Care Model

How to Negotiate an Employment Agreement With a Large Health Care Provider

Has the OIG Reached “The Age of Unreason”?

RISK MANAGEMENT

Meeting all of a Patient’s Needs Often Requires Outside Help

NOTEWORTHY

RAMSEY MEDICAL SOCIETY

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MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available.

J U LY / A U G U S T 2 0 0 0

PHYSICIAN’S SOAP BOX

President’s Message RMS Update Applicants for Membership/In Memoriam RMS Alliance HENNEPIN MEDICAL SOCIETY

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President’s Report

HMS Alliance

July/August 2000

Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Richard J. Morris, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Production Manager Sheila A. Hatcher Advertising Manager Dustin J. Rossow Cover Design by Susan Reed

Doctors MetroDoctors

HMS News: Community Internship Hoban Scholars/Shotwell Award/ Senior Physicians Association

Are contracts influencing how physicians practice? Options on the horizon

On the cover: Contracting options on the horizon. (Artwork by Outside Line Studio, 225 So. Owasso Blvd., Roseville, MN 55113.)

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The Journal of the Hennepin and Ramsey Medical Societies

July/August 2000

PHYSICIAN'S SOAP BOX

The Creation of a Medical Industry

Editor’s Note: Physician’s Soapbox is open to any responsible commentary from our readers. Dr. Handler is a well-respected physician who has often written very challenging opinions on a variety of subjects. This article should generate considerable debate and we welcome additional comments and/or rebuttals. Let the fur fly! Richard J. Morris, M.D.

MODERN MEDICAL CARE IS CHARACTERIZED by the abundant

use of diagnostic technology and exuberant therapy. This activist approach parallels the American way of life — bigger, better and faster. The media contribute to this attitude, regularly hyping “breakthroughs” and other “miraculous improvements” in care. Unfortunately, the media are far more interested in their viewers and readers than in the truth. Perhaps the real truth is too complex for the lay public; oversimplification and unproven conclusions are more acceptable. Physicians have a higher responsibility than the media. We are required to provide quality medical care, based on science (the current term is “evidence-based”) and cost containment. Unfortunately, the activist approach, which still exists today, does not permit cost containment. Further, despite the inflation of costs, in many instances care is not improved; at least what little improvement occurs is in no way proportional to the tremendous increase in cost. One disease group worthy of discussion relates to evaluation and therapy of lesions of the female breast. In my view, and with agreement from many clinicians, we may have created an industry out of breast disease, and with little outcome improvement for the patient commensurate with the increased cost and effort. In the olden days, an expression appropriate to my age, breast diagnosis and management was simple. Women with lumps detected by self-examination sought medical opinion. If the examiner thought the “lump” was a benign and probably functional lesion, particularly in the pre-menopausal patient, he/she would recommend observation and repeat examination in the not-to-distant future. If the lesion suggested a cyst, aspiration was performed. If the lesion did not aspirate, or felt suspicious in any way, a biopsy was recommended. If the biopsy of the lump revealed a cancer, modified (or radical, if one goes further back historically) mastectomy with axillary node dissection was performed. In the distant past, often depending on the presence of involved axillary lymph nodes, radiation therapy was added. Beyond surgical and/or

radiation therapy, the outcome for the patient was determined by factors intrinsic to the tumor. If the tumor was biologically aggressive, it would metastasize to nodes and throughout the body and cause death. We have long had good prognostic indices — axillary node involvement, size of tumor, involvement of skin or chest wall, and histologic grading. As is true of any system of prognosis, the prognosis is statistical; many errors occurred; some seemingly favorable lesions caused death of the patient; other lesions thought to be unfavorable turned out to permit long survival. To a great extent, beyond the primary surgical therapy, factors intrinsic to the tumor determines outcome, not the subsequent care. Beginning almost two decades ago, a series of changes in management of breast tumors began. The precise sequence of the changes is unimportant to this discussion. What is important is how the changes affected management and whether or not the changes made resulted in significant improvement in patient outcomes. Action is not necessarily progress; heat does not necessarily shed light. The major consideration is whether or not our efforts positively affect morbidity and mortality (survival from cancer), and whether or not the improvements, if any, are commensurate with the cost, energy and time expended. Finally, patient adverse side effects of therapy must be considered in terms of yield. Perhaps the earliest change in management derived from the realization that lumpectomy is equally as efficacious as mastectomy in terms of survival. This was indeed a major advance in therapy, avoiding the psychological and appearance effects of mastectomy. Although this had nothing to do with survival, avoiding an unnecessarily mutilating operation was a real advance. Although lumpectomy is a significant cosmetic advance and reduces the extent of the surgery, it is not costeffective. Lumpectomy is almost always followed by radiation therapy, thereby prolonging the duration of therapy. In addition to the time extension and radiation morbidity, costs escalate; radiation therapy does not come cheap. Mammography became widespread as a screening tool to detect early breast cancer, before positive physical findings. Although some authorities question the true yield of mammography in improving survival of women with breast cancer, it is fruitless to argue against the practice. It is so well regarded that it has become the law of the medical land. At best, if it does offer a survival advantage, the improvement is modest. There are disadvantages to mammography. Some physicians (Continued on page 4)

BY SEYMOUR HANDLER, M.D.

July/August 2000

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The Journal of the Hennepin and Ramsey Medical Societies

elping make MRI diagnostic affordable for everyone. For patients without Insurance

Over 249,000 Minnesotans are uninsured, including 71,000 who are under 21. Immediate Financial Approval To make referrals for patients with no insurance call:

(612) 529-6000 (651) 647-0000 FAX: (651) 647-1111

The newest generation of open high field magnetic resonance imaging serving the twin cities metro area physicians.

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The Journal of the Hennepin and Ramsey Medical Societies

July/August 2000

(Continued from page 2)

(and patients) forget that some breast cancers are not detected by mammography, and because of that erroneous impression, appropriate physical examination is occasionally not done. Despite all the printed disclaimers, this error continues. Perhaps more important as a negative effect is the detection of certain in-situ breast cancers which never become biological “cancers.” The ability of mammograms to detect microcalcifications of intraductal cancers mandates diagnostic procedures to explain the microcalcifications, despite the fact that as many as 40 percent of intraductal cancers never become real cancers and, therefore, represent a biological curiosity better left undetected. Of course, the 60 percent that do go on to become invasive cancers may be detected earlier and “may” improve survival. One must not forget that many cases of detected microcalcifications turn out to be benign processes. Unfortunately, the patients had to be studied, an additional source of anxiety, pain, and expense. And what additional industry have we created with our ability to detect microcalcifications? Radiologists are involved in one of two ways. Because the surgeon has no way of finding a microcalcification to biopsy, the radiologist must perform a localization process to guide the surgeon. If an open biopsy is not planned, radiologists now perform stereotactic or ultrasound-guided core needle biopsies. If the microcalcifications are not confirmed in the biopsy specimen, radiologically or pathologically, a whole new order of additional work is required. After all, if we detect something on mammography, it must be explained. Another aspect of “industry” in breast cancer work is the assay of estrogen and progesterone receptors in the tumor cells. Although it doesn’t affect the patient directly, it certainly entails expense. And is the information provided useful? Perhaps, but in so many cases, tamoxifen therapy is initiated no matter what the receptor studies show. The prognostic values of receptor studies are debated, possibly not offering anything not already available from clinical and pathological parameters. One of the statistically useful additions to breast cancer management is adjuvant chemotherapy in lymph node-positive or other highrisk situations. Adjuvant chemotherapy indeed offers a statistical improvement in long-term survival in selected patients. However, that improvement is modest at best, of value primarily because breast cancer is so frequent, thereby benefiting a significant number of patients. Unfortunately, there is a tendency to utilize adjuvant therapy when accepted standards do not indicate such therapy. Some oncologists curry favor with their patients or referring physicians by doing more, rather than doing less. After all, more is better than less; that is the American way. A byproduct of the intense interest generated by breast cancer is the formation of lay “advocacy” groups. As is true of the lay population in general, these groups promote “action.” More is always better to lay people and these groups promote physicians and centers whose practice is action-oriented. These groups minimize the importance of the adverse effects of therapy and jump on any bandwagon promoting even the smallest ostensible improvement. And costs mean nothing. The 4

July/August 2000

expansion of the practice of breast reconstruction following mastectomy probably relates to the activity and emphasis generated by advocacy groups. And do we have any idea of the cost of breast reconstruction? Multiply your guess by some numeric factor and you will still be too low. All of the above has created an environment in which “centers” compete for patients, offering one-step diagnostic testing in situations where the original treating physician is bypassed or ignored. I am sufficiently old-fashioned to believe that the diagnostic and therapeutic process should be controlled by the primary physician, not someone in a “center” generating additional activity without control. That is the way medicine is practiced nowadays, with self-styled “experts” who generate their own momentum. And what about the patient’s physician? It requires true expertise to manage and advise patients with breast tumors. Counseling the patient about options, procedures, yield, side effects, etc., may take hours. And then the patient goes elsewhere for second opinions. Microscopic slides are sent all over the country; countless additional opinions are sought; patient anxiety and indecision is rampant. If there is any doubt about the range of confusion in treating breast cancer nowadays, just sit in on an Oncology Conference. One might get the impression that nothing is known, and that confusion is universal. My final indictment of the breast “industry” relates to the introduction of unproven therapeutic modalities, their introduction into everyday practice, and worst of all, ignoring the evidence that the new approach is no better than far simpler and less expensive techniques. I refer, of course, to the practice of bone marrow transplantation (BMT) to augment high-dose chemotherapy (HDC) in women with advanced breast cancer. Without evidence that their modality was superior to traditional chemotherapy, medical and lay activists pushed the procedure, implying a superior level of care, and even suggesting that centers not involved in BMT were behind the times. In fact, a law was passed by the Minnesota Legislature mandating health insurance coverage for BMT. When several studies demonstrated that BMT/ HDC offered no survival advantage over traditional chemotherapy alone, did the centers promoting BMT cease and desist? I don’t think so. If all of the above “industry” clearly resulted in distinctly improved morbidity and mortality for the patient with a breast cancer, I would accept the efforts involved. Despite all of the activity, the gross death rate for breast cancer has remained constant for over 90 years. Somehow, so much of what is done can be considered “busywork,” simply expansion of activities in keeping up with the Jones’, and without obvious improvement in outcomes. Advances in management of breast cancer have occurred; it would be inaccurate to describe all the activity as “busywork.” Unfortunately, there is frightfully little improvement in outcomes to justify all the expense and effort entailed to realize the improvements. However, if one dares to question a new “advance,” no matter how inconsequential it may ultimately be, that person will incur an unendurable level of character and professional assassination. It would take an extremely courageous physician to take any stand questioning the newest “advance” in breast cancer therapy. Only a pathologist near retirement could muster that level of courage. ✦ MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Message from the Physican Advisors A Look at Various Contracting Issues

IN THIS ISSUE OF METRODOCTORS you will find a broad range of information on various issues within the realm of contracting. We did not attempt to give you an encyclopedia of contracting, however, we have attempted to give you a flavor of the broad scope of contracting. Perhaps we have at least whetted your appetite for more information. Our basic goal is to improve the knowledge base of physicians who are affected by contracts. Contracts may be between health plans and physicians or between an employed physician and his or her employer. In either case, the terms of the contract may well dictate many of

MetroDoctors

the conditions of a physician’s practice. The more knowledge each physician has about contracts improves that physician’s ability to negotiate positive changes. The Hennepin and Ramsey Medical Societies co-sponsor the Contract Review program with the Minnesota Medical Group Management Association (MMGMA) under the umbrella of the Metropolitan Medical Practice Forum. Contracts with Medica, HealthPartners, and Blue Cross and Blue Shield of Minnesota have been reviewed. In this issue we have included the latest contracts from Blue Cross Blue Shield AWARE and Referral BLUE PLUS

The Journal of the Hennepin and Ramsey Medical Societies

Agreements. We hope you find these reviews to be useful. We also understand that the contract issues facing employed physicians are unique and require an analysis of employment conditions. We hope we are responsive to all physicians’ contracting information needs. Please let us know if MetroDoctors is helpful and what we should be including in future issues. We need your feedback if MetroDoctors is to provide you with useful information. Thank you in advance.✦ Thomas Dunkel, M.D., and Richard Morris, M.D., are co-editors of MetroDoctors.

