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Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

Physician Co-editor Y. Ralph Chu, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reﬂect the ofﬁcial position of HMS or RMS. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: bauerfamily@earthlink.net.

CONTENTS VOLUME 8, NO. 4

Is IT Ready to Pay for Itself?

FEATURE

J U LY / A U G U S T 2 0 0 6

The Truth About Implementing Electronic Medical Records

Classiﬁed Ads

2006 Legislative Session Wrap-Up

COLLEAGUE INTERVIEW

Michael B. Ainslie, M.D.

MMA Champions Quality Health Care in Minnesota

Physician Values and Clinical Decision Making

Index to Advertisers

PHYSICIAN’S SOAP BOX

The New Pay-for-Performance Prescription for What Ails Medicine

An Overview of Female Urinary Incontinence

Lions Children’s Hearing Center at the University of Minnesota

Members in the News Medicaid Family Planning Services Expand July 1 RAMSEY MEDICAL SOCIETY

For advertising rates and space reservations, contact: Erica Nelson 2318 Eastwood Circle Monticello, MN 55362 phone: (952) 903-0505, ext. 3 fax: (763) 497-8810 e-mail: erica@pierreproductions.com.

25 26 27 28

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

President’s Message RMS In Action Board Meeting/Caucus/Senior Physicians Meeting RMSF Grants Awarded for Health Fairs/RMSF Receives Four Year Accreditation for CME/Blue Cross Selects RMS Proposal for Partnership for Healthy Air in Washington County HENNEPIN MEDICAL SOCIETY

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

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Chair’s Report HMS Caucus Gets Ready for MMA Annual Meeting/ Call for Delegates

HMS Awarded Three Additional Grants/ Quit and Win/Updated Web Site

Hoban Scholarship/Senior Physicians Assoc./In Memoriam

The Journal of the Hennepin and Ramsey Medical Societies

On the cover: Three physicians relate their experiences as they adapt to their Electronic Medical Records. Article begins on page 4.

July/August 2006

Is IT Ready to Pay for Itself? As information technology becomes a greater force in practices, physicians are wondering if the return on investment outweighs the initial costs and hassles.

IF YOU HAD TO SHELL OUT $20,000 to

$50,000 per physician for start-up costs and endure six months of operational hiccups in hopes of boosting your income 1 percent, would you buy an electronic medical record? That’s the question most health plans, corporations and others adopting pay-forperformance programs are asking, in hopes of encouraging physicians to use EMRs. Some pay-for-performance programs directly reward physicians for buying EMRs, while most ask physicians to provide information that’s much easier to capture and organize electronically. At several sessions held during February’s Annual Healthcare Information and Management Systems Society Conference & Exhibition, there was widespread recognition among industry professionals that 1 percent probably isn’t enough of a pay-for-performance bonus to convince physicians EMRs can pay for themselves. HIMSS is a Chicago-based industry group that produces the largest health care information technology conference in the country, luring more than 25,000 people and more than 860 health care technology companies touting their products at the San Diego Convention Center. But while many at HIMSS thought the current incentives probably aren’t enough, there was no consensus on what will get physicians to act. Physicians “need more money because that’s the only way they are going to be able to adopt systems and processes that are going to transform the way they can manage care,” said Francois de Brantes, program leader for health care initiatives at General Electric Co., BY TYLER CHIN AMNews staff

July/August 2006

a Fairﬁeld, Conn.-based conglomerate that is a key player in the Bridges to Excellence payfor-performance program run by a consortium of large corporations. Based on the experience of Bridges to Excellence, it will take bonuses amounting to 5 percent to 10 percent of a physician’s annual income to promote wide adoption of EMRs, de Brantes said. “We noticed that physicians at individual practices need to be at the higher scale. Physicians that participate in large groups can be at that lower scale.”

...there was widespread recognition among industry professionals that 1 percent probably isn’t enough of a pay-for-performance bonus to convince physicians EMRs can pay for themselves. Others, however, have proposed a much lower incentive bar. In 2005, Congress considered but failed to pass several bills authorizing the Centers for Medicare & Medicaid Services to offer pay-for-performance bonuses of 1 percent to 2 percent to physicians and hospitals, said Christine Bechtel, director of government affairs at the American Health Quality Assn., (AHQA) during a session at the symposium. A “meaningful” incentive for Louis Civitarese, D.O., a family physician at 35doctor Preferred Primary Care Physicians in MetroDoctors

Pittsburgh, would be approximately $25,000 per physician. That is about what his group paid to implement its EMR two years ago. Dr. Civitarese, however, recognizes it would be cost prohibitive for health plans or employers to cover the start-up costs of every group in the country, especially since smaller practices would see substantially higher perphysician costs. He’d settle for incentives that would cover the group’s EMR maintenance, which is about $11,000 annually per physician. “I don’t think pay-for-performance has to pay for the whole thing. But it has to pay for part of it.” Several groups in the Pittsburgh region have visited his group to check out its EMR. Without fail, their first question is whether Preferred Primary Care has recouped its investment after two years. His answer: Not yet. “It takes the wind out of their sails,” Dr. Civitarese said. “I think if physicians saw a realistic plan with regards to pay-for-performance to even allow them to recoup their investment and ongoing maintenance costs, then I think they would be much more willing to jump in.” It’s been four years with an EMR for Prairie Cardiovascular Consultants Ltd., of Springfield, Ill., and the 44-doctor cardiology group still hasn’t recouped its money. “We see pay-for-performance as an opportunity to at least get some return on investment for the cost, efforts and sacrifices that we made to try to improve quality,” said Frank L. Mikell, M.D., practice president. To prepare to participate in pay-forperformance initiatives, Dr. Mikell’s group is implementing an internal program to reward doctors who achieve certain measures on quality, adherence to information technology and patient satisfaction.

The Journal of the Hennepin and Ramsey Medical Societies

The group’s partners have agreed to set aside 5 percent to 10 percent of their income into a pool, to be awarded physicians who meet the performance criteria. The group independently concluded a few years ago that the incentive had to be this high “because otherwise people wouldn’t be motivated to do it,” he said. Whatever the size of the pay-for-performance bonus, the bottom line is that physicians must first know the concrete financial benefits as well as the costs for improving performance, AHQA’s Bechtel said during her session. “It’s got to pass the smell test for each practice. Additional Information: Exploring the Fine Print

If you’ve ever bought a computer system, you know health care technology companies don’t invite contract concessions. However, you’re not entirely at their mercy. Diana J.P. McKenzie, an attorney at Neal, Gerber & Eisenberg LLP, Chicago, offered to AMNews several contract negotiation tips while speak-

ing at February’s Healthcare Information and Management Systems Society convention in San Diego. • Ask for a “tiered one” performance effort rather than the routinely offered “commercially reasonable efforts.” Getting that language means better service after the sale. • Have a clear description of the functionality of the product. Insist the vendor describe, in the contract, exactly what you’re buying and how it’s supposed to work. • Watch for “lethal” words — such as “solely” and “goal” — used in relation to the vendor’s maintenance and implementation obligations. These words provide an out for the vendor to refuse to handle your service. For example, “solely” means that if a problem is determined to be 99 percent the vendor’s fault and 1 percent the customer’s, the vendor isn’t legally required to do anything. • Check the penalty for late payments. A lot of older contracts set the rate at 12

•

percent to 18 percent, but “if you just ask, you almost always get 6 percent to 9 percent.” Ask for an on-site meeting by a high-level executive from the vendor as the last step in a dispute resolution. “Key executives will always, almost inevitably, make sure that whatever the problem, it will be ﬁxed before they come on site,” because they don’t like to visit unhappy customers. Delete or signiﬁcantly curtail the scope of “force majeure” clauses. Typically, they referred to “acts of God,” but vendors have broadened the clauses to include acts of terrorism and an inability to obtain supplies. Hire an attorney.

This article is reprinted with permission from American Medical News. It originally ran March 13, 2006.

Go Paperless Improve Ofﬁce Efﬁciency, Spend More Time With Your Patients and Go Home On Time

Save 15% on NextGen® EMR and NextGen® EPM systems licenses MMA members can save 15 percent on individual physician licenses on the NextGen enterprise practice management and NextGen electronic medical record software systems. NextGen EMR and NextGen EPM systems must be purchased between April 1 and September 30 to receive the discount. For more information, contact Brian Salzman, MMIC Technology Solutions sales manager, at 763-201-0304 or brian.salzman@mmihc.com, or Gary Hinz at 847-550-6163 or ghinz@nextgen.com This offer is brought to you by the Minnesota Medical Association, MMIC Technology Solutions and NextGen Healthcare Information Systems Inc. MMIC Technology Solutions is a Minnesota-based information technology consulting ﬁrm for physicians, clinics and hospitals.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

July/August 2006

FEATURE STORY

The truth About Implementing

Electronic Medical Records

The MetroDoctors Editorial Board was interested in getting some ﬁrst-person feedback from colleagues who have gone through implementation of electronic medical records in their practices. What follows are three accounts that relate the physicians’ experiences as they adapt to their EMR. Our articles come from Eugene Ollila, M.D. who practices internal medicine with the Allina Medical Group on the Nicollet Mall, Thomas Siefferman, M.D. who practices at Pediatric and Young Adult Medicine, P.A. in downtown St. Paul and Richard Schmidt, M.D. an orthopedic surgeon at Veterans Affairs Medical Center. If you have a perspective that you would like to share with your colleagues, the editors would be willing to publish other accounts they judge to be of additional value to the reader. You’re invited to send your submissions to MetroDoctors care of the Editorial Board. The Electronic Medical Record—YOU Can Do It!

Eugene Ollila, M.D. I have been asked to write a few words about my experience with our ofﬁce paperless system of the EMR, called Excellian. I work in the Allina Medical Clinic on the Nicollet Mall in downtown Minneapolis. When we began this journey in August/September 2005, I felt it was the hardest thing I had done in the past 25 years as a physician — comparable to learning a new foreign language while working in that country. The system was logical but not very intuitive, and used different terminology than any of us had ever used before. And, one got very upset by the “ding” that went off every time there was an error. Our ofﬁce sounded like holiday bells were being played. Fortunately, we were given half time schedules for a time, and very good and helpful staff to assist us. (I understand the Hospitalists did not have reduced schedules, nor, I suspect, did any private physicians buying into the program). In addition, I was a pretty good typist (an 80 wpm back in my high school days), so I was not worried about this phase. However, this conceit probably put me behind in learning all the Smartphrase/Smarttext information in the Excellian database. I have a sense that patients were silently, and sometimes not so silently, having a good laugh at our incompetence. Six months later, there really is much that I have learned. Computer entry is going quite well, and I am probably about the same “speed” that I was before. Making refer4

July/August 2006

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

rals to others and giving a legible prescription to patients is quite simple (I have gotten good feedback on the latter, much to my chagrin and amusement), and I am still awed by the information available to me, at the time I need it in front of the patient. For example, click on the CDC site, and I not only can go over vaccination information with the patient, but I give them a take-home copy they can refer back to. I can bring up a consultant’s report and review it with the patient, making certain all have the same story (and sometimes a different one than the patient heard, but all for the good). I can look up the actual operative note to see if the appendix was actually removed, or what medication was given when a reaction occurred (this is also available from “elsewhere” if the information was scanned into the system). Prior to our going “live,” one experience made me want the EMR. A patient of my partner (out of town) had a problem that I wanted to treat with steroids. However, she was also being taken care of by a specialist at Mayo, and I was concerned about the interaction with her current Rx. I called Rochester, was referred to the physician who looked up the information on their computer, and stated that at his visit with her two weeks earlier, he had also considered using steroids. In just a few minutes, in front of the patient, my diagnosis was solidified, and everyone was a winner. I was in awe. I can now plan a treatment course much better and faster with the patient observing. I can place an order for a TSH six months in the future prior to my next visit directly in the computer, and the patient can go to any Allina lab that is live, and have the blood drawn. In our practice, we have patients from nearly 50 zip codes, and while they may not mind coming downtown to see us, they love getting labs drawn much closer to home or work. I also don’t mind not having a large pile of paper charts toppling over onto the floor, or having coffee stained records. How times have changed from when I used to think dial-up was fast. Now if the information is not in front of me lickety-split, I call the Help Desk number and complain that my screen was not responding in the five nanoseconds that it should have. We also faced the ultimate test, when the entire system went “down” for what was to be a simple housekeeping problem. You and I would probably have lost the critical patient in our world, but as I saw a patient the day we went back to scratching notes on a flat cellulose product, her daughter (who worked on computers for a large corporation) said, in effect, “we see this”! So much for malpractice. In summary, we will never go back to a paper record. When the system is working well, it is like, well, a cool Chardonnay with some good cheese in a swing. If you are worried that you can’t do it, remember how it felt when you started medical school —YOU can do it. Remember, your patients can now read what you said, and that is worth a lot. Certainly, there are some bugs, even some eight-legged arachnids, but those can be dealt with later on. I used some blue letter words in the beginning, but I am getting quite infatuated with my accomplice at this time. (Continued on page 6)

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

July/August 2006

Electronic Medical Records (Continued from page 5)

An EMR Enters a Child’s World

Thomas Siefferman, M.D. We are approaching our second year of paperless care and the Electronic Medical Record continues to allow innovations and improvements. Over the last 13 years our pediatric group has progressed from hand written notes to dictated notes, from voice recognition software and finally to the Electronic Medical Record. This progression was forced by the needs of partners to cover for complex patients, and the need to have a complete and legible record for patient care and to satisfy quality improvement requirements from insurers and other reviewers. This progression has been met with the usual and expected resistance from all of us. The EMR is far from perfect, but a dramatic improvement. Pediatric and Young Adult Medicine, P.A., is a ten-partner group practice with four offices in the East Metro area. We had determined that patient care was not efficient or accommodating of patients shifting between offices. A select group went to see a pediatric group in Tennessee that had produced their own templates to work with the NextGen EMR. After agreeing on this platform (which matched our MMIC provided Enterprise Management Program or EPM), financing was arranged with the help of Anchor Bank, and we delved into the world of Windows Servers, and wireless notebooks (and now VOIP phones). Two physicians started working on a 6

July/August 2006

few patients in the afternoon to help the doctors and staff work out the bugs and best practices for the EMR. The remaining physicians continued until all of us were utilizing the EMR in a limited fashion. Techniques learned were informally shared with each other and in the group meetings. The staff quickly enjoyed the efficiencies of the EMR and the ability to quickly cover for each other. Medical records and scheduling also found it easier to locate records and if follow-up visits were recommended. After a shakedown of four months, the office went paper-free. Most physicians review records directly from the EMR, but the reviewers audit master notes generated from the data points (or macros) entered by both doctors and staff. For security purposes, only one patient’s record can be open at a time. There is a “Home” page that lists all encounters, diagnosis, allergies and active medications for each patient. There is a natural flow through the visit from chief complaint to history and physical, procedures and orders, to laboratory findings, and finally plans. The physician can provide coding guidance. The doctors select a diagnosis from a list of the top 50 or they can type in for the coding staff to determine, or do a search from a built in ICD-9 code book. The EMR is quite flexible and the physicians usually complete the record of the visit in the patient’s room, but during hectic times the essentials are completed and the rest of the record is filled out at the end of the day. Instant access to the patient’s chart has greatly enhanced care and safety. Having a ready list of medications with instant checks for allergic reactions and interactions also improved patient safety. For handwriting-impaired doctors, the ability to fax or print prescriptions has reduced callbacks from pharmacists. The EMR provides a consistency to

MetroDoctors

our medical records that could never be achieved without it. Duplications of tests and procedures are prevented and results easily available. Outside laboratories can fax directly to the physician’s laptop and data easily incorporated into the EMR. Patients and parents are impressed with the EMR. The doctor is not constantly searching through old charts for information, and the ability to print up immunizations, physical forms, and patient information sheets amazes them to no end. Physicians can quickly access the Internet for information such as the CDC travel site. This generation of patients has grown up with the Internet and appreciates the effort put into their EMR record. Schools appreciate the Asthma Action Plans from the EMR, and consulting doctors appreciate the concise and complete medical record and growth charts we can generate. Our business ofﬁce has also beneﬁted from the combination of EMR and EPM for flexibility of coding, submittal of electronic billings, and monitoring accounts receivables. The ability to quickly tie coding questions to the EMR chart allows the doctors to clarify and quickly complete records for quick submissions. With a systematic approach to the record, and requirements for certain sections to be reviewed, the improvement in our ability to justify coding has improved our billing dramatically. The combination of stopping dictations and improved billing has nearly paid for the whole network of servers, desktop computers and laptops, as well as the fees for the EMR itself. Not everyone likes every aspect of the EMR, but all of us appreciate the improvements in readability and safety of the medical record, and the improved reimbursements are certainly an added bonus.

The Journal of the Hennepin and Ramsey Medical Societies

EMR at the VA Medical Center

Richard Schmidt, M.D. I suspect that most of us agree that if we continue to practice medicine that we will be tied to an electronic medical record both through the hospital and our individual clinics. Most large clinic and hospital facilities are already using electronic records and their use and application will continue to grow. Even solo physician practices will eventually be required to use an electronic medical record. We can only hope that these records will have compatibility from one to another as patients move from one physician to another. The VA Medical Center system has had an electronic medical record for many years. This has been named the Computerized Patient Record System (CPRS). While it was not initially utilized by all VA hospital facilities, it was anticipated that all would do so in the future. Eventually each individual facility was required to adopt the CPRS as developed. In fact, a start date was assigned to each facility and service. There was little time to prepare and when the date arrived there was no going back. Each system, clinic and institution must prepare in their own way for adaptation to electronic medical records. From my experience at the Minneapolis VA Medical Center lack of coordinated computing power created a number of issues at the start. It was slow and tedious to use the system in order to input and retrieve information effectively. As these problems were ﬁxed, efﬁciency began to improve. The preparedness of the Information Technology Staff, at start up,

MetroDoctors

is essential in order for proper function of the system. An electronic medical record, by itself, does not create efficiency. If anything, it creates inefficiency. The entry of information into a system creates a significant delay over the paper record in which nursing personnel and clerks were an integral part of the inputting process. Entry of information is often placed on the shoulders of the physician. This is highly inefficient in terms of taking the most expensive personnel and having them function in the role of a clerk. The inefficiency of logging in and out and data entry has created approximately a 25 percent decrease in the number of patients seen in clinic. Over time, efficiency does improve as one becomes more familiar with the system. With familiarity one is able to create templates and “order sets” which speed process of both information and orders. In my opinion this works up to a point, but one still needs help from supplemental personnel in order to diminish the input time of physicians. The medical staff needs to spend their time evaluating and treating patients. Despite the noticeable inefficiencies, an electronic medical record is unsurpassed in the retrieval of information. Anyone using an EMR would never elect to go back to a paper record. A paper record must be retrieved, delivered to the physician, read and sorted to find information, which can then be abstracted and copied, as necessary. The electronic medical record is immediately available. It can be sorted electronically for the information that is necessary and it can be saved or printed in multiple formats as is needed under circumstance. This is a time saving function. In addition to the efficiency of retrieving and sorting medical records, the record can be used for quality improve-

The Journal of the Hennepin and Ramsey Medical Societies

ment. Functions and tools can be built into the system that helps the physician choose appropriate medications such as antibiotics, graphically follow a patient’s progress, and be alerted by the pharmacy to potential medication conflicts. Physicians can be alerted to information in order to avoid oversights such as laboratory results or deviation from a usual standard. “Order sets” can be developed so that important care items are not overlooked in order to deliver optimum care. In summary, an abrupt change to an electronic medical record can be a shock to one’s system. However, with appropriate planning and information technology support, an electronic medical record system can be learned by almost anyone — even those who are computer illiterate. The challenge is to develop systems that improve efficiency rather than diminish efficiency and are helpful in improving patient care and eliminating errors.

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July/August 2006

2006 Legislative Session Wrap-up

AS THE 2006 LEGISLATIVE session draws

to a close, it may go on to be remembered as one that featured little change in health care policy. Legislators came to St. Paul in March keenly aware that many voters were unhappy with the government shutdown in 2005, and there has subsequently been a concentrated focus on keeping the agenda in 2006 concise and realistic. The legislature was successful in clearing authorization to begin construction on a hospital in Maple Grove. Fairview Health Services and North Memorial Health Care will team up to build the 300 bed facility, which will provide much needed health care services to the rapidly developing northwestern quadrant of the Twin Cities. Construction is expected to be completed in 2009. The Minnesota Supreme Court ruled in favor of upholding the state’s 75 cents-a-pack fee on cigarettes, passed at the end of the 2005 legislative session. Minnesota’s Tobacco Fee was struck down in December by Judge Michael Fetch, who ruled that the state’s fee on cigarettes violated a settlement agreement that was reached between the state and tobacco companies. The judge ruled that the fee is not allowed as a result of the 1998 settlement the state reached with tobacco companies. As part of the settlement, tobacco companies were required to pay the state for health care expense and in return were exempted from paying additional health costs. The Court concluded that the 75 centsa-pack fee does not violate the terms of the state’s settlement. Had the Court decided not to overrule the lower court’s decision, a $400 million hole in the state’s budget would have

B Y K AT H L E E N M I C H E L E T T I

July/August 2006

resulted due to rebate fees the state would have been forced to refund. Since the second year of the biennium is typically not a budget year, the Legislature can make adjustments as necessary to address any supplemental spending issues. The Senate rolled all of their finance provisions into one supplemental spending bill. The threat of abortion amendments on the Senate Floor precipitated the Finance Committee pulling all of the Health and Human Services provisions out of the supplemental bill before it went to the Floor for final passage. The House originally planned to pass separate supplemental spending bills from each division, but after those bills got bogged down with amendments, they stripped out all of the finance provisions and rolled them into one bill as well. As a result, multiple policy provisions were left behind this year. Language from Rep. Fran Bradley’s (R29B) health omnibus bill was included in the Supplemental Budget bill, though the measure had been scaled back considerably throughout committee deliberations. The remaining language complies with the recently passed federal Deficit Reduction Act of 2005 with sections addressing MA asset availability and transfers, the state long-term care partnership program and asset recovery, state health care program citizenship verification, and payments for services provided in hospital emergency rooms. Legislators opted against spending the $122 million Health Care Access Fund (HCAF) surplus due largely to time constraints and significant philosophical differences that were simply not going to be resolved given the legislature’s commitment to an efficient and productive session. Throughout the session, the House and Senate health committees each crafted, then MetroDoctors

incrementally dismantled, health omnibus bills that could hardly be considered companion measures. The bills more so reﬂected starkly contrasted philosophies between the bodies about how to address the rising cost of health care in Minnesota. While the vast majority of provisions included in the omnibus bills were stripped during committee deliberations, the contents of both measures may resurface in future sessions. The House version originally allocated $87 million of the HCAF surplus in FY 2007 to subsidize the Minnesota Comprehensive Health Association (MCHA), which offers policies of individual health insurance to Minnesota residents who have been turned down for health insurance by the private market, due to pre-existing medical conditions. An initiative strongly endorsed by the Chamber of Commerce, the funds directed to MCHA were meant to provide ﬁnancial relief to small businesses and employers that must rely on the plan to provide coverage to their employees. The House bill did not fund any of the governor’s mental health system transformation proposals. During debate before the Health Policy and Finance Committee, the House measure drew the ire of Democrats who continued their push to use the surplus for restoring cuts made to state-run health plans in 2003 and 2005. Amendments introduced by Rep. Barbara Goodwin (DFL-50A) and Rep. Mary Ellen Otremba (DFL-11B) seeking to divert funds from MCHA to Minnesota health plans were defeated in party line votes. Rep. Neva Walker (DFL-61B) also introduced an amendment prohibiting the transfer of monies from the Health Care Access Fund to items not related to MinnesotaCare, which sparked much debate on the original intent of the funds generated