July/August 2000

FEATURE STORY

Accountable Provider Network Becomes

Accountable Provider Network Viable Option for Metro Physicians

A An APN is defined as a “group of providers” and basically is regulated under state HMO law, with five exceptions.

AREA PHYSICIAN LEADERS ARE SHARPENING THEIR PENCILS to determine if an Accountable Provider Network (APN) may be the ticket to rebalance the current health care marketplace. An APN is legally defined, under Minnesota law, as “a group of health care providers” that organize to negotiate with a group of employers organized as a Purchasing Alliance (PA). The APN is a risk-sharing organization that is regulated under HMO laws with some significant waivers that provide operational and benefit plan flexibility. Under the law, the financial risk can be shared with members of the PA. The result can be a fully-insured product that contains significant physician oversight with reduced hassle, allows the network to deal directly with the employer and meaningfully engages the consumer in the process with reasonable incentives. The legislation that created APNs was passed in 1997, but certain provisions in the law caused many physician leaders to question if the whole concept was viable. This year, the state legislature honed the law, the Governor signed it upon recommendation of the Health Commissioner, and now the law is being taken seriously – by proponents and foes alike. Early in the legislative session, there were attempts to derail the bill with legislative maneuvering. A statewide, non-profit coalition called Advocates for Marketplace Options for Mainstreet (AMOM) served as the catalyst. Created was a formidable group of metro and rural physicians, hospitals and small employers supporting the bill. Eventually, the Senate gave the bill a unanimous vote and it passed in the House by a vote of 122-5. AMOM is continuing its efforts to assure physicians across the state that the Legislature is looking for viable, alternative options and pleading with the provider community to step out and lead the way to something new. Interestingly, the providers consistently “out in front” on the APN issue have been those from Northwestern Minnesota, where a provider cooperative was formed five years ago. The group is now preparing an APN license application. Leading the business side, is the Employers Association, a trade group of 1,700 members in Minnesota. Also helping out has been the state Chamber of Commerce and the Southwest Regional Development Commission. The Employers Association has formed a purchasing alliance and is seeking to contract with a group of providers, who have a license. The employers are pursuing the effort, with the goal of: 1) stabilizing employee health care costs (the spiking of premiums every few years wreaks havoc on a small business), while 2) promoting better accountability in the system. Their efforts, to date, have drawn them to the conclusion that: • Consumers have lost trust in the current system;

BY ELISABETH QUAM BERNE

July/August 2000

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The Journal of the Hennepin and Ramsey Medical Societies

•

If they believe they can trust the information they are receiving, consumers will respond positively to changes which offer them more accountability; • Employers are willing to participate in organized efforts to encourage better health decisions and healthy life-styles if they understand the value of the effort; • Delivery of quality care should not continue to be assumed; • True reform will not happen unless providers are also engaged in the decision-making/risk; and • Small employers are willing to fund part of the risk in a fully-insured product if the above issues are addressed to their satisfaction (this is significant and only possible because of the changes made this year). There is a growing understanding that the number of uninsured will grow with the first downturn of the economy and that, even now, there is inhibition to business startups because of the problem of obtaining health coverage. According to the U.S. Small Business Administration, from 1994-1998, of the 11.1 million net new jobs, microbusinesses with 1-4 employees generated 60.2 percent of all new jobs and firms with 5-19 employees created another 18.3 percent. Businesses with fewer than 500 employees created all of the net new jobs in the U.S. These are the companies that usually do not have resources or structure to self-fund their own risk, locking them into the tangled, antiquated “fully-insured” system of state regulation. In addition, • During these best of economic times, the number of small employers who offered health care coverage decreased. • The highest percentage of uninsured children have parents who are working at low paid jobs, in small companies, where there is no health insurance offered, or the employee cannot afford the family coverage. • Small employers pay up to 25 percent more for their health care premium, with fewer covered services, often resulting in the lowest paid workers paying more outof-pocket expenses at the “usual and customary” rate. • Uncompensated care is financially problematic for providers and publicly owned facilities. Offering a new, affordable option for small businesses, including businesses of one would be a strong, economic development step. If successful, the venture could alleviate some of the problems and expenses faced because of uninsured voters – who have obviously caught the attention of many politicians in this election year, offering their sometimes implausible “fixes” for the system. In Western Minnesota, this knowledge and the opportunity available under the re-

…no other model offers physicians the option of directing rather than contracting for their services.

(Continued on page 8)

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(Continued from page 7)

vised law, has pulled together two coalitions of providers, employers, elected officials and community service organizations. They agree that the current situation calls for new leadership and an unprecedented willingness to join together to assist in improving the health and health care coverage for employees and their families. More about them later, but first a primer on the law. Community Purchasing Arrangements Act In 1997, the Minnesota Legislature passed what is now MN Statute, Section 62T, which allows a new type of arrangement between providers and small business purchasers, through the creation of a purchasing alliance and an Accountable Provider Network. Basically, it moves the insurance entity to the side to allow purchasers and

July/August 2000

providers to negotiate directly, with some restrictions designed to protect consumers. Essentially, the PA can allow employers of any type to become members, including businesses of one and self-insured companies. The large, self-insured companies, who can fund their own risk, are designated as “affiliate members” to protect their ERISA status. For those companies who are not self-insured, the PA must negotiate with an entity that is licensed as a health plan company in the state. This can be an HMO, an indemnity company, or an APN. The PA can negotiate for other health-related services as well, on a risk or non-risk basis, such as dental care, workers compensation, alternative medicine services, or long term care insurance. The PA can be established as a “risk pool” but does not need to be. Currently, the few successful business purchasing groups for small employers usually: • Include self-insured members;

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•

Require a long-term commitment (35 years); and • Begin with member companies being rated individually. The affiliate members can make use of the PA’s administrative arrangements, the design of its benefit plan, health improvement programs and any other group health purchasing the PA does. An APN is defined as a “group of providers” and basically is regulated under state HMO law, with five exceptions. Of the five, the APN can apply for four broad waivers from HMO law as noted below, that must be approved by the Commissioner of Health. The fifth exception states that an APN is not required to offer the HMO benefits plans for small groups. Instead, the APN may offer a benefits plan(s) that has been negotiated with the PA, as long as it meets minimum state standards. The waivers are:

The Journal of the Hennepin and Ramsey Medical Societies

1. Solvency. • The APN must find an insurance partner to guarantee $500,000 (HMOs are at $1.5 million) to be available in case of insolvency; • plus have 15 percent of the premium set aside for its reserves; • plus be appropriately reinsured; • plus all participating providers must agree to see patients for up to 60 days past an insolvency (by law, all HMO participating providers must make a similar agreement for 30 days). 2. Financial Requirements Since the APN is expected to be community-focused but with a financial guarantor as a partner (the partner can hold up to 25 percent of board representation), the assumption is that another entity besides the state is going to be monitoring the financial health of the APN. Therefore, the APN is allowed to submit financial reporting data to the state differently, if this allows for efficiency. 3. Marketing As long as the APN can demonstrate that the enrollee is receiving comparable (or better) information, the APN does not have to follow the paper blizzard of HMO marketing mandates. Because the PA can include requirements in its membership criteria (even though the APN may not be able to under law), it is realistic to assume that employer members could be required to make internet time available to enrollees. For a basic example, this could save the APN from having to send out a provider directory. 4. Quality In Northwestern Minnesota, they are discussing taking down the HMO “silos” of consumer complaints, QA, QI, UR, etc., and blending those areas together. If the APN is truly provider-based, some fresh thinking on how to accomplish quality is possible. The Employers Association has a

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vision of the quality program aggressively going after the 20 percent of the enrollees who use 80 percent of the health care dollar. Because the APN and PA are a new concept, it may allow flexibility to build a more responsive system. Western Minnesota Leads the Way to a New Model In Southwestern Minnesota, a purchasing alliance has been formed by the Regional Development Commission and they are currently in negotiations with a non-APN licensed health plan. The Purchasing Alliance that formed in Northwestern Minnesota, has been facilitated by the University of Minnesota, Crookston. This group is working closely with its local provider cooperative which is in the process of seeking an APN license. The two different approaches offer varying and viable models for others. In the metro area, an attempt to form an APN in 1998 did not gather the support needed from within the provider community. Many of the technical changes made this year are based on those initial experiences in the Metro area: the enrollment cap is removed; small employers can clearly share in the risk and only one negotiated benefits plan must be offered. This has caused some metro physician leaders to focus new attention on the option. Other areas of the state are watching and listening closely to what is transpiring in these three areas. With technical assistance provided by AMOM, all three groups are shaping their model with the goal of providing a customized health care delivery system that includes: • Full disclosure between the purchasers and providers; • Opportunity for providers to direct overall medical and administrative decisions; • Incentives and accountability for all parties involved; • Innovative partnering for better health

The Journal of the Hennepin and Ramsey Medical Societies

maintenance and health improvement of employees/enrollees/patients; and • Stable, understandable pricing for the employer/purchaser. The Northwest and Southwest groups hope to begin offering a product as early as January of 2001 and metro efforts aren’t far behind. While there is a churning in the current marketplace, with new products being proposed almost daily, no other model offers physicians the option of directing rather than contracting for their services. ✦ Elisabeth Quam Berne is the Executive Vice President of Advocates for Marketplace Options for Mainstreet (AMOM) and president of a home-based business, Quam Berne Strategies. Formerly, she served as an assistant state health commissioner, overseeing health facilities and HMO compliance.

Medical Consultant CORVIEW, an independent medical review organization, is seeking a part time Medical Director to provide medical expertise in the monitoring of inpatient and outpatient services for self-funded health benefit plans. Flexible hours. Please send cover letter and resume to:

Jennifer Sherman Corview, Inc. P.O. Box 290176 Brooklyn Center, MN 55429 (612) 560-8818 (tel.) (612) 560-5103 (fax)

July/August 2000

Introducing Vivius, Inc. “Others question whether giving providers total autonomy to make medical decisions is, in fact, good for the health system.” Business Insurance, May 22, 2000

THE HMO MOVEMENT produced two im-

portant changes in medical care delivery—it helped control costs for a decade and it started the process of measuring quality. But it also created two major deficiencies in medical care delivery—it removed the patient from any responsibility for the costs of their health care and it displaced many medical decisions away from physicians. The preceding quote is evidence that “some experts” have simply gone too far. Vivius, Inc. creates a new concept called the personalized healthcare system (PHS) that once again involves patients and physicians directly in the decision making process. Equally important, both physicians and patients bear some financial responsibility for those decisions. The PHS offers control and responsibility to the two people who should own them—the doctor and the patient. Three features distinguish Vivius from other healthcare coverage programs. First, physicians determine their own prepaid fees. Patients decide if the fees are appropriate. Second, physicians decide what procedures are medically necessary. Once a physician and patient make a decision about care they don’t have to seek approval from anyone else. Third, there are no claim forms to submit. Despite the obvious philosophical appeal of these features, they also have important economic consequences. Contract negotiations, obtaining preauthorization and filing claims cost physicians 25 cents out of every dollar of revenue. None of that money actually makes a patient healthier.

How does Vivius work? Physicians, hospitals and other healthcare providers enroll with Vivius on the company’s

Internet web site. The process begins by loading basic demographic information about one’s medical practice. Free text space is available to describe unique interests or special procedures that are available. Next, providers establish the

monthly prepaid fees they will charge to provide care to men, women, and children in a variety of age categories. Vivius offers actuarial assistance to help physicians determine these monthly “retainer” fees. The prepaid fees have some important differences from traditional capitation. The fees can be changed at any time allowing physicians to adjust for increased costs (however, once a patient selects the fee it is locked in for 12 months for that patient). These fees cover the physician’s professional services and minor office supplies. There is no pooling with other physicians, hospital costs or pharmacy costs. Almost the entire fee represents the physician’s time—an item the physician can control directly. At the end of the year a physician will not be writing a check to cover pool deficiencies. Finally, all enrolling providers load their

The following lists detail the composition of the personalized panel that each Vivius customer will choose. PHYSICIAN SPECIALTIES

Mental Health Neurology Obstetrics/Gynecology Ophthalmology Orthopedics Physical Therapy Primary care Radiology Urology

Allergy/Immunology Anesthesiology Cardiology Dermatology ENT Gastroenterology General Surgery Laboratory Medical Oncology FACILITIES

Emergency Room Home Health Hospital Outpatient Surgery Pharmacy

BY LEE N. NEWCOMER, M.D.