The Journal of the Hennepin and Ramsey Medical Societies

by the provider tax, and legislators’ failure to adhere to those standards. Walker’s amendment was ultimately defeated. Health Policy and Finance Committee Chairman Fran Bradley (R-29B) also worked diligently to advance legislation that includes a contingent reduction of the provider tax rate by 1/10 percent increments in the event of a projected surplus in the Health Care Access Fund in odd years. Though the bill did not pass, the idea itself received a great deal of visibility and momentum that could prove beneficial in future sessions. The House omnibus bill also included a provision authorizing pharmacists to refuse to fill prescriptions under certain conditions. Pharmacists’ employers would be required to “establish protocols that ensure that the patient has timely access to the prescribed drug or device.” The Senate Health and Family Security Committee passed similar legislation; however, Sen. Steve Kelley (DFL-44) authored an amendment requiring the pharmacy whose employee refuses to fill a prescription to ensure that patient’s prescription is filled. A section prohibiting providers from allowing a patient to die from starvation or dehydration unless that patient has indicated in writing that he or she does not wish to live on life support was deleted during committee deliberations. Legislators floated a number of proposals crafted during a series of hearings held by the Health Care Cost Containment Division including a provision allowing for-profit HMOs to provide health coverage in Minnesota; authorizing HMOs to impose deductibles of up to $5,000 per person and $10,000 per family; a provision increasing maximum caps on outof-pocket expense, cost-share payments, and a provision allowing health plans to include $3,000,000 lifetime maximum benefits clauses in its contracts. Chaired by Rep. Jim Abeler (R-48B), the Health Care Cost Containment Division’s primary objective is to expand access to, and alleviate cost of, quality health care in Minnesota. Throughout the hearings, Abeler stated that his primary goal was to create a dialogue regarding the rising costs of health care, and at a minimum, prompt legislators to generate tangible proposals to quell this trend. The majority of his proposals focused on more price disclosure, authorizing small groups to MetroDoctors

form insurance pools, revamping the Public Employee Insurance Plan (PEIP) to make the plan more stable and enticing to counties or other public entities looking for coverage, and resurrecting the Minnesota Employee Insurance Program (MEIP). Representative Abeler and Senator Kiscaden were ultimately successful in passing legislation containing a number of policy provisions seeking to contain the rising cost of health care. The ﬁnal bill recommends that various state departments conduct a number of studies, directs the Commissioner of Health to encourage and assist providers to adopt and use electronic billing for state programs and sets parameters for the types of policies service cooperatives currently offer to school districts and other local governments. Staying true to its initial goals, the Senate proposed using the Health Care Access Fund surplus to restore cuts made to state-run health plans in 2003 and 2005. According to the Health and Human Services Budget Division, the Senate bill contained appropriations for the next biennium to fund the elimination of the add-back of depreciation for farm self-em-

ployed income for purposes of MinnesotaCare, to eliminate the MinnesotaCare limited beneﬁt set, to eliminate MinnesotaCare premiums for military members and their families, to increase from $10,000 to $20,000 the MinnesotaCare inpatient hospitalization cap, to eliminate dental co-pays for adults without children and parents at under 175 percent of the federal poverty level, to permit MinnesotaCare for undocumented immigrant children, to increase the provider rate through MinnesotaCare by 2.049 percent and to eliminate insurance barriers for children above 150 percent of the federal poverty level. The “NASPER bill,” which establishes a reporting system that would require dispensers of controlled substances to electronically report speciﬁed information to the Board of Pharmacy, was also included. Originally introduced by Sen. Linda Berglin (DFL-61), the legislation was crafted in conjunction with the National All Schedules Prescription Electronic Reporting Act (NASPER), which is a bill proposed by the American Society of Interventional Pain Physicians to “provide and (Continued on page 10)

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July/August 2006

Legislative Wrap-up (Continued from page 9)

improve patient access with quality care, and protect patients and physicians from deleterious effects of controlled substance misuse, abuse and trafficking.” The NASPER bill was never heard in the House, which led to its demise in 2006. The Senate also matched the Governor’s request for funding for the Mental Health System transformation, restored some funding cuts made to the Minnesota Food Assistance Program; restored cuts to child care subsidies made in previous years; funded a prescription drug discount program and uses a portion of the surplus to allow small businesses to enroll in MinnesotaCare. There were a number of legislative initiatives that did not receive the attention they merited, namely legislation addressing reimbursement for interpreter services. Medical interpreters are mandated by federal law, and the requirement is also backed up in state law. However, health care plans often do not cover the cost of a medical interpreter, if needed. This shifts the burden of cost to hospitals, clinics and providers, which often lose money when treating patients who cannot speak English. Sen. Linda Higgins (DFL-58) and Rep. Abeler introduced legislation in their respective chambers requiring health plans to cover the cost of interpreter services, and increasing the Minnesota health plans’ reimbursement rates to more accurately reflect the cost of an interpreter. Their bills also required the establishment of qualification standards for providing interpreter services. In 2005, the Department of Commerce began holding informal meetings on the issue, seeking to answer the question of who ultimately is responsible for paying for interpreter services. The Chamber of Commerce and a number of health plans are opposed to this proposal, and maintain that paying for interpreter services should be viewed as a cost of doing business. Opponents of the legislation have also referred to this proposal as an unfunded mandate. On a related subject, the U.S. Senate recently debated a bill prohibiting states from requiring health plans to cover certain services. Introduced by Sen. Mike Enzi (RWyo.), the bill would supersede at least 25 existing mandates in Minnesota including 10

July/August 2006

requiring health plans to cover blood tests to screen for prostate cancer, mammograms and supplies to treat diabetes. Supporters of the bill including Minnesota Sen. Norm Coleman and the National Association of Realtors claim it will make health insurance more affordable for working families. The American Cancer Society, 41 Attorneys General including Minnesota Attorney General Mike Hatch, Sen. Mark Dayton, AARP and the American Medical Association oppose the measure. The bill is currently stalled as Senate Democrats blocked a motion that would have limited debate by a vote of 55-43. Senate leaders needed 60 votes to limit debate. The U.S. House of Representatives has already passed companion legislation. Legislation to authorize a statewide smoking ban in all restaurants also fell victim to a short session and tight agenda. However, the proposal is bound to resurface in 2007 as supporters of the ban continue to accumulate and develop an increased presence at the State Capitol. The American Heart Association, American Cancer Society, American Lung Association, Minnesota Medical Association, HealthPartners and Blue Cross Blue Shield are all on record strongly supporting a statewide ban. Another bill that prompted immediate action in the provider community dealt with Certificate of Need (CON) reporting. Introduced by Sen. Kiscaden, SF 1640 originally banned self-referrals, and established a CON reporting procedure for expenses exceeding $1 million. After further consideration, Kiscaden amended the bill to require providers to put out a public notice on purchases exceeding $5 million, but no longer requires the Commissioner’s approval over a project. The rationale behind the Certificates of Need dealt with the perception that CONs can streamline the purchasing process, and subsequently accelerate the acquisition of resources. Realistically, the process has been known to have the opposite effect. SF 1640 never reached the House or Senate floor for a final vote. The House and Senate also approved legislation this year restricting radiation therapy facility construction by moving the expiration of a sunset provision from 2008 to 2013. The controversial bill is part of a campaign seeking to permanently require radiation therapy faciliMetroDoctors

ties to be constructed only by an entity owned, operated, or controlled by a licensed hospital. One bill Minnesotans may hear more about in future sessions requires private employers with more than 10,000 employees in Minnesota to pay to the state for deposit in the Health Care Access Fund account the difference between 8 percent of the wages paid to Minnesota employees and what the employer pays for medical costs of its employees. If the employer pays more than 8 percent, there is no payment obligation. Known as the “Fair Share” bill, similar legislation passed in Maryland, and several other states are working to advance comparable proposals. The full Senate is set to vote on the bill, though its companion legislation in the House, introduced by Rep. Joe Mullery (DFL-58A), was defeated in the Health Policy and Finance Committee. With the 2006 Session adjourned, it is imperative that physicians and medical professionals alike take advantage of a key opportunity to get involved at the grassroots level. All 201 seats in the state legislature are up for grabs, which means there will be plenty of chances to volunteer on campaigns. Legislators and candidates alike are going to need help with fundraisers, literature drops, posting lawn signs and even door knocking. If there is a legislator or candidate you would like to support, we would highly recommend that you contact their campaign and see where you can help. Lockridge Grindal Nauen now offers grassroots services, and we would encourage you to contact us at msschafer@locklaw.com to learn more. As you know, legislators debate and vote on complex health related issues regularly, and could beneﬁt greatly from hearing a physician’s or provider’s perspective. It is important that you take steps to ensure that you are the professional your elected ofﬁcials listen to, and volunteering on a campaign on a Saturday afternoon has the potential to pay dividends in the future. (For additional information on bills that HMS and RMS worked on, see page 26.)

Kathleen Micheletti is the manager of State Government Relations at Lockridge Grindal Nauen, P.L.L.P, a Minneapolis law ﬁrm providing comprehensive legal and government relations services to health care providers and organizations. The Journal of the Hennepin and Ramsey Medical Societies

COLLEAGUE INTERVIEW

Michael B. Ainslie, M.D.

Michael B. Ainslie, M.D., is a pediatric endocrinologist at Park Nicollet Medical Center and chair, Minnesota Medical Association, Board of Trustees. Dr. Ainslie received his medical degree at the University of Illinois Abraham Lincoln School of Medicine. He completed his internship and residency at Rush Presbyterian-St. Luke’s Hospital in Chicago, and continued his residency and fellowship training in pediatric endocrinology and metabolism at Michigan State University. He is board certiﬁed in pediatrics and pediatric endocrinology. The questions submitted to Dr. Ainslie were solicited from members of the HMS and RMS Executive Committees.

Photo by Scott Walker

How is presiding over the MMA Board of Trustees like coaching a football team?

Q A

What role do you see the MMA playing in statewide and local public health issues? The MMA has a pivotal role in statewide and local public health issues, especially regarding the health of all Minnesotans. It can serve as a sounding board for new public health measures. It can also serve as a central clearinghouse for issues related to mass public health issues such as the ﬂu epidemic.

How did your work with Hennepin Medical Society prepare you for your present Minnesota Medical Association role? I have gone through the Hennepin Medical Society Board of Directors in several roles. And this allowed me to understand the medical association better and to also develop the skills I need as board chair.

Why would anyone want to be chair of the MMA Board of Trustees? All of us need to be involved at some level in the county and state medical associations. It has been my privilege to serve both HMS and MMA. Health Care needs reform — my major goal during my tenure is to ensure that this moves forward. It is vital that the physicians coming after us work in a much better environment than we have now. I know what needs to be done; the devil will be in the details.

Some have likened the board chair’s role as a coach, or as a the role of herding cats. The most difﬁcult role is to allow individuals to have their say and feel they’ve been heard, but then come to some decision in a timely manner.