July/August 2000

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The Journal of the Hennepin and Ramsey Medical Societies

suggestions for the specialists they would recommend to their patients. The employer groups offering Vivius fund an annual healthcare spending account for each employee. The employees then access the vivius.com web site and follow a simple selection process, choosing their personal physician, 16 physician specialists, a hospital, an outpatient surgery facility, emergency room, home health agency and a pharmacy. These selections are mandatory to avoid adverse selection for specialists and facilities. Most employees won’t be able to select all of those choices without help, so Vivius uses the personal physician’s recommendations to complete the choices for the employee. The employee is free to change any of the recommendations. With each choice employees see the difference in prices between competing physicians or facilities. Additionally, they choose the levels of out-of-pocket copayment they pay for physician and hospital care. The Vivius web site calculates the annual cost of their healthcare coverage as they make their choices. Vivius customers can try several choices before finalizing their selections to keep their expenses within their budgets. Any excess money is saved and can be used to pay for copayments or other medical expenses, such as new contact lenses or eyeglasses. Vivius customers also purchase a mandatory wrap-around health insurance policy to cover services that their physician panel can’t provide including out-of-town emergencies. Actuarial studies show that the personalized panel covers approximately 90 percent of all needed healthcare services. The wrap-around insurance provides protection for the other 10 percent. Each month, Vivius electronically transfers money from the healthcare spending account of each employee to directly pay physicians, hospitals, and other healthcare providers selected for their customized panel. The company takes a small percentage, averaging four percent, of that money. The PHS is revolutionary because the monthly prepayments go directly from patients to physicians. There is no middleman or insurance company involved. There are no claims to process, no approvals to gain, no referral forms, and no negotiations. It’s the patients themselves that decide what they will pay for their personalized panel. MetroDoctors

A new concept: the open marketplace The PHS is a true marketplace. Physicians and hospitals that provide outstanding care can expect that customers will pay more for their services. However, consumers are careful shoppers and physicians will soon learn that they must have valid reasons for costing a few dollars more than their competitors. The PHS offers significant benefits to everyone involved in the paying for patient care. A directory no longer binds employees—they can select any health care provider they want, but they must be willing to pay for it. Employees use their own values when they make the selections. Making selections every year forces employees to understand the costs of health care. Competition between providers in an open marketplace should keep prices as affordable as possible. All of these issues are important to employers. Employees no longer have anyone making medical decisions except their doctors. Their physicians have the opportunity to be rewarded for exceptional efforts. All physicians have the opportunity to take home more money if they can reduce their operating costs by eliminating

The Journal of the Hennepin and Ramsey Medical Societies

claims, preauthorization and contract reviews. Most importantly for everyone, a PHS creates an environment for improvement. Physicians and hospitals that charge more will need to demonstrate why they are worth the extra cost. Consumers will ask for useful information to help them understand those differences. The providers who offer the best service and quality are rewarded in this marketplace—an event that doesn’t occur with standardized fee schedules. Does Medicare give physicians an incentive to perform better? Vivius offers the chance for physicians and patients to make their decisions together and to share the responsibility for those decisions. The company is enrolling Minneapolis and St. Paul physicians beginning July 1, 2000 on its web site, www.vivius.com. These changes are revolutionary and I expect lots of questions. You can get those questions answered by e-mailing or calling me at lnewcomer@vivius.com, or (763) 525-8500. We welcome your thoughts and look forward to your participation. ✦

Lee Newcomer M.D. is Executive Vice President & Chief Medical Officer for Vivius, Inc.

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

July/August 2000

What Physicians and Practice Administrators Were Not Told

PROVIDER CONTRACTING STAFF at Blue

Cross and Blue Shield of Minnesota (Blue Cross) recently met with leadership of the Hennepin Medical Society, Ramsey Medical Society, and Minnesota Medical Group Management Association (MMGMA) to begin a dialogue about contracting and payment issues. Representatives did agree the meeting had been helpful and that further dialogue would benefit the physicians they represented. HMS, RMS, and MMGMA subsequently provided colleagues with an “analysis” of the provisions in the 2000/2001 Blue Cross Blue Shield of Minnesota (Blue Cross) and Blue Plus professional agreements. (Reprinted on page 14 of this issue.) While we respect the organizations’ efforts to educate their membership, we were disappointed by the tone of the document. Nonetheless, Blue Cross is committed to continuing our dialogue with physicians and their representatives in good faith. Blue Cross is also committed to doing a better job of helping providers understand the contracting process, its limitations and the terms of conditions. The best solutions will be made when all are represented and all viewpoints are heard.

Contracts Protect Both Parties Contracts are a part of every major buying decision we make, whether it is a computer, a house, a car, or a loan. Contracts are a response to today’s high-intensity legal and regulatory environment. They spell out safeguards and expectations about how business will be conducted. They protect both parties. • Contracts between health plans and providers are comprehensive. • Contracts reflect administrative cost concerns, information system capabilities, and special needs of customer accounts. • Contracts address business strategies that B Y J O D I E L . R O O T, C M P E

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• •

focus on cost trend, access to care and quality of care concerns. A significant amount of contract language is devoted to regulatory requirements and oversight agency rulings or guidelines. Contracts serve as substantial protection for health plan members and provider patients when they access care.

Contracts Have Limitations Contracting is not a perfect process and there is room for improvement on both sides of the table. Blue Cross welcomes provider comments. We track common themes or issues and attempt to respond to them. Where appropriate, we also make changes in our standard provider contracts and business practices. At the same time, we recognize we cannot meet all needs. Blue Cross is the only statewide payer. We contract with over 25,500 providers, including 13,000 physicians, in 8,000 contracts. We contract with 700 institutions, including 189 hospitals. The sheer volume of these contracts requires standardization. The result of individual negotiations and/or customized contract language would be to increase administrative costs and result in lower payments to providers and higher premiums. Currently Blue Cross maintains very low administrative costs of less than 10 percent of premiums, and we are devoted to on-going administrative cost efficiency. In some cases, “individual” negotiation is cost-effective, primarily with large volume care systems or hospitals for multi-year terms. All providers are able to contact Blue Cross at any time with questions or concerns regarding their contracts. Although the volume of our contracts requires some standardization, the value of the relationship we have with smaller clinic systems and provider groups is not diminished. In fact, the value we place in our network is critical to our ability to meet the needs of our members throughout the state and make a healthy differMetroDoctors

ence in their lives. Increasing the number of individual negotiations would not result in contracts with more money or more attractive contract terms for providers. Contract language variation costs money and providers would likely bear the expense of such negotiations. Parts of our contracts include agreements that both parties wish to retain and not constantly revisit. These agreements are referred to as “evergreen” contracts and “passive amendments.” These agreements demonstrate the desire to have a continuing relationship, although both parties still have equal opportunity to exit the relationship should circumstances change. Blue Cross’ option to propose contract amendments allows us to adapt to changing legal and market conditions. The effect is ultimately to reduce the transaction costs associated with an on-going relationship for both parties. It is Blue Cross’ practice to highlight substantive changes in a separate document when distributing the new agreements to providers. We do not, however, note when there is a nonmaterial change in language such as changing “BCBSM” to “Blue Cross” in multiple places in the contract body as we did in the 2000 agreements. Like other health plans, we have chosen to save some administrative expense and not burden provider files by making redline copies of the contracts, showing all changes; however, these are available upon request. As a result, it is a good idea for physicians or administrators to review their contracts at least annually so that they understand the impact of changes and can identify new issues of concern. Contract Stacking Contract stacking is a hot topic where consensus may not be reached on all issues. Blue Cross is moving forward to assure that its contracts are in compliance with recent Minnesota legislation. From our perspective, the advantage of “joinder” contract language is that the majority of our consumers want to have access to the full The Journal of the Hennepin and Ramsey Medical Societies

family of Blue products — including auto, workers comp, or new products — through their current provider(s). Joinder language represents another administrative efficiency, but also helps to maintain the provider-patient relationship. It allows for the “Blue Cross Family of Companies” concept that is important to our brand name. Several providers have informed us that they feel contract stacking works in their favor because it is intended to be inclusive rather than exclusive. When offering a new product Blue Cross has used the Blue Plus network of providers and this assures that they are able to continue participating in the new offering without the worry of being excluded or the administrative hassle of tracking another contract. We recognize, however, provider concerns with this practice and are considering ways we might address those concerns. At the same time, we are reflecting on the impact of contract stacking imposed on health plans by the provider community. Contracts which are negotiated by groups of providers through a single ownership or administrative structure force health plans to accept all providers affiliated with that business relationship (unless credentialing standards are not met). This joindering of provider affiliations for contracting purposes is not necessarily in the best interests of consumers, especially if it serves to limit market competition for delivery of quality costeffective services. Fee Schedule Updates Although Blue Cross is unable to conduct individual provider negotiations, we do attempt to listen to the concerns of providers when updating our fee schedules. In 1999 we adopted recommendations from a Blue Ribbon panel of providers that resulted in development of a single conversion factor and annual updates of RVUs. We will continue to engage providers in discussion and solicit their recommendations as we move to build new payment methods. We also must make sure that our fee schedules are fair and reasonable in order to maintain an adequate provider network, while controlling costs for our members. We continue to believe that standardization of fees between like providers is a fair and equitable approach to administering payments. We want to avoid having providers with market monopoly power command an unbalanced share of the payment budget. This year we elected not to provide information on the conversion factor update when distributing the Aware agreement. Instead, we MetroDoctors

provided an extensive listing of high volume CPT code allowances. Providers are well informed about the payment levels for hundreds of the most commonly performed services. Experience shows that, even following education, many clinics do not understand the RVU methodology and inappropriately attempted to compare the Blue Cross conversion factor to our competitors without making adjustments for variations in methodology. We are looking at possible ways to convey the conversion factor for the 2001/2002 agreements. Future Improvements Blue Cross recognizes that the contracting process, as well as keeping track of credentialing requirements, policy and procedures changes and guidelines represents a source of frustration for providers and clinic administrators. While we believe we hit the mark on many fronts, we also recognize that we don’t do some things as well as we would like. Blue Cross encourages providers to work collaboratively and in good faith to assist us to continue to improve. We continue to support the concept of constructive non-inflammatory dialogue with providers to address their concerns and to con-

vey our issues. It is important that we reach improved solutions within the constraints of our mutual business requirements, available resources, and fiduciary and regulatory responsibilities. Blue Cross is investing in strategies that we believe will result in operational improvements. For example, in the not too distant future there will be the ability for providers to communicate more efficiently with our health plan using new technologies. Providers will be able to access our contracting agreements and related documents or information without the hassle and expense of hard copy mailings. Health care continues to evolve, and Blue Cross and other health plans are evolving to respond to the needs of our customers. Physicians and other providers can help us in this evolutionary process. We urge leadership in organized medicine to work productively with health plans in this process so that the next generation of managed care meets the needs of all stakeholders in the system — patients, purchasers, providers and plans. ✦ Jodie L. Root, CMPE, is vice president, contracting and payment, Blue Cross and Blue Shield of Minnesota.

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The Journal of the Hennepin and Ramsey Medical Societies

800/387-3585 218/387/9599 www.RedPineRealty.com

July/August 2000

Metropolitan Medical Practice Forum Comments on 2000/2001 BCBS AWARE and Referral BLUE PLUS Agreements Editor’s Note: During the last several years, physicians and their practice administrators have faced increasing economic pressures with patient demand escalating at the same time that managed care companies have gained disproportionate market power and have virtually unlimited negotiating power. The need to be aware of the provisions contained in provider agreements with the health plans is more critical today than ever in the past. In response to the growing need for information that is useful in analyzing the provisions in provider agreements, the Hennepin Medical Society, the Ramsey Medical Society, and the Minnesota Medical Group Management Association have agreed to collaborate with Healthcare Management Resources and Lockridge Grindal PLLP, to provide physicians and practice administrators with current information regarding provider agreements. The following information is designed to give you, your attorney and your accountant a starting point to consider the contractual decisions that could make a significant impact on your practice. The following article was originally sent as a memo to HMS and RMS members. Although the deadline has passed, we thought the information provided is important enough to be repeated here.