Outline your vision of the steps needed to reform the Minnesota insurance and health plan market to allow patients, rather than employers or government, to shop for insurance products and health care services. This question is certainly an important one for all of Minnesota medicine. I could certainly spend all my allowed space on discussions of what insurance and health plan market reforms need to be done. In response, I would refer my colleagues to my editorials in Minnesota Medicine regarding these particular issues. In short, I will be a champion for the free-market solution to these problems.

What should Minnesota health plans do now, without legislation, to help patients have access to insurance allowable payments before services are provided? This information should be posted on a Web site for each insurance plan so that patients can ﬁnd what various providers are paid, how much will be covered, and what will be the patient’s expectations. If we go to a new system where the patients will have the choice, then they will know those prices up front. (Continued on page 12)

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The Journal of the Hennepin and Ramsey Medical Societies

July/August 2006

Colleague Interview (Continued from page 11)

What can the Minnesota Medical Association do to rectify the current bed shortages for psychiatric patients? The best way for the MMA to rectify the shortages in any specialty is to ensure that the occupants of all hospital beds receive the best care possible. We need to understand that there may be needs at times for ﬂexibility in certain areas of assigned hospital beds. I hope, in the future, that hospitals will become more ﬂexible in their bed assignment.

What can the MMA do to improve public access to its members’ professional fees and scope of practice? I hope with the new Web site design at the MMA that accesses to member’s fees and scope of practice will be available for anyone who cares to ﬁnd out that information.

Some physicians feel that the Minnesota Medical Association devotes more resources to being an advocate for public health programs than being an advocate for practicing physicians. How would you respond to this constructive criticism if the topic came up in a conversation? I feel the MMA is an advocate for practicing physicians. While there are many varying needs of all of our physicians in the state of Minnesota, many of the issues are public health; the issues are of broad scope. I would hope that most Minnesota physicians understand that advocating for public health programs is also advocating for practicing physicians.

State medical associations across the nation have been advocating and promoting legislation to resolve and remedy the ever-present adversarial medical malpractice environment. What proactive initiatives and how many resources has the Minnesota Medical Association devoted to address this issue in our state? The MMA has lobbied hard to have tort reform take place in Minnesota. One of the problems we face is that we are not in crisis yet and the Legislature does not want to help us in that respect. Also, the trial lawyers have been very effective in displacing the argument onto the insurance companies. Until we get a change in the Legislature, I don’t feel that this will be a viable issue.

The Minnesota Medical Association works closely with the MMIC on various issues and some of the ofﬁcers of the MMIC hold elected positions within MMA. Could you comment on this issue and explain what role the Chair of the Board has to maintain transparency in all MMAMMIC relationships and transactions?

members sit on the MMIC board. I feel the transparency between these organizations is good. We have several meetings with the MMIC staff that outlines various areas of concern and where malpractice reform is going.

Physicians around the country have experienced economic problems with for-profit insurers. Current law does not allow for-profit health insurers to offer products in Minnesota. What position do you feel the medical association should play in the current legislative initiatives to allow for-profit insurers to operate in Minnesota? At present, the current MMA policy is to not allow for-profit health insurers in the state of Minnesota. Through our health care reform initiative, we will see what the recommendations are regarding this issue. There are certainly pros and cons to having for-profit insurers in a wide-range of insurance options for all Minnesotans.

The current issue involving the pathologists and primary care physicians may signal a trend in the economics of health care that will increasingly pit specialty against specialty. How will the MMA Board of Trustees respond to these complex economic issues dividing the House of Medicine? The MMA will respond to these complex problems by hopefully serving as a clearinghouse so that dialogue between these groups can occur. Where there is an overlap means there will be issues. I hope an amicable relationship can ensue and wise choices made in the end. We must all hang together or surely we will hang separately.

With legislative pressures increasing in the areas of scope of practice, pay-for-performance, malpractice reform, regulation of medical practice, and diversion of provider tax revenue, will the MMA Board of Trustees devote additional resources to government relations/lobbying? A substantial portion of the MMA budget is devoted to the legislative issues that come before us. I hope that with health care reform, we will come to the point where the Legislature will come to us for ideas, rather than the other way around. Thank you for these provocative questions; they were certainly most interesting to answer. Changes are coming and we must prepare ourselves for the future. I’d be happy to discuss these issues with any member who wants further information.

The MMA and MMIC have very close relations. We receive annual reports regarding MMIC activity and, as you know, many of our board 12

July/August 2006

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

MMA Champions Quality Health Care in Minnesota

MMA LEADERSHIP BELIEVES physicians

should neither miss nor get hit by the quality improvement bus. Instead, they should drive it. In today’s health care market, third party payers, government agencies, and employers are all measuring and reporting the quality, safety and efficiency of the care physicians provide to patients. And, more and more, these payers plan to reward, and possibly punish, physicians based on their performances. In Minnesota, quality initiatives range from implementation of systems-wide electronic medical records, encouraging patient safety reporting, collecting and reporting statewide quality data, and receiving financial incentives for quality improvement. The MMA has formed a Quality Health Care Committee, and committed itself to being one of the leading champions for quality health care in Minnesota. The fact is no one is more qualified to answer the question “what is quality health care?” than physicians. Starting in 2006, this physician-led committee will kick off its efforts to highlight the important role doctors have in advocating for quality health care and shaping Minnesota’s quality initiatives. The committee has defined the areas it will pursue. Here’s a summary of what the MMA plans to do. 1. Promote positive cultural change toward quality improvement. In health care, “how things are done” is rapidly changing and the culture of health care must change to accommodate quality, efficiency and safety. Physician leaders are the key to changing the culture within Minnesota health care. In its efforts to move the culture toward one BY BECKY SCHIERMAN, MPH

MetroDoctors

that supports quality and safety, the MMA will grant a Physician Leadership in Quality Award; develop a publication delivered quarterly with Minnesota Medicine; create a Web page focused on quality and safety in health care, and provide online tools that help physicians implement quality and safety initiatives in their practices.

mance and quality measures. As the voice of physicians in Minnesota, the MMA monitors, supports and collaborates with national and local organizations to identify effective quality indicators and ensure that the concerns of Minnesota’s physicians are represented. The MMA is also one of the founding organizations of MN Community Measurement.

2. Advocate for evidence-based practice. Implementation of evidence-based medicine guidelines must consider the needs of individual patients. Physicians can provide the expertise needed to modify guidelines based on peer and collegial professional consultation, patients’ health status, illness severity, response to past treatments, and demographic variations. The MMA will educate its members, patients, policy makers, health plan administrators, corporate insurance purchasers and the public about the beneﬁts, proper uses of, and limitations of clinical care guidelines.

5. Support health care information and technology infrastructure. Electronic health records (EHRs) are an effective tool for improving patient safety, capturing and tracking performance measures, and improving efﬁciency. The MMA is working with Stratis Health to help members with EHR adoption by providing resources and tools. The MMA and Stratis Health can help practices determine their EHR needs and create guidelines for choosing a system. The MMA will also help provide information about available grants for buying systems. The pressure to improve health care provided has never been greater. The MMA is dedicated to helping prepare Minnesota’s physicians to engage in quality improvement by providing the necessary tools, resources and education. While the MMA does not plan to develop clinical practice guidelines or quality indicators, the MMA is taking the lead in helping Minnesota’s physicians integrate quality into practice, measure the results, and work to create a professional health care community that supports quality care. For more information on the MMA quality efforts, please contact MMA staffer Becky Schierman, M.P.H, Manager, Quality Improvement at rschierman@mnmed.org.

3. Provide quality and safety resources. Physicians work hard to ensure that the health care they provide is effective, safe and efﬁcient. However, without the necessary skills, tools and resources, collecting data and making improvements is difﬁcult. The MMA will collaborate with other organizations such as Stratis Health, ICSI and Minnesota’s medical schools to provide access to quality improvement and safety resources including, online tool kits, lectures and information on successful quality improvement activities occurring nationally and in Minnesota. 4. Serve as a catalyst and physician voice for quality measurement and use of data. Both nationally and locally, payers, providers and purchasers are rushing to develop perfor-

The Journal of the Hennepin and Ramsey Medical Societies

July/August 2006

Physician Values and Clinical Decision Making

Editor’s Note: The purpose of reprinting this article is to expose HMS and RMS members to some of the important ethics work done on behalf of medicine by the AMA. Please let us know if you would like to see more content provided by the Ethics Resource Center. The Virtual Mentor is an online publication of the Ethics Resource Center, American Medical Association and is reprinted here with their permission.

KARL HARRIS IS A RELATIVELY new patient in Dr. Breck’s practice. Dr. Breck knows that Karl, who is 20 years old, moved to the city from his rural hometown just over a year ago. Karl has been waiting tables and has talked about pursuing a college degree. He comes to Dr. Breck’s ofﬁce complaining of a burning sensation when he urinates, but seems uncomfortable speaking about his chief symptoms. During the course of the history, Dr. Breck asks Karl about his sexual interactions. Karl is very hesitant to speak about this, but eventually admits that he has had several unprotected homosexual encounters in the past year. Dr. Breck also asks Karl about his obvious anxiety, and Karl eventually opens up about how he left home soon after telling his family that he was homosexual. Karl states that his family was not at all supportive and that he immediately felt ostracized by his friends. He admits that much of their rejection was based on religious ideology. “I just couldn’t take their constant judgment anymore, so I decided to leave,” he says. The physical examination leads Dr. Breck to suspect an infection, possibly a form of gonorrhea. He takes a few samples for culture to conﬁrm his clinical suspicion and places Karl BY JACK DRESCHER, M.D. AND ANDREW FERGUSSON, MB, MRCGP

July/August 2006

on a course of ceftriaxone and azithromycin as initial therapy. Dr. Breck schedules Karl for a follow-up visit to go over the lab results and “talk about some of the issues that might be affecting your physical, emotional, and spiritual health.” When the results of the cultures return, Dr. Breck finds that Karl did have a gonoccocal infection with a strain that is responsive to the antibiotic therapy he prescribed. Nonetheless, Dr. Breck has his office staff confirm the follow-up appointment with Karl. At that next appointment, Karl is relieved that his symptoms are resolving. At that point, Dr. Breck brings up his concerns about Karl’s sexual behavior and speaks about blood testing for HIV and hepatitis C. Karl seems hesitant to have any blood tests, stating that “no one I have been with would have any of those diseases.” Dr. Breck then brings up the issue of Karl’s family and their response to his sexuality. “I understand that your experimentation with homosexuality has caused a major rift between you and your family,” Dr. Breck says, suggesting that his parents’ reaction was most likely “one of shock at seeing a child lose his way.” Dr. Breck then recommends that Karl see Dr. Talbert, a local psychotherapist and personal friend of Dr. Breck’s, well known for his work in “conversion therapy” — counseling interventions focused on eliminating homosexual thoughts and behaviors. Commentary 1 by Jack Drescher, M.D. During his visit with Dr. Breck, Karl revealed a fact related to his medical problem: he is a sexually active gay man. But being gay is a secret so volatile that its revelation to his family and friends (colloquially referred to as “coming out of the closet”) led to strong judgmental MetroDoctors

responses and Karl’s ultimate decision to leave home. Given the “religious ideology” of Karl’s background, it is reasonable to presume that his understanding of sexuality is limited. For example, it is likely that he does not know how to use a condom, has had little sex education, and was advised to remain abstinent until marriage. Frank conversations about same-sex behaviors were probably out of the question, with such activities strongly discouraged by quotes from Leviticus and threats of punishment in the afterlife. But now, estranged from his lifelong support system and with limited tools or knowledge of the wider world — for example, he thinks he can spot someone with hepatitis or HIV — 20-year-old Karl contracts an STI and he seeks a physician’s help. Dr. Breck conscientiously takes a sexual history, makes a diagnosis, and prescribes appropriate antibiotic treatment. He also encourages Karl to undergo further testing for other STIs. In a follow-up visit, Dr. Breck expresses concern about Karl’s “major rift” with his family and their “shock at seeing a child lose his way.” He refers Karl to a “conversion” therapist who claims to change sexual orientations. Is it ethical for Dr. Breck to interject his own values (strong identiﬁcation with his adult patient’s parents antihomosexual beliefs) into this clinical encounter? No physician can claim to practice value-free medicine. Undoubtedly, physicians are raised with values, religious or otherwise, that shape their decisions to become professional caretakers. Their training is further inﬂuenced by professional values, embodied in the Hippocratic Oath, the Oath of Maimonides, and the AMA’s Principles of Medical Ethics. In addition, mainstream practitioners

The Journal of the Hennepin and Ramsey Medical Societies

choose evidence-based, as opposed to faithbased interventions — another medical decision that cannot be viewed as value neutral. Consequently, I think it unreasonable, if not impossible, to ask physicians to practice “valuefree” medicine. Nevertheless, while being aware of our own values, we must also respect those of our patients, even those with which we might disagree. Otherwise, there is a risk that our personal values may interfere with medical judgment. How this happened in Dr. Breck’s case requires a brief, sociocultural analysis of contemporary debates about homosexuality.