THIS ARTICLE PROVIDES a brief analysis of

some of the most significant terms of the two new Blue Cross and Blue Shield (BCBS) 2000 Renewal Amendments to the AWARE Agreement and the Referral BLUE PLUS Amendment sent April 25, 2000 (the Agreements). The information provided in this article is not a substitute for legal and accounting advice. Providers interested in determining the specific application of the BCBS Agreements to their prac-

July/August 2000

tices or in negotiating the terms of the Agreements should discuss the matter with their own attorneys, accountants and consultants. Providers may also wish to review last year’s memo addressing the Blue Plus Provider Service Agreement since many provisions are similar. • What’s Changed? The distributed Agreements are restated agreements incorporating BCBS’s proposed amendments to the existing AWARE Agreement and Referral Blue Plus Agreement. Although BCBS has listed some of the substantive changes it has made to the Agreements, the specific changes to the Agreements (including any changes not deemed “substantive” by BCBS) are not marked. As such, it is very difficult to discern all the changes BCBS has actually made to the Agreements. Providers may wish to specifically request a black line version of the Agreements showing all proposed changes. • Take It or Leave It. The amendments do not require a Provider signature to take effect. The AWARE amendment goes into effect automatically on 7/1/ 2000 unless you give notice of termination by 6/1/2000. The Blue Plus Amendment goes into effect automatically on the first of the month following 90 days notice from BCBS unless you give notice of termination (August 1, 2000 based on the BCBS letter date of April 25, 2000) — despite the BCBS letter stating that the Blue Plus Amendment is effective 7/1/2000 unless you give notice by 6/1/2000. The current AWARE and Blue Plus Agreements contain a provision permitting “passive amendment” by BCBS. This passive amendment process avoids direct negotiation of terms and invites misunderstanding through lack of communication between the BCBS and Providers. A commercially reasonable healthplan/ MetroDoctors

provider agreement and all amendments should be negotiated between the parties prior to acceptance and implementation. The passive amendment process puts the Provider in a disadvantaged negotiating position relative to the healthplan. Under this process, the Provider’s only recourse is to terminate participation if the Provider does not like the terms unilaterally imposed by BCBS. A corollary to the passive amendment process gives BCBS the right to issue Rules and Regulations relating to the Agreement (Aware III.J, BP III.3). Again, the provider’s only recourse is to terminate participation in the case of newly issued Rules and Regulations that “materially affect the responsibilities or rights of Provider.” There is no right and no process for a Provider to negotiate terms with BCBS. • Contract Stacking. Like previous BCBS contracts, the proposed Agreements include extensive “contract stacking” language that mandates Provider participation in other and/or future unknown healthplans, workers compensation or auto medical insurance or PPO products under the terms of the Agreements. No other terms of participation, reimbursement, or benefits coverage are open for negotiation prior to implementation. Providers may be obligated to provide health care services for unknown volumes at un-defined co-insurance and deductible reimbursement levels that may or may not fully cover the cost of these obligatory services. The Provider has no right to accept or decline participation in each new product, network or benefit plan sold by BCBS, joint ventured with other healthplans, or sold to self insured employers nationwide. Although titled as Aware or Blue Plus Agreements — the Agreements thus cover the following products/programs: 1. All health benefit plans underwritten or adThe Journal of the Hennepin and Ramsey Medical Societies

2. 3. 4. 5. 6.

Different undefined fee arrangements apply to these other products. • Blank Check. The Agreement makes multiple references to other documents and requirements, such as BCBS Policies and Procedures, which, while not attached, are considered to be a part of the contract between the Provider and BCBS. In the Agreement, the Provider agrees to accept responsibility to perform under these current (and future) documents and requirements. These include: 1. Fee Schedule (2000 RVUs, but no Conversion Factor). 2. “Rules and Regulations” (Aware II.M, III.J, BP II.18, III.3). 3. Electronic claim submission formats, process and procedures (Aware III.B, Blue Plus III.12). 4. Subscriber medical records which conform with reasonable documentation standards established by BCBS. 5. “Clinical correctness” (Aware III.C, BP III.11). 6. Billing requirements established by BCBS based on coding guidelines as interpreted by BCBS (Aware III.C, BP III.11). 7. Quality assurance and managed care requirements and procedures established by BCBS (Aware III.C, BP VII.1). 8. Preadmission Notification (Aware III.L, BP VII.1). 9. Concurrent Review (Aware III.L, BP VII.1). 10. Prior Authorization of Services (Aware III.L, BP VII.1). 11. Utilization of a prescription drug form formulary (Aware III.L, BP VII.1). MetroDoctors

12. “Referral” policy guidelines (Aware III.M, BP III.6). 13. Blue Cross provider selection appeal process (Aware III.Q, BP, VIII.4). 14. Provider Bulletins (Aware VI.A, BP XII.1) (This is a major change). 15. Utilization Review (Aware III.B, BP III.10). 16. Quality and Care Management Reviews (Aware III.B, BP III.10).

17. Additional Provider Participation Requirements. Providers may want to obtain and review copies of these current documents and requirements prior to accepting the amendment for either the AWARE or BLUE PLUS Agreements.

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Hennepin County Medical Center (HCMC) is one of the major teaching hospitals in Minnesota. Continuing Medical Education (CME), formerly known as the Office of Academic Affairs, was established at HCMC in 1983. The mission of HCMC's CME Program is: "to provide organized, planned education activities to help physicians improve delivery of medical care." FALL CONFERENCES:

September 15-16 Advanced Life Support in Obstetrics Location: HCMC, Minneapolis September 29 Contemporary Issues in Dialysis Location: Sheraton Inn Midway, St. Paul October 5-6 Annual Forensic Science Seminar Location: HCMC, Minneapolis November 2-4 Annual Orthopaedic and Trauma Seminar Location: Minneapolis Convention Center November 3 A Global Affair: Caring for Immigrants and Refugees Location: HCMC, Minneapolis

Will be held in conjunction with the HCMC/MMRF (Minneapolis Medical Research Foundation) fundraising gala: A GLOBAL AFFAIR: CARING FOR A CHANGING WORLD on November 4, 2000 at the Minneapolis Marriott Hotel

November 10 Annual Minneapolis/St. Paul Diabetes Forum Location: Radisson Conference Center, Plymouth December 8 Ninth Annual Family Practice Update Location: Sheraton Inn Airport, Bloomington We would like to hear your comments and suggestions for future CME activities! For More Information Hennepin County Medical Center Continuing Medical Education 701 Park Avenue, Mail Code 861-B Minneapolis, Minnesota 55415-1829 email robin.hoppenrath@co.hennepin.mn.us

The Journal of the Hennepin and Ramsey Medical Societies

612-347-2075 Fax: 612-904-4210 Toll Free: 888-263-4262

2000 CME @ HCMC

ministered by Blue Cross (which includes at Blue Cross discretion, its Affiliated and Joint Venture Companies). Certified Workers Compensation Plans. Non-Certified Workers Compensation Plans. Disability Plans. Other benefit plans sold by BCBS, but paid by employers. Persons covered under benefit plans underwritten or administered by other Blue Cross and Blue Shield Plans approved by the national BCBS Association. All “Network Access Arrangements” made by BCBS. “Select Network Provider” (i.e., Blue Plus).

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3. • Expanded Obligations. The Agreement expands Providers’ contractual obligations and holds Providers to much more stringent standards in the following areas (Aware refers to the AWARE Agreement and BP refers to the BLUE PLUS Amendment); 1. CREDENTIALING. Aware III.O, BP VIII.1. Annual recredentialing may be required of every Provider as opposed to recredentialing at the time of a change event. Immediate termination may be imposed on Providers failing to meet BCBS’s standards for re-credentialing or if BCBS fails to obtain required information for credentialing. 2. COORDINATION OF BENEFITS. Aware III.Y, BP III. 3. Providers are required to abide by BCBS’s benefit determinations and cooperate fully with BCBS in the administration of the Coordination of Benefits and subrogation provisions. When BCBS or the Plan Sponsor is the secondary payor, no greater benefits or payment will be provided than if BCBS or

the Plan Sponsor were the primary payor. TERMINATION. Aware V.B.7, BP VIII.1. Immediate termination is added for Providers that fail to meet any BCBS credentialing standard or provide required information, however, no comprehensive documentation of all “standards” is attached with the amendment. No accountability on the part of BCBS as to timeliness in making credentialing decisions is provided in this amendment. Despite raising the ante with respect to credentialing and termination, BCBS has not also detailed provider due process rights with respect to appealing such credentialing determinations. PATIENT (SUBSCRIBER) COMPLAINTS. Aware VI.A, BP XII.1. Providers will be required to comply with any requirements contained in BCBS Provider Bulletins with respect to receiving and resolving Subscriber Complaints. PROVIDER-PATIENT COMMUNICATION. Aware VII.B & E, BP XIII. 5. Language stating that Agreement confidentiality and non-interference provisions are

not intended to interfere with communication between the provider and the patient has been added in accordance with the NCQA. The addition of this new language to the Agreement’s already broad, restrictive confidentiality and noninterference provisions directly conflicts with a Provider’s ability to clearly advise or possibly even answer direct patient questions regarding the way BCBS contract language or policies control health service operations that directly affect health services delivered to the patient. PROVIDER PARTICIPATION REQUIREMENTS. Aware II.P, BP VIII.2. The Agreement includes an extensive set of Provider Participation Requirements setting forth minimum Provider guidelines and requirements for participation in BCBS’s provider network. Despite these Requirements, BCBS reserves the right to consider additional factors in its sole discretion including “whether or not a provider or practitioner acts in a professional and courteous manner.” ✦

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Products and Services Offered to RMS Members by RCMS, Inc. For more information call 612-362-3704. 16

July/August 2000

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

The Integrated Care Model Ramsey County Seeks Medicaid Research & Demonstration Waiver This summer, the State of Minnesota and the Ramsey County Board of Commissioners will request that the U.S. Health Care Financing Administration grant a research and demonstration waiver under Federal Medicaid law. The waiver will allow the county to design and implement an integrated health, behavioral health and human services delivery system for the county’s lowincome, Medicaid and General Assistance Medical Care population.

UNDER THE CURRENT SERVICE DELIVERY SYSTEM, providing

superior patient care can be problematic, particularly when the patient has multiple problems and requires services that cross historically separate program/service lines. The current delivery system is fragmented, often requiring that patients and providers navigate multiple and complex systems in order to stitch together packages of discrete services to meet the patient’s complex needs. Under Ramsey County’s proposal, the county, rather than the State of Minnesota, will be the purchaser of Medicaid funded health care on behalf of low-income county residents, beginning with health care for individuals currently on the Prepaid Medical Assistance Program (PMAP) and eventually including persons with disabilities. The county intends to provide the current health benefit set on a shared-risk basis through contract with HMOs; contracts with Care Systems will be added later. The core of the proposal is, however, to use this foundation as the basis for establishing Integrated Care Systems to meet the multidimensional, complex needs of the families and individuals served by the Medicaid Program. Integrated Care Systems involve contracting with several consortiums consisting of health, behavioral health, and human services providers who agree to meet negotiated outcomes for consumers. These contracts are funded through more flexible funding streams created by blending monies from currently independent funding sources. This program is being developed in order to: • Meet the complex health and human service needs of the Medicaid population; • Focus on achieving long-term positive outcomes for consumers; • Define appropriateness of care based on achieving the outcome; and • Provide incentives for providing care at the right time and in the right amount and by the right provider.

BY MARY MAHONEY

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

The decision to pursue a waiver in order to implement this program was considered at length by the County Board because of both the potential opportunities and the potential risks. Improving both immediate and long-term outcomes for consumers is the focus of the program. In addition, our analysis identified four additional benefits. Better patient care. Under the current system, the delivery of superior patient care is problematic. Care is fragmented; patients must navigate multiple, complex systems; and providers are encouraged to give minimum amounts of service and define the service so the consumer becomes the responsibility of another provider. Under the new model, Integrated Care Systems would provide coordinated, seamless health, behavioral health and social services care. The burden of navigating multiple systems would shift from the patient to the consortium, and one provider would assume responsibility for the overall health of a patient. Contained costs. This outcome-focused model will result in healthier citizens less likely to need sustained long-term assistance or access to other more expensive services funded by the county. A key goal is to retain high risk/high cost consumers in the care systems’ managed care networks to improve outcomes as well as contain costs. Early intervention – a good investment. The county intends to use the savings generated by the model’s efficiencies to invest in the development of preventative and early intervention models of care that reduce the need for longer-term intensive care. Targeted innovation. The county’s proposal would accomplish major systems change while providing consumers with enhanced benefits and choice of providers. It builds on the strengths of good but separately run programs. Any savings generated by the model’s efficiencies can be invested in the development of preventative and early intervention models of care that reduce the need for longer-term intensive care. We would welcome your comments, thoughts and suggestions regarding this new model and ways in which we can improve health care outcomes for our communities low-income citizens. For more information or to share you comments please contact: Mary Mahoney, Director of Integrated Care Management, Ramsey County, at (651) 523-7955 or e-mail, mary.mahony@co.ramsey.mn.us. ✦ Mary Mahoney is Director of Integrated Care Management, Ramsey County. July/August 2000

How to Negotiate an Employment Agreement With a Large Health Care Provider

The Big Picture Most of the large health care employers in this area are not-for-profit corporations. Assuming your prospective employer is a not-for-profit, there will be no buy-in to stock or receivables. It is important to know that an employment contract with a large employer is often a contract of “adhesion” where the physician is told that all of the employment terms are standard and that the only choice is to accept or reject employment on those terms. Many large employers refuse to individually negotiate and tailor employment contracts. The agreement is treated as immutable. In such cases the individual physician would be unrealistic to expect that he or she would have any real impact on the course of conduct of this new employer. For that reason, the most important decision of the physician joining a large employer, is usually to choose the right employer in the first place. If you cannot change the employer, you had better match your own personality and career goals (lifestyle, research, money, etc.) with the style of the institution that will employ you. The Check List Before you sign an employment agreement you should consider consulting with a lawyer or other advisor, but be sure that they specialize in the health care field. The following checklist should raise most of the important issues: 1. The overall financial health of the institution you are about to join is terribly important to your compensation and the level of pressure and aggravation to which you will be subjected. Is it financially strong? 2. In the new market, not all business strategies work and you need to make an assessment of whether the way in which your BY WARREN MACK, ESQ.

July/August 2000

proposed institution has structured itself and positioned itself in the marketplace makes sense for the long run. 3. Is the culture of the institution compatible with your goals on items such as lifestyle, money and research? Does the compensation system fit your style? Do you see yourself as average or above or below average in terms of your own productivity and ambition? 4. Before you sign the employment agreement with a large institution, be sure to first check your pulse to see if you might be one of those physicians who will only be happy pursuing the traditional American dream of owning and controlling your own business. If so, consider joining a traditional clinic owned by the physicians. 5. Is there a seniority based compensation system that operates as a disguised requirement to purchase blue sky? 6. Do you understand the incentive compensation formula and is it based on first-year collections or billings (you will only have about eight months of collections in the first year)? 7. Is there a noncompete and, if so, is it fair? Does it still apply if you get fired? 8. If you terminate or are terminated by the employer, do you pay the malpractice tail? 9. When do you come into participation in employee benefits and are they on top of or part of your stated income? 10. Does your prospective employer have risksharing contracts that could go poorly or are they even paying back on risk-sharing contracts that went poorly in previous years? 11. What is the employer’s policy on inventions or other intellectual property that may be created by you? 12. Does your prospective employer have a financial cloud hanging over it because of past MetroDoctors

or incipient Medicare compliance problems? 13. Does the employer have an effective Medicare compliance program? 14. Is there anything unusual about your prospective employer’s contracts with payors such as an exclusive contract to provide services to a single payor? 15. Do the incomes of the other physicians employed by your prospective employer meet the averages in the surveys for their specialty and level of production? 16. Are you joining a clinic in an under-served area where hospital subsidy is permitted by the new regulations? 17. The above checklist is equally applicable to employment with traditional clinics with physician owners if you add the following points: • When do you buy stock and will it be a full equal share and will it be priced at book value? • Accounts receivable are always the biggest asset of for-profit clinics, so it is important to know how you will acquire your interest in accounts receivable. Will you buy into the existing accounts receivable balance or will you only acquire an interest in increases in accounts receivable from their current balance? • Is there a separate partnership buy-in for the office building? • Are there other related entities into which you should buy or which may be important profit centers for the senior physicians? These might include participation in equipment partnerships, ambulatory surgery centers, imaging centers and the like. ✦ Warren Mack, Esq., is vice-chairman of the law firm of Fredrikson & Byron and can be reached at (612) 347-7015. The Journal of the Hennepin and Ramsey Medical Societies

Has the OIG Reached “The Age of Unreason”?

IN THE 1990 BOOK by Charles Handy en-

titled The Age of Unreason published by Harvard Business School, the forward by Professor Warren Bennis quoted the American author Graham Green saying that, “There always comes a moment in time when a door opens and lets the future in.” As someone who started his healthcare career in the 1950s, I’ve been privileged to participate in our healthcare delivery system for all or part of now six decades. What has been extremely consistent throughout that time, and why I like the quote from Graham Green is that the healthcare door for the 21st century is wide open and change will continue to come in. My opportunity to discuss change in the future in this article is limited so I’ll start with an overview discussion of a major, if not the most important factor impacting healthcare in the 21st century — governmental change. Those of us in Minnesota can certainly talk about Minnesota Care and managed care as being strong forces of change. However, I believe that the changes impacting healthcare providers in the 21st century that will be the strongest will come from the federal government. Obviously, as with every healthcare provider today, we are already well aware that HCFA, as part of the federal government, has become the 800 lb. gorilla shaping the way that healthcare is provided and how healthcare providers are reimbursed. Now, let us look at the future changes and impact which will come from a different part of the federal government — the Office of the Inspector General (OIG). The ancient Chinese defined “chaos” as “opportunity.” In this time of “chaos” within healthcare, physicians need to seize the opportunity to take a strong stance for their survival

B Y J O H N F. M c C A L L Y

MetroDoctors

and to be proactive in their actions to operationally and strategically position themselves appropriately. As most of us realize, HCFA has become the largest payor of medical services in the country. What we have seen in the past as some government oversight will turn 21st century healthcare delivery into a pattern of regulatory control via legislation, regulations and enforcement. The balance of this article is designed to provide its readers with some insight into relatively new key areas of such regulatory control by the OIG. Let me first start with indicating that last year the Office of the Inspector General (OIG), the Department of Health and Human Services, issued a special Advisory Bulletin addressing the application of sections 1128A(b) (1) & (2) of the Social Security Act. That bulletin addresses the civil monetary penalties set forth in section 1128A(b) (1) of the Act which prohibits any hospital from knowingly making a payment directly or indirectly to a physician as an inducement to reduce or limit services to Medicare or Medicaid beneficiaries under the physician’s care. While this article does not provide legal interpretation of the special Advisory Bulletin, it does seem appropriate to point out that the OIG is clearly concerned about arrangements between hospitals and physicians which are often considered “gainsharing” arrangements. The special Advisory Bulletin went on to indicate that in exercising its enforcement discretion, it will take into consideration whether a “gainsharing arrangement” was terminated expeditiously following publication of the Advisory Bulletin. As both a former clinic and hospital administrator, and having worked with physicians since the late 1950s, I must say that most physicians I’ve worked with and most administrators I know do not routinely receive/read the

The Journal of the Hennepin and Ramsey Medical Societies

special Advisory Bulletins from the OIG. That is why it is so important to be part of your county and state medical societies so that as physicians you can become knowledgeable about the major changes that are going to impact you created by either governmental regulations or federal laws like Stark II. And, just in case you have not been informed or heard of the civil monetary penalties under section 1128A(b) (1) of the Act, you should know that hospitals are prohibited from making a payment (gainsharing) to induce physicians to limit or reduce services and that such gainsharing payments are liable for a civil monetary penalty of up to $2,000 per patient covered by the gainsharing. I do believe that most of the healthcare providers and their leadership in Minnesota have made efforts to ensure that they are in compliance with regulatory actions like the special Advisory Bulletin listed above. And if, in fact, that was the only issue about which the OIG was concerned, this article would not have been written. However, in October of last year the OIG made its fiscal year 2000 work plan available to the public. This work plan provides a description of more than one hundred project areas to be addressed by the OIG in fiscal year 2000 which ends September 30, 2000. What is important to recognize is that the OIG develops such work plans every year. Such work plans are broken into sections devoted to specific types of providers and programs including hospitals, physicians, skilled nursing facilities, home healthcare agencies and other programs and topics. While some of the projects are carryovers from previous year work plans, the fiscal year 2000 work plan has new key target areas. Many have been triggered by increased utilization of specific procedures resulting in increased Medi(Continued on page 20)

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(Continued from page 19)

care reimbursement. It, therefore, would seem prudent that those providers with high Medicare patient populations insure that their own data and outcomes are appropriate and accessible. Some of the OIG fiscal year 2000 items of particular note include the following: • The OIG will examine whether errors found in Medicare billings for physician services are caused by the use of automated encoding software. In addition, the OIG will examine physician billing processes to identify billing issues for physician offices with independent billing compared to those using third party billing companies. • As pointed out earlier in this article, the increase in Medicare patient utilization has triggered considerable concerns on the part of HCFA and OIG. It is both a political, as well as a financial issue, since such increases can change the actuarial predictions for the Medicare funds available to pay for

•

services of Medicare beneficiaries in the future. As an example of billing increases for a particular service, the work plan indicates that myocardial perfusion imaging accounts for a large portion of a 23 percent increase in billing for all nuclear imaging services between 1997 and 1998. Because of that, the OIG plans to assess the medical appropriateness of such myocardial perfusion imaging in an attempt to understand the high increase in utilization. The OIG work plan also indicates that the OIG plans to assess the medical appropriateness of laboratory tests and other services ordered for end-stage renal disease. The OIG will also examine claims for dialysis services to assess variability in provider billing patterns and identify “aberrant” providers. According to the OIG, aberrant providers are easily identified by examining data showing physician billing patterns. Particularly in situations such as in the greater Twin Cities area where there are

•

hospital systems with multiple hospitals, OIG will work with both HCFA and the Department of Justice to pursue overpayments which results from transfers between hospitals that have been incorrectly reimbursed as a discharge from the first hospital and admission to the second hospital. Similarly the OIG also will continue examining claims for patient’s discharged and then readmitted to the same hospital later the same day. The OIG also plans to “evaluate the reasonableness” of payments for Medicare beneficiaries who stay only one day in a hospital. The OIG will assess whether HCFA needs to establish controls over Medicare payments for routine physician nursing home visits. The work plan asserts that some physicians are receiving extraordinarily high reimbursement rates for their routine monthly examinations, indicating they are billing for more services than could be provided by the physicians in a normal work day. The OIG will also study the medical necessity of physical and occupational therapy services provided to nursing home patients.

These are but a few of the over 100 key areas of the OIG fiscal year 2000 work plan. These are representative of the ongoing and ever increasing amount of governmental influence on the delivery of medicine in the 21st century. As we now move into the 21st century with its ongoing changes and controls, it will be prudent to remember the theme of another 20th century book, 1984, which was Big Brother is watching you. As stated earlier in this article, now is the time to ensure that your services and data relating to patient care are operationally and strategically appropriate. Questions regarding this article can be addressed to John F. McCally, President, Physicians Consulting Services of America, Ltd., (651) 483-6814, e-mail, johnfmccally@ earthlink.net; or Paul A. Wilkus, President, Health Financial Group, Inc., (612) 825-8527, e-mail, pwilkus@visi.com. ✦

Offering comprehensive legal advice to clients in the health care and medical device industries Health Law Practice Margo Struthers, Chair 612.607.7000 oppenheimer.com

Amsterdam Brussels Chicago Geneva Los Angeles Minneapolis New York Orange County Saint Paul Silicon Valley Paris Washington, D.C.

John F. McCally is the president of Physicians Consulting Services of America, Ltd.