Attitudes toward Homosexuality Today’s moral and legal debates about homosexuality are embedded in the “culture wars” whose opposing sides argue either that: (1) homosexuality is normal and acceptable; or (2) homosexuality is neither normal nor acceptable. The ﬁrst position I call a normal/identity model1. It regards homosexuality as a normal variation of human expression, analogous with left-handedness, and views a homosexual orientation as a distinguishing feature of a gay or lesbian identity. Acceptance of this position is an outgrowth of the 1973 American Psychiatric Association (APA) decision to remove homosexuality from its diagnostic manual (DSM)2. Following the APA decision, shifting cultural perspectives had medical support: (1) if homosexuality is not an illness, and if one does not literally accept biblical prohibitions against homosexuality; and (2) if gay people are able and prepared to function as productive citizens, then what is wrong with being gay? The normal/identity view is accepted by the American Medical Association, national, state, and local governments that provide civil rights protections for gay people, and religious denominations that sanctify same-sex relationships. Some segments of society strongly oppose homosexuality’s removal from the DSM. They advocate an illness/behavior model that regards any open expressions of homosexuality as either: (1) behavioral symptoms pathognomonic of psychiatric illness; (2) a moral failing; or (3) some combination of the two. This position, that illness or immorality cannot provide a foundation for creating a normal identity, is

MetroDoctors

held by “conversion” therapists and religious and political groups opposed to the normalization of homosexuality. While the mental health mainstream has depathologized homosexuality, sexual conversion therapists criticize the mental health and medical fields and believe individuals can modify their behavior to reflect a more acceptable heterosexual norm. Their arguments often dismiss scientific facts that disagree with religious dogma, focus on gaps in scientific knowledge to discredit the entire scientific enterprise, and confuse the general public about the current state of accepted scientific knowledge. Furthermore, the religious and social conservatives who market conversion therapies as a viable alternative to being gay seem to be unaware of, uninterested in, or dismissive of warnings of the possible harms such “therapy” can do3-6. Subscribing to the illness/behavior model, Dr. Breck refuses to perceive Karl as gay — an identity. Instead, he refers to Karl’s “experimentation with homosexuality” — a behavior. Dr. Breck’s advice is an attempt to convince Karl to change his sexual orientation. (The question of whether such treatments are either effective or ethical is not the focus of this discussion.) From the illness/behavior perspective, Karl can reduce his risk of contracting STIs, and perhaps be reunited with his family and religious community by changing his homosexual “behavior.” A physician who believes homosexuality is a sin, an illness, or both, might reasonably believe he has discharged his professional duties by challenging the patient’s sexual identity. However, in choosing Karl’s homosexuality rather than unsafe sexual practices as the object of the therapeutic intervention, Dr. Breck provides two examples of poor practice. The majority of HIV cases worldwide are heterosexually transmitted, yet we do not advise heterosexual patients to change their orientation to avoid AIDS (or other STIs). Counseling gay patients to change their sexual orientation to avoid disease is both a form of medical excess and poor public health policy. The more prudent, medically conservative, and nonjudgmental alternative would have been to counsel Karl about safer sexual practices, including sexual restraint — just as one does with a heterosexual patient. A second example of poor practice stems from Dr. Breck’s imposing his own antihomo-

The Journal of the Hennepin and Ramsey Medical Societies

sexual beliefs on the patient. Karl has already left family and friends who do not accept him as gay. Why would a physician who barely knows the patient use his medical authority in this way? One possible outcome of this intervention is losing Karl to follow-up and, perhaps, Karl’s avoidance of future medical treatment. There may be other consequences as well. In February 2006, a lesbian patient sued her Florida doctor’s practice for giving her unsolicited religious, antigay literature7. Physicians, like everyone else, are entitled to their personal and religious beliefs. But physicians are constrained in the exercise of those beliefs by state laws and professional, ethical guidelines. In other words, our medical authority derives from secular, not religious sources. In this case, Dr. Breck confused the two sources of his authority. Acting on personal beliefs led to an error in medical judgment and possible alienation of his patient. References 1. Drescher J. Ethical issues in treating gay and lesbian patients. Psychiatr Clin North Am. 2002;25:605-621. 2. Bayer R. Homosexuality and American Psychiatry: The Politics of Diagnosis. New York, NY: Basic Books; 1981. 3. American Psychiatric Association Commission on Psychotherapy by Psychiatrists (COPP). Position statement on therapies focused on attempts to change sexual orientation (Reparative or conversion therapies). Am J Psychiatry. 2000;157:1719-1721. 4. Drescher J, Zucker KJ, eds. Ex-Gay Research: Analyzing the Spitzer Study and Its Relation to Science, Religion, Politics, and Culture. Binghamton, NY: The Haworth Press Inc; 2006. 5. Haldeman DC. The practice and ethics of sexual orientation conversion therapy. J Consult Clin Psychol. 1994;62: 221-227. 6. Shidlo A, Schroeder M, Drescher J, eds. Sexual Conversion Therapy: Ethical, Clinical and Research Perspectives. Binghamton, NY: The Haworth Press Inc; 2001. 7. Lesbian files complaint against doctor for prescribing unwanted anti-gay “treatment” [press release]. Kissimmee, Florida: National Center for Lesbian Rights; February 2, 2006. Available at: http: //www.nclrights.org/releases/pr-doctor020206.htm. Accessed April 3, 2006.

Jack Drescher, M.D., is a training and supervising analyst at the William Alanson White Institute in New York City. He is adjunct clinical assistant professor at the New York University Postdoctoral Program in Psychotherapy and Psychoanalysis and clinical assistant professor of psychiatry at State University of New York-Downstate (Brooklyn).

(Continued on page 16)

July/August 2006

Physician Values (Continued from page 15)

Commentary 2 by Andrew Fergusson, MB, MRCGP How frustrating it can be to have to comment when the material in the case history is sometimes so tantalizingly brief at key points. Those of us asked to respond will inevitably read into the gaps from our own presuppositions, and that, of course, is what this discussion on physician values in clinical decision-making is all about. When I was taking the membership examination for the UK Royal College of General Practitioners some 25 years ago, I was required to make, in every primary care consultation, a diagnosis with three elements: the physical, the psychological, and the social. As a committed Christian who often had to struggle with situations where patients’ value systems conﬂicted with mine (though I would have faced other conﬂicts had I been a committed atheist) I wanted to add a fourth element: the spiritual. Since 1998 the World Health Organization has been encouraging physicians to do so.

July/August Index to Advertisers Allina Health Systems.................................20 The Birkeland Group .......Inside Back Cover Children’s Physician Network......................... Inside Front Cover Classified Ads ...............................................7 Crutchfield Dermatology ............................9 MMIC .........................................................3 RCMS, Inc.........................Inside Back Cover Minnesota Healthcare Network and Triium ...........................................21 University of Minnesota CME ....................... Outside Back Cover Weber Law Office ......................................21 Whitesell Medical Locums, Ltd..................23

July/August 2006

Until recently the health professions have largely followed a medical model, which seeks to treat patients by focusing on medicines and surgery, and gives less importance to beliefs and to faith — in healing, in the physician and in the doctor-patient relationship. This reductionist or mechanistic view of patients is no longer satisfactory. Patients and physicians have begun to realize the value of elements such as faith, hope, and compassion in the healing process1. This rediscovery reminds us of the historic concept of the doctor-patient relationship, that it is a covenantal one which goes far beyond the merely contractual2. On the (regrettably) ever more dominant contract basis, the physician is reduced to being the garage mechanic of the human body, offering a menu of options with their prices and their penalties. The patient is the customer who selects the physical fix they most feel they want at that time. But the recent WHO guidance reinforces the traditional covenantal model, and there is now a renewed recognition that it is ethical to approach our patients’ needs holistically. The fictitious Dr. Breck handled the initial physical diagnosis and treatment correctly, and I commend him for conscientiously taking a sexual history. Sadly, some physicians are still too embarrassed to broach the topic. Unfortunately he did it in the wrong way. Beyond counseling Karl about “safer sexual practices, including sexual restraint” he should have explored the wider aspects of Karl’s sexuality far more holistically. In the catchphrase of the famous British sociologist, Professor Margaret Stacey, who devoted much of her life to patient-physician relationships, Dr. Breck is an example of those many doctors who “mean well, but do badly.” As a profession we continually need to acknowledge that our corporate and individual assumptions, presuppositions, and biases need to be remembered and reviewed. After all, we might be wrong. And that is perhaps particularly true in the highly politicized field of sexual ethics. It should be obvious (though it often is not) that secular biases are as value-laden as the religious biases we attribute to Dr. Breck. The imperative to review and acknowledge the effects of our beliefs and values on patients binds all physicians — Dr. Breck and those whose biases differ from his. MetroDoctors

Let me end with Karl, because I think so far we have not really considered him adequately. He is the patient who came for help. He is the one who should be receiving compassion in the healing process. What approach best respects his autonomy? What approach most recognizes and increases his sense of dignity? It strikes me that, after the initial treatment of his infection, what this young man most needed was a good listening-to. So far, it sounds like he’s only had good talkings-to — from his family who were “not at all supportive,” his friends who “ostracized” him, from Dr. Breck who uses the language of “major rift” and “shock” and possibly recommends “conversion therapy,” and, perhaps, from a gay community interested in recruiting members and molding their individual identity in order to maintain the community’s corporate identity. Letting Karl tell his story, and listening to him in a nonjudgmental way, would in itself have helped him to understand himself more and explore his options. If he then chose, in the way of fully informed consent, to continue living according to a value system that conﬂicted with the physician’s, then the physician has to accept that. But at least their relationship would have some of that holism the WHO encourages, and would probably continue healthier for both of them. References 1. World Health Organization. WHOQOL and Spirituality, Religiousness and Personal Beliefs: Report on WHO Consultation. Geneva, Switzerland: WHO; 1998. 2. See, for example, Adam MB. Physician unions: guardians of the covenant or keepers of the contract? In: Kilner JF, Orr RD, Shelly JA, eds. The Changing Face of Health Care: A Christian Appraisal of Managed Care, Resource Allocation, and Patient-Caregiver Relationships. Grand Rapids, Mich: William B. Eerdmans; 1998.

Andrew Fergusson, MB, MRCGP, is president of the Center for Bioethics and Human Dignity in Bannockburn, Illinois. He was a practicing family physician in a deprived area of London for 10 years. Human sexual ethics are beyond the scope of the Center’s work, and these views, based around the concept of human dignity, are his own. He takes sole responsibility for them.

The Journal of the Hennepin and Ramsey Medical Societies

PHYSICIAN'S SOAP BOX

The New Pay-for-Performance Prescription for What Ails Medicine—Is This Public Policy Malpractice?

cure health care system ailments of inflation and quality have found a new prescription: “pay for quality.” It is derived from classic “incentive bonus” pay for clinics decreasing use of services. The real P4P game of controlling use of care has not changed. Economic and Social Irrelevance. It might have been predictable that pay for P4P behavior at the bedside would be irrelevant to causes of medicine’s ailments. The persistent rapid rise of medical sector inflation in the U.S. appeared after 1965 (Fig. 1),1 a tipping point in time when political forces driving popular tax subsidies meant insurance had been acquired by approximately 85 percent of the population (workers, seniors, and the official poor and disabled). Populationcentered quality statistics are driven by a myriad of socioeconomic factors. These factors are poverty and cultural status2 as well as population demographics, patient compliance,3 network referral guidelines, price fixing of services, the vagaries of government funding, and the general economy. Clinicians have no control over these forces and factors, yet population “metrics” are prescribed as the basis for clinic pay-for-performance. One certainly might ask: If a prescription does not address the fundamental causes of medicine’s ailments, is the treatment not only futile but then also public policy malpractice if it makes things worse? Doctors are trained to diagnose and treat the ailments of their patients. They cannot treat the ailments of politically created regulatory systems that don’t work. The conflicting goals of the politicians are open access and quality care with cost control. For insurance corporations underwriting care, these goals present the familiar managed care catch-22 dilemma of “cost, quality, access — pick any two.” “Pay for quality, not volume” has become the latest slogan by which managed care advocates seek to escape the dilemma as well as the blame for system dysfunction. They transfer to clinicians as much as possible of the onus of financial risk in underwriting these conflicting goals as well as the negative Managed Care Organization (MCO) image of rationing access to care. Policy Pitfalls. The problem for clinicians underwriting care is that they must make the same cost-quality-access trade-off as does any other MCO. Quality is not an isolated item. Pay-for-performance B Y R O B E RT W. G E I S T, M . D .

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

“bonus rewards” and punishments are an “at risk” clinic’s profits and losses contingent on its behavior in making the trade-offs. The problem for patients is that a financial conflict of interest with them is created when doctors become double agents playing the dual roles of caregiver and insurance underwriter. We, as patients, want care based on our medical problems and not on the financial or image interests of MCO corporations, “at risk” clinics, or the state. The only reason that any person or entity would not want to conform with the principle that physician payment be restricted to pay for services as caregiver, would be to do something which might not be in the best interests of the patient — the ultimate pitfall of payfor-performance contingent on behavior instead of for services. Futile Prescriptions. Managed care is a system often said to be “broken” when inflation persisted after rationing schemes to curtail access proved futile. Attempts to ration access to care (primarily administered prices for services and queuing) have not only resulted in diminished quality of patient-centered care, but also problems found in population studies of disease care and public satisfaction with care. Why? Paternalistic microeconomic sectors proved to have a fatal flaw demonstrated by the 1980s in many nations, which with good intentions had subsidized “free” (low copay) goods and services. These paternalistic systems crashed4 and were deregulated.5 It was clear that (Continued on page 18) Fig. 1

National Health Insurance and Inﬂation 1750 Price level (1950 = 100)

POLICY MAKERS WITH FAITH in pay-for-performance (P4P) to

Medical CPI Consumer Price Index

1500 1250 1000 750 500 250 0

1950

1960

1970

1980 Year

1990

2000

1965: the “Tipping Point” when 85% of Americans have tax subsidized health insurance. Modiﬁed from Phelps CE (Ref. #1).

July/August 2006

Soapbox (Continued from page 17)

no central authority, however powerful, brilliant, or good willed the managers, can accomplish the function of freely determined prices for the allocation of labor, capital and human ingenuity.6 The medical managed microeconomic sector has proved no exception and results have been the same — diminished quality of services and system inflation, which is overt here, but hidden abroad by longer queues and worse erosion of plant, personnel and technology. Managed care may not be fixable, but it can be made worse when the effects of P4P are counterproductive. For instance, morale suffers when a highly trained workforce dedicated and loyal to the interests of all their patients, is threatened with various financial and even decertification punishments for “non-compliant” behavior for a few high profile diseases important to what corporate and/or state authorities believe will best serve society if not their own financial and image interests. Although evidence-free faith in irrelevant P4P schemes cannot beneficially affect a “broken” system’s fundamental flaws, the faith of many policy makers remains where they placed their bets years ago despite decades of system failure. Investment Prescriptions. There are many areas for real quality initiatives of value. Public health campaigns have had a real impact. Examples are seatbelt and driving while intoxicated laws, better highway construction, campaigns for vaccinations and maternal care, as well as awareness of hypertension and tobacco harm. The negative impact of the “obesity epidemic” has yet to be realized. But this increases the importance of investment in continuous quality improvement and education at all medical workforce levels as well as private employer and community health initiatives.

Conclusion. Old and new clinic pay-for-performance are prescriptions irrelevant to treatment of medicine’s ailments, since the causes are beyond clinic control at the bedside. Inflation of insurance prices is due to demand driven by politically popular tax subsidies. Population quality statistics are driven by a myriad of socioeconomic factors including poverty, cultural status, and the vagaries of public funding and the general economy. P4P nostrums also create double agency when doctors play the dual roles of caregiver and insurance underwriter. Quality does not stand alone since “at risk” doctors must make trade-offs between quality and volume of care or suffer financial and even decertification penalties from corporate and/or state authorities. It is investment in, not threats to, the activities of a professional work force loyal to patient interests that is the right prescription for quality care. An inherently flawed managed care system and pay-forperformance double agency need a different prescription that “pay for quality.” Robert W. Geist M.D. is a retired urologist residing in North Oaks. He can be reached at: rgeistmd@comcast.net. Footnotes: 1) Phelps CE. Chap 2: An overview of how markets interrelate in medical care and health insurance. In: Health Economics. Addison Wesley, Boston MA 2003:48. Fig. 2.2 (a). 2) Kawachi I, Kennedy BP. Chap.3 Prosperity and health. In: The health of nations: why inequality is harmful to your health. The New Press NYC, NY; 2002:58-60; Marmot M. The influence of income on health: views of an epidemiologist. Health Aff. 2002;21(2):31-46; Marmot M. The status syndrome: how social standing affects our health and longevity. N Engl J Med. 2005;352(11):1159. 3) McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA. The quality of health care delivered to adults in the United States. N Engl J Med. 2003(26)348:2635-2645. 4) Landes DS. Chap. 28. Losers. In: The wealth and poverty of nations. W.W. Norton & Company, New York, 1999: 495-499; McNeill WH. Part II. The human condition: an ecological and historical view. In: The global condition: conquerors, catastrophes, and community. Princeton , New Jersey; Princeton University Press, 1992:127-131. 5) Yergin, D, and Stanislaw J. Chapter 5, Crisis of Confidence. In: The Commanding Heights. New York, NY: A Touchstone Book. Simon and Schuster; 1998:128-129, 137. 6) Cassidy J. The price prophet. The New Yorker. February 7, 2000:44-51.

Editor’s Note: When in medical school, expounding on my newly acquired knowledge, my mother gave me some sage advice, “You don’t know much and half of what you know is wrong.” The truth of this remains today; we are constantly changing our ideas of what constitutes “the best practice of medicine.” Many things that we intuitively think must be right turn out to be wrong. Changes, however, occur irregularly and there is great geographic variability on how a practice is delivered. Clearly, we are not part of a system. Excellence in medical care and more rapid diffusion of information will depend to some degree on a better information system than now exists. I applaud the MMA in joining the discussion for its practicing physicians. We need clear guidelines for data collection and evaluation and uniform hardware and software resources. The start-up costs of electronic health records usually runs $50,000 to $100,000

July/August 2006

per physician. How can already squeezed practitioners afford the cost unless there are incentives to do so? Establishing what is the “community standard” in the broader aspect of the community, and actually reimbursing more for quality outcomes, is essential. If “paying for quality” is just a smoke screen for shifting proﬁts and declining reimbursement as Dr. Geist implies, there will not be a movement toward the kind of information systems physicians need to improve their practice. Providing standardized hardware and software systems, which communicate with each other and which are supported over the long run, will be essential and MMA’s activity in this area is most appropriate. Thomas B. Dunkel, M.D. Co-Editor, MetroDoctors

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

An Overview of Female Urinary Incontinence Where Have We Been, and Where are We Going?

IT IS ESTIMATED that from 15 to 38 mil-

lion women in the United States are affected by involuntary loss of urine or urinary incontinence (UI). The direct cost of this burden to our society is estimated to be 19.5 billion dollars (year 2000 dollars) per year. Urinary incontinence can have adverse implications on many quality of life domains such as social interactions, function in the workplace, sexual and domestic relationships, emotional wellbeing and ultimately affects physical health. Most unfortunate are the beliefs that this is a “normal” component of aging or worse, that no help is available. Thus many women, uniformed or too embarrassed to discuss the issue suffer in silence. All too often we, as health care providers, fail to screen for the issue feeling we are not equipped to offer effective solutions, that we “do not have time” or that it is a “lost leader” to our practice viability. These beliefs could not be further from the truth. These patients can be easily screened and the initial treatment is easily administered which is very often, quite effective. This is of great value to the practice bottom line as it fosters patient retention, new referrals and is a proﬁtable service line. Ultimately this is better for our practices, our patients and women everywhere. There are essentially six major types of involuntary urinary loss in women. Of these, 96 percent is accounted for by three of the six. Of those, only two need to be remembered as the third is a mixture of the ﬁrst two. These are Stress Urinary Incontinence (SUI), Urge Urinary Incontinence (UUI) and a combination of stress and urge, Mixed Urinary Incontinence (MUI). SUI accounts for approximately 50 percent of all urine loss, UUI alone about

BY JAMES RADERS, M.D.

MetroDoctors

14 percent, and mixed urine loss (MUI) responsible for about one-third or 32 percent. Urge incontinence is defined by the International Continence Society as urine loss preceded by or accompanied by “urgency.” Urgency, somewhat difficult to describe and quantify is the sudden onset of the desire to void that is difficult to defer. Contrast this to the normal desire to void that has a gradual onset and amplification so that voiding can be accomplished at a convenient time in a socially acceptable environment. Urge incontinence is often a part of a greater disorder known as Overactive Bladder (OAB). OAB is urgency, with or without urge incontinence often accompanied by frequency of urination (going too often) and nocturia (getting up at night to void). In fact, 43 percent of women affected by overactive bladder do not have actual “accidents” related to urgency while 57 percent will experience some degree of urine loss. The etiology of this disorder is most often idiopathic. Multimodal treatment is most effective consisting of a bladder “diet” (avoidance of bladder irritants), bladder retraining (timed voiding and urge suppression) along with antimuscurinic medications which act at numerous levels to inhibit bladder overactivity.