July/August 2000

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

RISK MANAGEMENT

Meeting all of a Patient’s Needs Often Requires Outside Help

WHEN A “DIFFICULT” PATIENT situation

arises, physicians often must seek outside help to meet all of a patient’s needs. The following case describes a situation where good medical care will be insufficient to fully address this young patient’s problems. Amy, a fourteen-year-old girl, presents in the Emergency Department complaining of a fever, sore muscles and fatigue. Her family is vacationing in the area and the physician on call sees Amy and her mother. Amy’s mother is abrupt and irritable, frustrated that she must take time away from her vacation to come to the ED for what she insists must be the flu. Amy appears anxious; she keeps insisting she is fine and wants to leave. Her mother orders her to cooperate. Finally separated from her mother for the examination, Amy confides to the physician that she is sexually active. An examination reveals that Amy is experiencing an initial outbreak of herpes, with large lesions in her vagina. Amy begs the physician not to tell her mother as she “will kill me.” The physician knows that Minnesota law allows minors to consent for their own treatment for sexually transmitted diseases, and that the mother’s consent is not necessary. It also requires that such treatment and diagnosis remain confidential, with the minor in control of information release. This hospital will present the vacationing mother with an itemized bill for services at the end of the visit. Extending the system is the term for seeking out other resources when confronted with a difficult patient situation. Sometimes a team approach involving non-medical personnel, family and others is the way to ensure a patient like Amy is given the best possible care. Physician awareness of external resources can be critical to obtaining appropriate help.

What help is needed? First ask, what kind of assistance is needed? Physicians easily recognize when a consult from a specialist or a colleague is necessary. But what if the help needed is outside that comfortable scope, as in Amy’s case? Amy’s situation presents several unique concerns. First, Amy now has a life-altering illness with serious potential consequences. Second, she has a mother whom she fears. Finally, Amy has the right to confidentiality regarding her care and treatment in this circumstance, but the hospital will give her mother an itemized bill — a common practice that unfortunately is

at odds with Amy’s rights. Because her mother will learn of the diagnosis at the end of the visit, and because Amy’s medical needs extend beyond this ED visit, the physician must engage Amy and secure her cooperation in telling her mother. As part of the discussion with Amy, the physician should identify the evident needs. Clearly, she needs ongoing medical care and treatment. Amy likely needs an advocate, someone she can trust. She may need someone present to support her when telling her mother. She also will need age-appropriate education (Continued on page 22)

BY MIDWEST MEDICAL INSURANCE COMPANY RISK MANAGEMENT COMMITTEE

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

July/August 2000

(Continued from page 21)

about her condition and the future precautions she will have to take. What are the sources of help? Once a patient’s needs are defined, other medical providers and various hospital staff are commonly-known sources of help. Nurses and dieticians may do patient teaching. Social services may help locate daycare, housing, financial assistance, or counseling. In Amy’s situation, the physician should also explore Amy’s support systems and determine who may be called upon for help. Parents, friends, other relatives, or the family physician are all potential sources of support and advocacy for Amy. Gaining Amy’s trust and confidence will be key to determining what help is available. How to get help? There are several steps that can make the process of extending the system easier. First, inform the patient of the need for help. Amy should be told the options she has and the consequences

July/August 2000

of those options. She should be assured of the physician’s commitment to confidentiality, but the billing situation will have to be explained. Any sources for assistance should be evaluated. Second, ensure that the patient is part of the decision process. Ask her where she usually turns for help. Are any of those people available? Will family members be involved in or excluded from the decision-making process? After exploring her resources and making suggestions, make sure Amy agrees with the plan. Third, determine who has responsibility. Amy should know what the physician can do, and what is expected of her. What are the expectations of the support person? Fourth, is this to be a referral or a collaboration? Many malpractice claims arise when it is unclear to the patient who will be following up with their care. Decide what role each person in the extended care team will play. How much involvement will social services or the patient educator have? Let Amy know where to go for further care and treatment — will she continue to see the emergency physician for the duration of her vacation?

MetroDoctors

Finally, establish whether there are laws, rules or policies that require physicians to extend the system further. For example, Amy should know that her illness must be reported to the health department or other agencies. Relationship difficulties arise when expectations are misaligned, success is frustrated or flexibility is insufficient. The challenge for physicians dealing with “difficult” patients is to acknowledge the problem, show compassion and empathy for the patient, discover the meaning of the illness and its impact on the patient and family, then extend the care system to provide for needs unmet by medical treatments and procedures. Knowing available resources ahead of time will ensure an easier transition when a difficult situation does present. ✦

Midwest Medical Insurance Company is a physician-owned medical malpractice insurer covering physicians, clinics, and hospitals in Minnesota, Iowa, Nebraska, North Dakota, South Dakota, Wisconsin, and Illinois. For more information call 1-800-328-5532.

The Journal of the Hennepin and Ramsey Medical Societies

NOTEWORTHY

Metrodoctors.com “Hits” Explode Metrodoctors.com, the joint web site of the Ramsey and Hennepin Medical Societies, has experienced an explosion in hits. Earlier this year the site was experiencing around 50 hits per day. Not an unreasonable number for a site that has little or no promotion. Metrodoctors.com is now experiencing 600700 hits per day! Through the end of June metrodoctors.com exceeded 50,000 hits. Committee Chair Russell Welch, M.D., encourages all RMS and HMS members to complete, if they haven’t already done so, the on-line census form. Simply log on to www.metrodoctors.com/census and complete the information requested. To date, approximately 1,000 of your colleagues, out of the 4,000 physicians listed, have taken this step. The next issue of MetroDoctors will include a more detailed analysis of the recent web site activity. ✦

Medical Student’s Lunch n’ Learn with Attorney General Mike Hatch Attorney General Mike Hatch participated in the HMS/RMS sponsored Lunch n’ Learn session at which time he discussed his work with the Medicare Justice Coalition. Pictured with Attorney General Mike Hatch (second from left) are: medical students Ben Baechler, Bret Yonke and Kelley duFord.

Recommended Blood Lead Screening Guidelines Childhood lead poisoning is a major, preventable environmental health problem in the United States. Although blood lead levels have dropped in Minnesota and nationwide, many children at risk of developing blood lead poisoning are not being tested or screened. The Minnesota Department of Health (MDH) has released new Blood Lead Screening Guidelines that were developed to target children who are most at risk. A copy of the Blood Lead Screening Guidelines for Minnesota, a Risk Questionnaire for use in clinical settings, or the Blood Lead Screening Work Group Final Report can be obtained at www.health.state.mn.us/divs/ eh/profinfo.html, or by contacting Becky Krueger at (651) 215-0785, or becky.krueger @health.state.mn.us. For information about lead surveillance or epidemiology, contact Myron Falken, Ph.D., at (651) 215-0877 or myron.falken@health.state.mn.us. ✦ MetroDoctors

“Professional Projects for the Professional” • Clinics • Professional Buildings • Hospitals •

Morcon Construction, Inc. 5905 Golden Valley Road Golden Valley, MN 55442 763-546-6066 Phone: 612-546-6066 Bill Jundt Medical Construction Specialist Member MMGMA/Gold Sponsor

The Journal of the Hennepin and Ramsey Medical Societies

morcon@isd.net

July/August 2000

PRESIDENT’S MESSAGE J O H N R . G AT E S , M . D .

RMS-Officers

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

Kimberly A. Anderson, M.D. Charles E. Crutchfield, III, M.D. Peter J. Daly, M.D. Kelley C. duFord, Medical Student Thomas B. Dunkel, M.D. Michael Gonzalez-Campoy, M.D. James J. Jordan, M.D. F. Donald Kapps, M.D. Kathryn M. Klingberg, M.D., Resident Physician Charlene E. McEvoy, M.D. Ragnvald Mjanger, M.D. Joseph L. Rigatuso, M.D. Thomas F. Rolewicz, M.D. Paul M. Spilseth, M.D. Jon V. Thomas, M.D. David C. Thorson, M.D. Randy S. Twito, M.D. Russell C. Welch, M.D. RMS-Ex-Officio Board Members

Blanton Bessinger, M.D., MMA President-Elect Raymond Bonnabeau, M.D., Sr. Physicians Association President Kenneth W. Crabb, M.D., AMA Alternate Delegate Stephen P. England, M.D., Community Health Council Chair Michael Gonzalez-Campoy, M.D., Education Resource Council Chair Eleanor Goodall, Alliance President Frank J. Indihar, M.D., AMA Delegate William Jacott, M.D., U of MN Representative F. Donald Kapps, M.D., Council on Professionalsim & Ethics Chair Melanie Sullivan, Clinic Administrator Lyle J. Swenson, M.D., Public Policy Council Chair Russell C. Welch, M.D., Communications Council Chair RMS-Executive Staff

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

July/August 2000

May 26, 1900 Dr. Justus Ohage presented Harriet Island Park to the City of St. Paul with the stipulation that, “It should be conducted solely as a place of wholesome recreation, free of money-making amusement features.” He declared that, “From 6 o’clock in the morning to 6 o’clock at night, [the park] will stand open everyday throughout the summer, the gates of this pure and purifying paradise, and all may enter here save liquor, sin and cigarettes.” May 26, 2000 Today, I had the opportunity to participate in an equally historic event in the history of Ramsey County and Ramsey Medical Society. It was the re-dedication of the Clarence W. Wigington Pavilion on Harriet Island, on the 100th year anniversary, to the day, that Dr. Justus Ohage, a former president of the Ramsey County Medical Society, donated Harriet Island to the City of St. Paul. On this beautiful Friday afternoon, I learned much about Clarence W. Wigington, the first African-American architect in Minnesota, who designed more than 100 buildings in St. Paul — three of which are named to the National Historic Register, as well as the original Harriet Island Pavilion; and also a lot about the 16th RMS president, Dr. Justus Ohage, who

purchased Harriet Island for $8,000 by refinancing his own home, to provide a public park devoted to the “healthful betterment” of the community. A leading surgeon in America at the turn of the last century, Dr. Ohage was a courageous risk-taker. He performed the first successful cholecystectomy in the United States at St. Joseph’s Hospital, subject to the great personal risk of being prosecuted for manslaughter if his 40-year-old female patient had died. She survived and lived to the ripe old age of 80. Dr. Ohage also served as Public Health Commissioner for St. Paul, responsible for instituting several highly unpopular sanitation regulations, which ultimately caused St. Paul to become recognized as a model, healthful U.S. city. Dedicated to improving public health for all citizens, Dr. Ohage’s gift to the community then inspired others to raise additional moneys to build walking and riding trails, swimming beaches, public baths, playgrounds and day care facilities. Baths were free to those who brought (Continued on page 25)

Dr. John Gates, RMS president, had a prominent role in the dedication of the Ohage Great Lawn on Harriet Island on Friday, May 26. Dr. Ohage was president of the RMS in 1889 and 1890 and served as president of the Minnesota State Medical Society in 1895. St. Paul Mayor Norm Coleman announced the RMS contribution of $15,000 for a monument to Dr. Justus Ohage on Harriet Island. Dr. Robert Moravec, RMS President-Elect (right) joined Dr. Gates (left) and Mayor Norm Coleman (center) at the dedication.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

R M S U P DAT E ROGER K. JOHNSON, RMS CEO

Two Year Strategic Planning The RMS Board of Directors concluded a strategic planning review process on June 7. A review of the RMS Strategic Plan adopted in 1998 and a survey of the current Board of Directors were important elements of the

President’s Message (Continued from page 24)

their own soap, towel and “bath suit.” It cost two cents to obtain these items on site. Harriet Island Park became a great community gathering place, ultimately attracting a million visitors a year. On this particular, lovely May afternoon, the grandchildren of Clarence W. Wigington and the great-grandchildren of Dr. Justus Ohage were present to acknowledge and honor the contributions of their illustrious forefathers, men who probably never dreamed they would be honored a century after their personal commitments became public property. Personal remembrances and stories of these two community MetroDoctors

work. Consultant Sue Laxdal facilitated the discussions and will present a report for the Board members. Key aspects of the plan include providing value to members; recruiting new members; collaboration with other entities; expanding the physician voice in health care policy; improving communications with members and the public; and, expanding community recognition of RMS.