The Journal of the Hennepin and Ramsey Medical Societies

Many strides have been made to recognize, define and treat this disorder. A number of newer medications have recently been introduced as well as treatment modalities such as neuromodulation (stimulation of sacral nerves) through both the sacral modality (Interstim) with a pulse generator implanted in the buttock, and a more recent minimally invasive method administered via the tibial nerve at the level of the medial malleolus in the ankle (Urgent PC). Intensive research is being pursued with such methods as intracystic botox injections, intravesicle instillation of antimuscurinics, capsaicin and resiniferotoxin. Perhaps the greatest strides in the treatment of female urinary incontinence over the last 15 years have been made in the treatment of stress incontinence. Close to 29 million women over the age of 20 in the United States experience SUI on a weekly basis or more. One must consider however, that about only one in four describe the problem as “bothersome,” significantly affecting their quality of life. This still leaves over seven million women affected by a condition that is ultimately, in most cases, easily treated. It has been estimated that only one in four women with the problem will ultimately seek medical attention. In addition, 70 percent of women with UI say they worry about coughing, sneezing and even laughing in public for fear of having an accident, 35 percent report avoiding exercise, traveling less frequently and avoiding sex to accommodate, 62 percent wait a year or longer before discussing their condition with a doctor and17 percent wait five or more years. Perhaps most distressing is the fact that 9/10 women who discuss UI with

(Continued on page 20)

July/August 2006

Female Urinary Incontinence (Continued from page 19)

to incontinence. Stress incontinence is deďŹ ned by the ICS as involuntary loss of urine with coughing, sneezing, effort or exertion. This is a problem with the urethra, the conduit from the bladder used for elimination, which in the female is 3-5 cm in length. Although a gross oversimpliďŹ cation and the exact mechanism is poorly understood, several factors contribute to the urethral closure: the urethral â&#x20AC;&#x153;sealâ&#x20AC;? provided by the periurethral vasculature, urothelium and urethral elasticity; the intrinsic resting tone of the involuntary (smooth muscle) sphincter; the augmented closure provided in times of valsalva by the voluntary (striated) sphincter of the pelvic ďŹ&#x201A;oor along with the amount of the valsalva pressure transmitted to the urethra; and importantly, the support of the urethra provided by its connective tissue attachments within the pelvis and provided by the underlying vaginal wall. The latter provides a â&#x20AC;&#x153;dynamic hammock,â&#x20AC;? if you will, that the urethra can use to effectively â&#x20AC;&#x153;crimpâ&#x20AC;? itself off during times of sudden increase in intra-abdominal pressures and thereby maintain continence. Incontinence can be caused by the loss of any one, or more likely a combination of the above factors.

providers say they initiated the conversation. Several reasons for the above facts are that stress incontinence is predictable, results in small volume leaking episodes and is therefore easily compensated for. Coping often involves wearing protection, avoiding physical activities associated with urine loss such as exercise, walking, lifting, travel etc.; wearing dark clothing, avoiding social interactions inside and outside the home; and avoiding intercourse among others. Perhaps the most powerful reasons women do not seek therapy are the myths surrounding treatment. These include: treatment requires general anesthesia, an invasive operation with an inpatient hospital stay, long recovery times, habitual avoidance of physical activity and perhaps worst of all, that success does not last very long. In the past, all of these myths had some element of validity. Today, none of these need be true. Before discussing new and evolving therapies, a brief word about the physiology of continence and the derangements that lead

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July/August 2006

MetroDoctors

Treatment strategies focus on the restoration or the augmentation of the above factors. For example, pelvic floor muscle exercises probably work by assisting in the augmented â&#x20AC;&#x153;squeezeâ&#x20AC;? during valsalva by the striated muscle groups as well as assisting in urethral support and possibly by increasing resting tone. A medication currently approved for use in Europe and Canada, augments the chemical â&#x20AC;&#x153;messagesâ&#x20AC;? within Onuf â&#x20AC;&#x2122;s nucleus in the spinal cord that control the urethral sphincters. More â&#x20AC;&#x153;messagesâ&#x20AC;? means increases in resting and probably augmentation of closure during times of increased abdominal pressure. The drug duloxetine, is a serotonin/ norepinephrine reuptake inhibitor approved in this country as the antidepressant, Cymbalta. It is currently within the consideration process with the FDA for use in America. When conservative therapy such as pelvic ďŹ&#x201A;oor muscle exercises or medications, have failed or no longer offer relief from bothersome stress incontinence, surgical intervention is often contemplated. Since Howard Kelly described his suburethral plication in 1914, over 110 different procedures have been described in the literature to treat stress incontinence in females. All of these interventions work on the same principle: that is to restore the urethral â&#x20AC;&#x153;backstopâ&#x20AC;? for closure while augmenting in some way the pressure transmitted to the urethra during sudden increases in abdominal and therefore vesicle pressures. There has been very little level 1 evidence to support a general agreement on the â&#x20AC;&#x153;bestâ&#x20AC;? procedure for urinary incontinence. As recently as 1996, Black and Down in England, after an extensive literature review concluded that there is â&#x20AC;&#x153;no best procedureâ&#x20AC;? for treating SUI. One year later an American Urological Association (AUA) panel concluded that based on the evidence, traditional sling and retropubic procedures were the best choices for treatment. There existed a caveat in that recommendation however that if the patient desired a less-invasive procedure or a more rapid return to normal activities, a less effective needle procedure was the treatment of choice. In the early 1990s a Scandinavian, Ulf Ulmsten, and an Australian, Peter â&#x20AC;&#x153;Papaâ&#x20AC;? Petros, began a reexamination of the continence mechanism in females. Out of that work the concept of a â&#x20AC;&#x153;tension-freeâ&#x20AC;? mid-urethral sling

The Journal of the Hennepin and Ramsey Medical Societies

was born. They described the placement of a synthetic material at the mid-urethra in a tension-free fashion with no anchoring using minimally invasive techniques. This concept was met with great skepticism when the authors originally published their work on Tension-Free Vaginal Tape (TVT) in 1993. Over the ensuing years, the surgical approach to the treatment of female stress urinary incontinence throughout the world literally changed overnight. A great deal of level 1 evidence now exists to support the fact that mid urethral synthetic slings are equal to or more efďŹ cacious than previous treatments while offering lower morbidity and cost. The most longitudinal experience is in a patient population in Finland that have demonstrated an 81.3 percent â&#x20AC;&#x153;dryâ&#x20AC;? and a 16.3 percent â&#x20AC;&#x153;signiďŹ cantly improvedâ&#x20AC;? rate after TVT placement for SUI. This is comparable to the one and ďŹ ve year rates in the same population. More recent advancements in the placement of mid-urethral sling placements have been made by using the obturator foramen in the pelvis for access to placement thereby avoiding the retropubic space. This has resulted in an increased safety proďŹ le while offering a lower postoperative rate of complications such as overactive bladder and voiding dysfunction. Short-term studies have suggested similar excellent clinical outcomes. We have recently presented a series of 106 patients who underwent the TVT-Obturator procedure that have been followed for at least one year. In that series all patients with TVT alone were done under local anesthesia as outpatients with an average OR time of 22 minutes and an average same day surgery length of stay of three hours and 22 minutes. We had no major intra- or postoperative complications. Examination of the subjective clinical outcomes revealed 86.9 percent of the patients were â&#x20AC;&#x153;dryâ&#x20AC;? and an additional 10.7 percent were â&#x20AC;&#x153;signiďŹ cantly improved.â&#x20AC;? The rate of new-onset overactive bladder was low at 2.4 percent and only one patient had voiding dysfunction requiring intervention. As time passes, with the careful required scrutiny, medicine advances will provide better outcomes with less and less morbidity. Certainly this has been the case in the treatment of female pelvic ďŹ&#x201A;oor disorders and in particular, urinary incontinence. The truths

MetroDoctors

of yesterday yield to progress and pass into the realm of myth, gradually to be forgotten. It is incumbent upon us as providers of health care and advocates for women to thoughtfully, cautiously and passionately move forward to dispel the â&#x20AC;&#x153;truthsâ&#x20AC;? of today. In this way we move forward to improve the lives of those we care for. James Raders, M.D. is the medical director of Female Pelvic Medicine and Reconstructive Surgery and an Assistant Clinical Professor of Obstetrics and Gynecology at the University of Minnesota. Dr. Raders received his medical degree from the University of Iowa. He completed his internship and residency at the University of Florida at Gainesville. He later completed a surgical fellowship in Urogynecology and Pelvic Reconstructive Surgery at the Institute for Female Pelvic Medicine and Reconstructive Surgery in Allentown, Pennsylvania and a research fellowship at the Cleveland Clinic, Florida. Dr. Raders has been board certiďŹ ed in obstetrics and gynecology since 1986.

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July/August 2006

Lions Children’s Hearing Center at the University of Minnesota

ABBY DID NOT PASS the newborn hear-

ing screen and was referred to the audiology clinic at the University of Minnesota. By two months of age she was diagnosed with moderate hearing loss in her right ear and severe loss in her left ear, and was fit with hearing aids. At nine months, it was discovered that her hearing had again decreased, and that the loss was fluctuating. An otolaryngologist identified an enlarged vestibular aqueduct and a further appointment with the Genetics department revealed that Abby has Pendrid’s Syndrome. Working with a speech-language pathologist, Abby is making good progress with verbal skills. Abby’s success is due to her parents’ persistence and timely treatment by a number of specialists. Many children are not this lucky. Undoubtedly you’ve seen a child like Abby and have been challenged by the complexities these cases present. Until recently, it was difficult to determine where to refer children with hearing loss. Once referred, the process of multiple appointments and follow-ups was daunting to even the most organized of new parents. As a result, children were suffering costly delays in diagnosis and treatment, often seeking help well past the six-month-old target age for optimum benefit from treatment (the Minnesota Department of Health recommends identification by one month, diagnosis by three months and intervention by six months). “The Lions Children’s Hearing Center is a complete, ‘one-stop’ referral center for children with hearing disorders where

BY SARAH BARKER

July/August 2006

they can receive the most advanced treatment,” said pediatric otolaryngologist Frank Rimell, M.D. The Lions Children’s Hearing Center, established near the end of 2005, brings together otolaryngology, audiology, genetics, pediatric infectious disease, aural rehabilitation, speech-language pathology and behavioral psychology in one location. It is the only attends a speech-language group session at the such comprehensive center in Catherine Lions Children’s Hearing Center. the upper Midwest. At this point, a primer in pediatric hearing loss might prove useful. Foundation, established the Lions Newborn About 200 babies per year are born deaf in Hearing Screening Program in 1999. When Minnesota, making it the most common this program began, only 8 percent of Minanomaly present and detectable at birth. nesota hospitals screened newborns’ hearing Being completely invisible and difficult to and the Department of Health did not yet identify without specific testing, hearing have a newborn hearing-screening program. loss was not usually identified until 2-1/2 Six years later, all of the hospitals in Minneyears of age. Since speech and language skills sota were able to screen newborns’ hearing develop explosively between birth and two and the average age at which hearing loss is years, hearing loss detected after that time first detected had fallen from 2-1/2 years to period is extremely detrimental to the de1.92 months. Minnesota is one of 16 states velopment of communication. For example, that does not have a state-funded newborn a child with even mild to moderate hearing hearing-screening program. Since hospitals loss can miss up to 50 percent of a conversaare not required to screen, nor are they retion. Without intervention, a deaf child may imbursed for it, compliance and reporting have 50-60 words by age six, compared to are sometimes inconsistent. Early childhood 3,000 for the average hearing child. If identiadvocates are drafting a bill requesting that fied, diagnosed and treated prior to one year newborn screening be funded by the state. of age, most children will develop language This bill will be introduced in the 2007 on par with their hearing peers and be able to legislative session and it is hoped that the attend school in a mainstream classroom. medical community will be actively engaged The Department of Otolaryngology, toin advocacy. gether with their partners, the Lions Hearing While the Lions Newborn Hearing MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Screening Program was very successful, it only addressed part of the problem. For any number of reasons — parent noncompliance, inaccessibility of audiology services, pediatrician indifference — babies who did not pass the newborn hearing screen were not always returning for more advanced testing. So even though more children are being identified at an early age, diagnosis and treatment still lag. The Lions Hearing Foundation once again stepped forward with financial support to garner and coordinate the specialties already in existence at the University into the Lions Children’s Hearing Center. The Center is a definitive referral source for physicians and audiologists. It streamlines what can be a complicated series of appointments for parents, and it provides superior patient care in that each case is managed as a team and a treatment plan devised. A child was recently referred to the Lions Children’s Hearing Center (LCHC) after having failed newborn screening. A sedated ABR was recommended, but this procedure can only be performed at two sites in Minnesota. Since the LCHC can provide this and any other advanced evaluation services associated with hearing disorders, it’s a simple referral choice for busy pediatricians, audiologists or family practitioners. While many audiology services can evaluate hearing, they are not equipped to manage physiological anomalies that may cause the hearing problem. That’s the domain of an otolaryngologist. Furthermore, pathology and therefore treatment methods may be influenced by the presence of a genetic condition or infectious disease. Families may need the insights of a behavioral psychologist to help them decide on a course of action — signing, hearing aids, cochlear implant. Any treatment plan requires the work of a speech language pathologist, and fine tuning from other specialists as issues arise over time. It’s a daunting task for a new parent, perhaps with other young children, to schedule appointments, shuttle to different locations and make sure information is shared between specialists. The LCHC streamlines this process by providing comMetroDoctors

prehensive, coordinated care with one phone call, in one location. An important function of the Lions Children’s Hearing Center is to work in concert with professionals in the child’s home community. For example, if a child is referred to the Center by a pediatrician in Mound, the team can thoroughly evaluate the child’s condition and prepare a treatment plan. This plan can then be shared with the original pediatrician as well as audiologists, early childhood educators, speech-language pathologists and others in the Mound community who may be involved with the child’s day-to-day activities.