Meetings with Health Plans RMS officers and staff have participated in meetings with Medica, Blue Cross and Blue

Shield of Minnesota, and HealthPartners in recent weeks. The purpose of the meetings is to learn about the implementation of new health plan policies and programs and to provide physician input to the plans regarding proposed changes in policies and programs. The RMS leaders also have the opportunity to advise the plans about those elements of the systems that are working well and the elements that are not working. The efforts to improve communications should result in expanded opportunities for physicians to voice their concerns to the health plans. The Ramsey Medical Society will continue to work with the Hennepin Medical Society and the Minnesota Medical Group Management Association to provide contract review information to physicians and practice administrators such as the BlueCross BlueShield Minnesota Aware and Blue Plus Agreement review that was mailed in May and appears on page 14 of this issue. ✦

benefactors were shared from the rich family traditions of these two great families with deep, firm roots in our community. I felt honored to participate, on behalf of Ramsey Medical Society, in the celebration of these two innovative, generous visionaries from the last century of St. Paul. This gathering underscored for me how our community was not built overnight, that we stand on the shoulders of our strongest predecessors, and that the depth of traditions of medical care in this community of innovation, courage and dedication goes deep and is long-lived, well tended and respected. What a proud professional heritage! We, as members of the medical community, are an integral part of the whole, diverse St. Paul community. Personally, I hope to carry-on in the

finest tradition and standards that Dr. Justus Ohage set for himself and would have insisted upon for us. We can take a page from the book of these two dedicated and determined men, for our own personal and professional re-dedication must be to uphold — and demonstrate — the values of courage, intelligence, innovation and leadership in our own time of challenge and change — the current health care crisis. In honor and recognition of the still-living traditions of these two great men, the Board of Ramsey Medical Society donated $15,000 for the plaque honoring our former president. It will be found at Harriet Island Regional Park, in the Ohage Meadow surrounding the new Wigington Pavilion where displays honoring both men are located. ✦

Fund-raiser for Congressman Bill Luther Dr. Thomas Dunkel and Dr. Diane Dahl hosted a MEDPAC fund-raiser for Congressman Bill Luther on May 31 at their home in Lake Elmo. The event was well attended by physicians from throughout the metro area. Congressman Luther gave an update on developments in Washington, D.C., on the patient’s rights bill (Norwood, Dingell), the physician collective bargaining bill (Campbell), and on prescription drug coverage for Medicare patients.

The Journal of the Hennepin and Ramsey Medical Societies

July/August 2000

Ramsey Medical Society

RMS Delegation to Carry 16 Resolutions to the MMA House of Delegates The delegates and alternate delegates to the MMA House of Delegates from RMS caucused on May 17 and June 6 to consider more than 25 suggestions for resolutions. Sixteen have survived and those resolutions will be sponsored by the Ramsey Medical Society in the MMA House of Delegates. The resolution topics range from global risk sharing to support for the University of Minnesota Medical School. RMS has 27 delegates who will vote at the MMA Annual Meeting in Duluth, which begins on Wednesday, September 13 and concludes on Friday, September 15. Dr. Lyle Swenson, RMS past president, chairs the delegation. In past years, RMS resolutions have initiated new policies of both the MMA and the AMA.

Keiko Kimura, M.D. Albert Einstein College of Medicine Internal Medicine Regions Hospital Franz-Josef E. Reisdorf, M.D. University of Minnesota Internal Medicine/Cardiovascular Disease St. Paul Heart Clinic, P.A.

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

Active Thomas F. Campbell, M.D. University of Minnesota Obstetrics/Gynecology Metropolitan Obstetrics and Gynecology, P.A. Sean J. Ennevor, M.D. University of California-Los Angeles Anesthesiology Associated Anesthesiology, P.A. Kathleen R. Flanagan, M.D. University of Minnesota Pediatrics Central Pediatrics, P.A. John P. Hamerly, M.D. University of Minnesota Family Practice/Sports Medicine/Palliative Medicine Allina Medical Clinic - Cottage Grove James J. O’Hearn, M.D. University of North Dakota Diagnostic Radiology St. Paul Radiology, P.A. Marilyn F.A. Mellor, M.D. University of Nebraska Pediatrics/Pediatric Emergency Medicine Children’s Health Care - St. Paul Anne M. Pearson, M.D. Loyola University Family Practice HealthEast Vadnais Heights Clinic Christine N. Rhodes Dekko, M.D. University of Minnesota Pediatrics Central Pediatrics, P.A. Jane M. Stark, M.D. Medical College of Wisconsin-Milwaukee Occupational Medicine Multicare Associates of Twin Cities

July/August 2000

Active — 1st Year in Practice Aaron Wu Tsai, M.D. University of Minnesota Ophthalmology St. Paul Eye Clinic, P.A. Resident Stephen B. Eigles, M.D. Georgetown University Radiology University of Minnesota

Charles G. Terzian, M.D. Universidad Autonoma De Guadalajara, Mexico Internal Medicine United Hospital

Transfer into RMS — Resident David M. Hajek, M.D. Cedric J. Ortiguera, M.D. New York University School of Medicine Orthopedic Surgery/Sports Medicine Orthopaedic Consultants, P.A. Kristen R. Radtke, M.D. University of Minnesota

Kathryn M. Klingberg, M.D. Loyola University Family Practice Bethesda Family Practice Clinic

Sonya B. Redetzke, M.D. University of Minnesota

Student

Deborah L. Suppes, M.D. Mayo Medical School Regions Hospital

Joel A. Sagedahl, M.D. University of Minnesota

(from the University of Minnesota)

Jessica A. Bergan Lori M. Bethke Jennifer A. Carpenter Shannon R. Duffy Amanda Engelking Steve Jacobson Beth A. Keller Mary J. Lawler Robroy H. MacIver Dan R. Metcalf Jamie M. Pelzel Michael P. Rafferty Steven J. Rudolph

Scott A. Uttley, M.D. University of New Mexico ✦

In Memoriam

Transfer into RMS — Active Richard Boortz-Marx, M.D. Wayne State University Anesthesiology University of Minnesota Rodelio M. Buco, M.D. University of the Philippines Internal Medicine HealthPartners Bloomington Clinic S. Folley Dunna, M.D. Institute De Med Si Farm, Romania Family Practice

MetroDoctors

LAURA EDWARDS, M.D., an OB/GYN, died April 19 in a motor vehicle accident while doing medical missionary work in Cameroon, West Africa. She was 78. Dr. Edwards began helping with the Life Abundant Program in Cameroon in 1985, taking three months off each year from her position at Regions Hospital. She was born in Calcutta, India, and graduated from the University of Minnesota. Dr. Edwards received the 1992 RMS Community Service Award. She joined RMS in 1971. ZONDAL MILLER, M.D., a neurologist for more than 50 years, died June 7 at the age of 81. He graduated from the University of Minnesota. In 1949 he opened a neurological practice in St. Paul. Later, other neurologists joined. Then, while in his 60s, he left to start a solo practice. Dr. Miller received United Hospital’s Service to Humanity Award in 1991. Dr. Miller joined RMS in 1950. The Journal of the Hennepin and Ramsey Medical Societies

RMS ALLIANCE NEWS ELEANOR M. GOODALL

you might think. So, let’s get specific. Last year, the RMS Alliance supported (as in, made monetary contributions to), with Alliance members being active in the following organizations and projects promoting the health and well being of our community: • American Cancer Society • Caring Hearts for the Homeless • First Steps • Model Cities • Sexual Violence Center • Wigs Without Worry • Genesis II • Festival of Trees • HIV/AIDS Education Folder In addition, the Alliance holds an annual Health Fair — a week long event, attended by hundreds of third graders in the St. Paul schools. These kids learn how to take care of their bodies and how to live a healthy, violence free lifestyle. This dynamic program receives rave reviews every year from teachers, parents and the students who attend. Let’s get back to the expected return on your investment of time. In the most narrow sense, as in “what’s in it for me?” your return is truly multifold. You get to: • Meet with people who have a commonality; • Make great new friends; • Help sponsor beneficial community programs;

RMS Family Night

Tuesday, August 29, 2000 Tailgate Party: 6:00 p.m.-7:00 p.m.

(Please bring a chair or blanket to use for the tailgate party.)

Game: 7:05 p.m.

St. Paul Saints vs. Schaumburg Flyers

Where: Midway Stadium

Energy Park Drive Tailgate party: Picnic Lot #12

Call (612) 362-3705 to check availability of tickets.

St. Paul Saints Ticket Order Form

Reserved Bleacher Reserved Adult ____ @ $16.00 =_________ Adult ____ @ $14.00 =_________ Child 2-12 ____ @ $12.00 =_________ Child 2-12 ____ @ $10.00 =_________ Name: ___________________________________________________________________________ Address: ________________________________________________________________________ Mail to: Ramsey Medical Society, P.O. Box 131690, St. Paul, MN 55113-0015

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

•

Explore personal learning — wine tasting, gourmet cooking, floral arranging, career change options, art museum tours, etc.; • Experience personal growth (we’re working on Maslow’s self-actualization, here); • Feel good about giving of your time; and • HAVE FUN! You need to take a look at the RMS Alliance as a place to invest in the future. We have something for everyone. You can be as involved or as uninvolved as fits your personal needs. To continue with the investment metaphor, you can invest very, very conservatively—and simply pay your dues to support the Alliance efforts. Or, you can be a little less conservative and pick and choose to attend programs and events of particular interest to you. You can invest moderately and maybe volunteer to help with one or more of the Alliance projects. And, of course, you can be aggressive with your investment of time and work with others to formulate and implement policy and direction of the organization. The RMS Alliance Board is in the midst of planning a wonderful year, specifically with YOU in mind. We gained input from members at the May annual meeting and we will continue to do so in the fall. This way, we can plan programs and events that make a difference to the community and/or are of interest to Alliance members. We need you to help the Alliance accomplish its mission of enhancing the health and well being of the community. Like the Uncle Sam posters, we want you to join the Alliance, to be part of a wonderful group of people, to participate whenever and however suits you and to help us put our collective investment of funds, time and energy to its best use. My point is there’s a place, a special place, just for you in the Alliance. Come on out and find “your” place. As we say to our kids — try it, you’ll like it! To find out more about the RMS Alliance, request membership materials, give us your ideas and thoughts, etc., please call Eleanor Goodall at (612) 441-8308. ✦

July/August 2000

Ramsey Medical Society

Invest in the Future Let’s take a look at investments, in general. Why do we invest our money? To make more money is the obvious answer, right? If we’re conservative, we pick “safe” investments with a lower rate of return. Or, maybe we’re aggressive with part of our portfolio, putting money into tech or biotech companies, for potentially greater return. How about our time? Isn’t that an investment as well? Like money, we have a finite amount of time. Unlike money, however, when we invest our time the return can never be more “time.” Interestingly, when people say, “I don’t have time to do...” or “I need more time for…” they’re not talking about a problem with regards to time. They’re stating a preference. Time is the most finite of things and we all have exactly the same amount of it given to us every day — 24 hours, no more, no less. Preference comes in when we simply choose to use that allotted time in different ways. And, I just happen to have a recommendation for a little of your allotted time. I want to encourage each spouse of a Ramsey Medical Society physician to make the Ramsey Medical Society Alliance a preference for your time. Now, you might legitimately ask, “Just what kind of return can I expect to get for this investment of my time?” In the broad sense, your return is a better, healthier community in which to live. “Yeah yeah — I’ve heard that generality before,”

SPI

St. Paul Internists A DIVISION OF MEDICAL ASSOCIATES OF MINNESOTA, P.A.

Welcomes New Physician

SOPHIA H. KIM, M.D. DR. SOPHIA H. KIM is certified by the American Board of Internal Medicine. She began seeing patients on June 5, 2000. Dr. Kim graduated from Rockhurst College in Kansas City, Missouri and graduated from the St. Louis University School of Medicine in 1996. Her internship and residency were completed at the University of Colorado Health Science Center in Denver, Colorado. She has a special interest in cardiology and congestive heart failure. Dr. Kim is an avid outdoors-woman and excellent cook.

Two Office Locations High Point Health Campus (651) 702-6887

Downtown St. Paul Gallery Bldg. (651) 232-4300

If you are interested in running a professional announcement, contact Doreen Hines at (612) 362-3705.

DERMATOLOGY CONSULTANTS, P.A. DR. JANE BLOWERS MOORE grew up in Janesville, Wisconsin. She graduated with a B.A. in Biology from St. Olaf College, Northfield, Minnesota. She gained her M.D. in 1996 from the Medical College of Wisconsin, Milwaukee, Wisconsin. Her Transitional Internship was completed at Hennepin County Medical Center in 1997. Dr. Moore completed her Dermatology residency at the University of Minnesota where she served as chief resident in 1999-2000. She currently resides in Woodbury with her husband Matt.

July/August 2000

David W. Anderson, M.D. Lori R. Arnesen, M.D. Jennifer A. Biglow, M.D. Daryl A. Brockberg, M.D. Charles E. Crutchfield III, M.D. Humberto Gallego, M.D.

Pierre M. George, M.D. Noel A. Hauge, M.D. Dennis M. Leahy, M.D. Harold G. Ravits, M.D. Jerry W. Stanke, M.D.

are pleased to announce the association of JANE BLOWERS MOORE, M.D. in the practice of Dermatology St. Paul - Downtown 101 E. 5th St., #2106 St. Paul, MN 55101 (651) 291-9166

Maplewood Office 1560 Beam Ave. Maplewood, MN 55109 (651) 770-0110

Midway Office 720 Central Medical Bldg. St. Paul, MN 55104 (651) 645-3628

Woodbury Office 7616 Currell Blvd., #115 Woodbury, MN 55125 (651) 578-2700

MetroDoctors

Burnsville Office Suite 372 305 E. Nicollet Blvd. Burnsville, MN 55332 (952) 435-2433

The Journal of the Hennepin and Ramsey Medical Societies

PRESIDENT’S REPORT VIRGINIA R. LUPO, M.D.

HMS-Officers

HMS-Board Members

Ben Baechler, Medical Student Michael Belzer, M.D. Carl E. Burkland, M.D. Herbert K. Cantrill, M.D. William Conroy, M.D. Dianne Fenyk, Alliance Co-President James P. LaRoy, M.D. Barbara C. LeTourneau, M.D. Edward C. McElfresh, M.D. Monica Mykelbust, M.D. Ronald D. Osborn, D.O. Joseph F. Rinowski, M.D. Marc F. Swiontkowski M.D. T. Michael Tedford, M.D. D. Clark Tungseth, M.D. Trish Vaurio, Alliance Co-President Joan M. Williams, M.D. HMS-Ex-Officio Board Members

E. Duane Engstrom, M.D., Senior Physicians Association Lee H. Beecher, M.D., MMA-Trustee Karen K. 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 Robert Finke, MMGMA Rep. HMS-Executive Staff

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

AT THE UNIVERSITY of Minnesota Medical

School faculty assembly meeting held on May 31, Dr. Scott Giebink laid out the simple message that the medical school is trying to communicate to legislators as well as the public about the additional legislative funding that is crucial to the survival of the school. Currently, less than 10 percent of the medical school’s operating budget comes from annual funds supplied by the state. Since the competitive health care market has greatly decreased the income the faculty earns from caring for patients to bridge the gap between federal grants, state support, and educational costs, the medical school is lobbying for $25 million in an ongoing annual contribution to sustain this vital source of new physicians as well as cutting edge research. Faculty members were urged to draw on their contacts in the various medical organizations that are active within our state (American Cancer Society, American Lung Association, American Heart Association, etc.) as well as in local community organizations to help secure endorsements for this funding. The faculty is laying the groundwork now for the next legislative session, scheduled to begin on Wednesday, January 3, 2001. Medical School Dean, Al Michael, M.D., has been urging the faculty to become active members of their component county medical societies if they are not already, so don’t be surprised if you see some faculty faces at commit-

tee meetings of the metro medical societies. An additional area in which the medical school is focusing internally is identifying a strategic plan to lay out a matrix of high priority programs which will provide the focus for future investment of energy as the school moves to regain its standing within the top 20 medical schools in the country. A faculty-wide retreat will be held in the fall of 2000 to allow for broad input into the final plan. A preliminary strategic planning retreat has already been held, with participation by key representative faculty. Dr. Jonathan Ravdin, Chair of the Department of Medicine, is coordinating the strategic planning effort. The appointment of Roger Becklund, M.D., to the Medical School Admissions Committee was also announced at the meeting. Dr. Becklund is the new representative to the committee nominated by the Hennepin Medical Society. Previously, that time-intensive volunteer position was held for ten years by Paul Bowlin, M.D. At the conclusion of this faculty meeting I had the distinct opportunity to present the Charles Bolles Bolles Rogers Award to Dean Al Michael, M.D., on behalf of the Hennepin Medical Society. The recipient of this award is selected annually by the chiefs of staff of the west metro hospitals. Dr. Michael is noted for his outstanding contributions to the medical school, not only as the Dean, but as a pediatric nephrologist and former chair of that department as well. Despite his embarrassment and apologies to the faculty for the venue of this award presentation, the faculty acknowledged his accomplishments and the award by a standing HMS President Virginia Lupo, M.D., presents the ovation. ✦ Charles Bolles Bolles Rogers Award to Alfred Michael, M.D., Dean, University of Minnesota Medical School.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

July/August 2000

Hennepin Medical Society

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

HMS NEWS

Community Internship Program Held in June SIX MEMBERS OF THE COMMUNITY par-

ticipated in the HMS Community Internship Program June 12-15. The interns experienced new life through labor and delivery and neonatology rotations; healing through surgical interventions, emergency care and technology; and

the value of the patient-physician relationship in most every encounter. Each of the community “interns” is given the opportunity to observe four different specialties for one-half day. A special thank you to the physicians who served as faculty! ✦

Collen Moriarty and Susan Ferron, M.D., Community-University Health Care Center.

Commissioner Penny Steele, and Kevin Ose, M.D., surgeon at Methodist Hospital.

HMS President Virginia Lupo, M.D. with interns Annie Nelson, director, Youth Coordinating Board; Frank Gilbertson, director, Provider Network BC/BSM; Hennepin CoCommisioner Penny Steele; Collen Moriarty, chief of staff to Mayor Sharon SaylesBelton. Not pictured: Greg Rye, vice chair, the Foundation HealthSystem Minnesota and Representative Satveer Chaudhary, District 52 A.

Richard Lussky, M.D., neonatologist at HCMC and Annie Nelson.

July/August 2000

Tim Henry, M.D., cardiologist at HCMC and Frank Gilbertson.

MetroDoctors

Thank you to the following physicians for participating in the Community Internship Program: Carol Arneson, M.D. Patrick Carolyn, M.D. Kenneth Casey, M.D. Gary Coon, M.D. Susan Ferron, M.D. Tim Henry, M.D. Cindy Howe, M.D. Gail Joyce, M.D. Peter Kapernick, M.D. Richard Lussky, M.D. Edward Maeder, M.D. Kevin Ose, M.D. Brian Patty, M.D. Robert Payne, M.D. David Schmeling, M.D. William Simonet, M.D. Joseph Van Camp, M.D.

The Journal of the Hennepin and Ramsey Medical Societies

Hoban Scholars Attend Educational Event “EPIDEMIOLOGY OF OTITIS MEDIA in

Hennepin Medical Society

Minnesota’s American Indian Children”; “Attitudes and Beliefs about Herbal Products”; and “How Technology Can Contain Costs and Improve Patient Satisfaction in a Medical Clinic” were the topics presented by three Hoban “Scholars” at the recent Thomas W. and Mary Kay Hoban Scholarship Educational Event. Doug Shaw, Chief Operating Officer, Minnesota Healthcare Network, opened the event with a presentation on “Thriving in a rapidly changing Health Care Environment.” His comments were dedicated to Thomas W. Hoban, the former CEO of the Hennepin Medical Society, his mentor and friend. ✦

Those present at the Hoban Scholarship Educational Event included: (front row): Kristine Rhodes, Hoban Scholar; Kim DeRosier, Hoban Scholar; Carole Vetter O’Hare, selection committee; (back row): Roger Becklund, M.D., selection committee; Paul Hamann, M.D., selection committee; Eric Nielsen, Hoban Scholar; H. Thomas Blum, M.D., chair, selection committee; and Doug Shaw, guest speaker.

Dr. Etzwiller Receives Shotwell DONNELL D. ETZWILLER, M.D. was awarded the prestigious Shotwell Award on behalf of the Allina Foundation and the Hennepin Medical Society. The award, a Granlund sculpture entitled “Sprites,” was presented by Judith Shank, M.D., vice-chair of the Allina Board of Directors and HMS member, at the Allina An-

nual meeting in May. In presenting this award, Dr. Shank cited Dr. Etzwiller’s exemplary and professional efforts in the improvement of diabetic care worldwide. He pioneered the transformation of treatment to a team approach involving all aspects of diabetic management, including patient education. ✦

Senior Physicians Association SIXTY-FIVE MEMBERS of the HMS Senior Physicians Association gathered at the Phillips Eye Institute on Tuesday, June 13. Hennepin County Judge, Isabel Gomez was the featured speaker with a compelling message about the unfairness in the laws of this state relating to violence against children versus adult incidences and her quest for improving the laws to protect the children. ✦

Correction In the May/June issue of MetroDoctors we erroneously transposed the education of the two “In Memoriams.” We apologize for the error. The corrected information is below. RICHARD T. CUSHING, M.D., graduated from the University of Rochester School of Medicine-Dentistry, NY, and completed his residency at Yale University.

Barbara Subak, M.D., president, HMS Senior Physicians Association with Judge Isabel Gomez and Elizabeth Craig, M.D.

MetroDoctors

Donnell D. Etzwiller, M.D., recipient of the 2000 Shotwell Award.

The Journal of the Hennepin and Ramsey Medical Societies

JOHN (JACK) R. GORDON, M.D. graduated from Queens University Faculty of Medicine, Kingston, Ontario, and completed his residency at the University of Minnesota. ✦

July/August 2000

HMS ALLIANCE NEWS

YOU HAVE PROBABLY HEARD that the

Hennepin Medical Society Alliance is the oldest Alliance in the country at 90. None of us knows how much the Alliance/Auxiliary has done to promote healthy living in the Twin Cities in those 90 years, but every effort we have made has made a positive difference in the lives of Minnesotans. When HMSA recently held its annual meeting, several 40-year members attended. Those people were new members when the Auxiliary had its 50th birthday, and they have maintained the organization with the highest standards of excellence for more than 40 years. Remarkably, we had a 67-year member in attendance — ninety-two year old Helen Rusten graced us with her presence. What a testament to the bonds of the medical family! By keeping traditions, the long-time members have given us a sense of history; by working tirelessly for better health in the community, they have been exemplary role models; by continuing to participate they have given those

who have followed a support system like that of a family. Their values and efforts, along with those Auxiliary/Alliance members who have gone before all of us, have given the rest of us a wonderful legacy of commitment to the community. My name may sound familiar to you because I am a returning Alliance officer; five years ago, I was installed as HMSA President. This time I am fortunate to be sharing the job with Trish Vaurio. I am proud to be representing the Alliance again as co-president because I believe in the members and in the organization with all my heart. The work we do in the Alliance makes a difference in so many lives everyday, that we will never know the true extent of our efforts. The Alliance is far from a static organization; we are proactively working to meet the changing needs of our community’s well being. I have been lucky to participate in some wonderful projects and programs in just the past five years. Five years ago, the concept of an HIV/ AIDS education folder did not exist. The

HMS and the HMS Alliance invite you to join in celebrating the

90th Anniversary of the Alliance Saturday, September 23 The 1st annual Stepping Stones Gala will feature dinner, dancing, and an auction to benefit the Annex Teen Clinic, TAMS, and West Suburban Teen Clinic.

Stepping Stones… promoting a foundation for healthy choices. 32

July/August 2000

MetroDoctors

Dianne Fenyk Co-President

Trish Vaurio Co-President

HMSA developed, found funding for and distributed more than 150,000 of them to Middle School and High School students, first in the West Metro — then all four corners of Minnesota and increasingly in classrooms around the country. In less than one week after order forms were sent to principals, we have had orders for more than 20,000 for the upcoming school year. Our anti-violence efforts are aimed toward younger students. In the past five years we have served more then 8,000 third graders at Body Works and each of them has signed a Pledge Against Violence. The past two years, the Mayor of Minneapolis has recognized our work by issuing a proclamation declaring Hennepin Medical Society Alliance Body Works Week. We now have Alliance members who were just finishing high school five years ago. We welcome with open arms and open minds the Medical Student and Resident Partners — their willingness to join hands with us can only make the Alliance stronger and the future of good health in our communities brighter. Just think of all the Alliance will have accomplished when they are 40-year members. Now we have another exciting program in our future: Stepping Stones — A Gala Promoting A Foundation for Healthy Choices. We are pleased, honored and excited to be collaborating with the Hennepin Medical Society on this project. Set for September 23, the gala will celebrate our 90th birthday and raise much needed funds for the Annex Teen Clinic, TAMS and West Suburban Teen Clinic. Make a commitment to your community…plan to attend the gala, work on a committee, buy a table, invite your friends, solicit an auction item or a sponsor and help start our next 90 years on a meaningful high note. ✦ Dianne Fenyk, Co-President The Journal of the Hennepin and Ramsey Medical Societies