Just as childhood hearing disorders are complex, treatment options abound. The LCHC provides families with medical information, a network of services available in their home community and contacts with other parents of hearing-impaired children. “We’re hoping that if we can make it easier for both referring professionals and for parents, more kids will get treatment early, when it’s most effective,” said Dr. Rimell. Sarah Barker, is communications coordinator, Dept. of Otolaryngology, University of Minnesota, Lions Children’s Hearing Center.

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The Journal of the Hennepin and Ramsey Medical Societies

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July/August 2006

Members in the News Editor’s Note: The “Members in the News” section is used to recognize HMS and RMS members who have received awards and/or honors, as well as announcements of election to ofﬁce. Please send your news items to: Editor, MetroDoctors, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413, fax to (612) 623-2888 or e-mail: dhines@metrodoctors.com for consideration by the editorial board. PRASANNA ALLURI, Ph.D., University

of Minnesota medical student, is one of 40 recipients of the American Medical Association Foundation’s 2006 Seed Grant Research Program. The program provides grants for medical students, residents and fellows who conduct basic science, applied, or clinic research projects.

GAIL AMUNDSON, M.D., HealthPartners associate medical director for quality improvement, will serve on two national panels created to develop national quality measures. As a member of the National Quality Forum’s technical advisory panel on composite measurement, Dr. Amundson will provide advice on developing more consumer-friendly composite measures to be used in public reporting. She will also provide expert advice to the Agency for Healthcare Research and Quality’s Quality Indicators Program. Dr. Amundson leads the performance measurement, quality improvement, and pay-for-performance programs at HealthPartners and practices internal medicine within HealthPartners Medical Group in Minneapolis.

Medicaid Family Planning Services Expand July 1 As a Medicaid provider you have received two notices in the past couple of months regarding an expansion of Medicaid services for family planning. The Minnesota Family Planning Program (the ofﬁcial name of the 1115 family planning waiver) becomes effective July 1, 2006. Minnesota is the 22nd state to be approved for a waiver by CMS. The purpose of the waiver is to expand access and use of family planning services to improve health outcomes for women and infants, increase child spacing, and save costs to the state and federal governments. Subsidized family planning services cost the state of Minnesota approximately $500/year. In contrast, the average cost of a pregnancy is about $10,000/year. During the term of this Medicaid waiver, the state of Minnesota must

July/August 2006

show budget neutrality. In other words, it cannot cost the federal government more to do this program than it would if it were not in place. A unique aspect of this project is presumptive eligibility, which is determined by the provider at the time of service. In order to be a presumptive eligibility provider, a clinic or provider must register for training. The details of this training are spelled out in the provider updates sent to you by the Department of Human Services. To ﬁnd out more about the Minnesota Family Planning Program, visit this Web site: http://www.health.state.mn.us/divs/fh/mch/ familyplanning/waiver.html. Contact information is provided in the Web document for any questions you may have.

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Minneapolis St. Paul Business Journal honored CHARLES E. CRUTCHFIELD III, M.D.

as a recipient of the 2006 Minority Business Award on June 15, 2006. Dr. Crutchﬁeld is the founder of Crutchﬁeld Dermatology in Eagan. WILLIAM E. JACOTT, M.D., has been

elected to the board of directors of Stratis Health, the Bloomington-based quality improvement organization. Dr. Jacott’s health care career spans nearly 40 years. He has served as head of the Department of Family Medicine and Community Health at the University of Minnesota Medical School; as the AMA commissioner for the Joint Commission on Accreditation of Healthcare Organizations (JCAHO); and as chair of the Board of Commissioners for the JACHO. Dr. Jacott also served nine years on the AMA Board of Trustees. BRIAN D. PATTY, M.D., has joined HealthEast Care System as chief medical information ofﬁcer. Dr. Patty’s responsibilities include supporting clinical applications of technologies that improve systems for care management, physician order entry, electronic health records, lab services, pharmacy robotics, and PACS (Picture Archive Communication System, which eliminates the need for x-ray ﬁlm). He recently received a national award for excellence and outstanding achievement in applied medical informatics. ARTHUR PUFF, M.D., was named regional

medical director of MedicareBlue, a new Medicare Advantage alliance involving six Midwest Blue Cross health plans. MedicareBlue covers essential Medicare beneﬁts and additional beneﬁts such as preventive care, drug coverage, and coordination of medical services.

The Journal of the Hennepin and Ramsey Medical Societies

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

Looking Beyond the Patient in the Room RMS-Ofﬁcers

President James J. Jordan, M.D. President-Elect V. Stuart Cox, M.D. Past President Charles G. Terzian, M.D. Treasurer Peter B. Wilton, M.D.

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

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

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

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The Journal of the Hennepin and Ramsey Medical Societies

groups may ask patients to fill out health history questionnaires that allow the patient to provide such information. When the patient is a child, it is always prudent to assess the parent’s ability to manage a treatment plan. You might, at this point, ask if this is a can of worms we want to open. While we all want the best possible outcome for our patients, our time with them is already limited. Here are some ways in which patients, families, physicians, and even health plans would benefit if we take the extra step: • It is an investment in better outcomes for patients. • Successfully treated patients cause less financial strain on health plans. • If a “virtuous cycle” is initiated, there is the potential for two successfully treated patients, further reducing financial strain. • It creates professionally rewarding opportunities for physicians to interact with colleagues through consultation and referrals. • It doesn’t take as much time as you might think. You may have access to a built-in set of consultation and referral resources and educational materials if you practice within a health care system. If not, the time to develop a small informational library and a short list of resources might be well worth the investment. It could be a rewarding project for a pre-med student or a social work intern. Just as our patients do not exist in a vacuum, neither do physicians. Past columns have referenced data indicating that it is our relationships, both with patients and colleagues, which physicians identify as a primary source of career satisfaction. An investment in deeper patient relationships and broader professional relationships would benefit our patients and our profession as well. Weissman, et.al. Remissions in Maternal Depression and Child Psychopathology A STAR*D-Child Report, JAMA March 22/29, 2006. Vol. 295, No. 12.

July/August 2006

Ramsey Medical Society

RMS-Board Members

A RECENT JAMA ARTICLE (Weisman, et.al.) caused me to pause and reflect upon the limitations doctors face if we focus solely on the patient before us. The cited study referenced a 2-3-fold increased risk for childhood anxiety, depressive and behavior disorders in children whose parents have depression. The children in this study with diagnosed mood or behavior disorders, whose mothers suffered from a depression that was successfully treated, demonstrated a statistically significant reduction in their own symptoms. The study noted a “virtuous cycle” of symptom reduction in both parents and children. This report validates what we know empirically — that our patients do not exist in the vacuum of a clinically-controlled environment. We all understand that children reflect the turmoil or well-being of their parents. What happens when there is another patient who is not in the room? The symptomatic children of depressed mothers provide an excellent example. Let us imagine that successfully treating my patient — a child — requires the administration of medication at prescribed times and dosages, and a regular schedule of therapy. If the responsible parent has untreated depression, her own disease could compromise her ability to help manage my patient’s treatment. Will she be able to arrange transportation for the child’s therapy? Will she be able to administer the child’s medications as prescribed? But if the mother is successfully treated, the child’s life situation improves. Correspondingly, as the child improves, the strain on the mother is relieved, and her symptoms may improve as well. We might hypothesize that a similar “virtuous cycle” could be initiated by successful treatment for any number of conditions in a patient’s parent or significant other. If, for example, I am treating a patient with an anxiety disorder, and her spouse successfully completes treatment for chemical dependency, I would bet that my patient’s symptoms would improve, too. How do we find out about a patient’s life outside the exam room? The patient might mention something directly. The patient’s affect might cause us to ask, “Is there anything else going on in your life that is causing you distress?” Practice

RMS IN ACTION ROGER K. JOHNSON, RMS CEO

2006 RMS Annual Meeting The 2006 RMS Annual Meeting at Midland Hills Golf Club on January 27, 2006, attracted over 100 physicians and guests as Dr. James Jordan of the Hamm Clinic was installed as the 136th president of RMS. The Community Service Award was presented to Dr. Vern Sommerdorf in recognition of his extensive record of service to the community. The program featured a panel discussion on the topic “Doctors: Can we be Devoted Without Being Devoured.” 2006 Winter Medical Conference Thirty physician learners and lecturers were involved in the 2006 Winter Medical Conference at the Melia Vallarta in Puerto Vallarta, Mexico February 18-25. Twenty hours of CME Category I credits were awarded to the participants who evaluated the conference that covered a wide range of medical topics to be superior in quality. Over 50 physicians and their guests enjoyed the resort and the warm and sunny weather in Puerto Vallarta. 2006 Session of the Minnesota Legislature The 2006 Session was gaveled to order in the ﬁrst week in March and was to be a shortened Session in an attempt to atone for last year’s extra Session. The Ramsey Medical Society, working in collaboration with HMS, MMGMA (clinic administrators), MMA, and the Minnesota Provider Coalition, worked on numerous bills. The Supplemental Budget bill enacted at the end of the Session included $2.8 million from the Health Care Access Fund in this biennium and $6.5 million from the General Fund in the next biennium to increase reimbursements for mental health providers, which will increase rates to psychiatrists by 23.7 percent. Other mental health provisions total about $1.7 million. A one-time $1.5 million appropriation

July/August 2006

from the Health Care Access Fund for Health Information Technology Grants to implement interoperable EMR systems was included. Over $9 million was appropriated from the Health Care Access Fund to improve access to dental care for patients on Medical Assistance (MA) and MN Care. $1.8 million in FY 07 and $5 million in FY 08 in funding from the Health Care Access Fund was saved by shifting some GAMC recipients back to the General Fund.

a new mandate and the bill never made it to the ﬂoor of either the House or the Senate. The Department of Commerce has agreed to reconvene a study committee to look at the issue over the interim. A bill to expand the scope of practice of physical therapists by

The provider tax was visited with the introduction of Representative Bradley’s bill to reduce the provider tax based on projected surpluses in the Health Care Access Fund for odd years. The bill was never heard in the Senate but did receive attention in the House. The bill relates to a bill drafted by the Minnesota Provider Coalition to establish a “blinking provision” that would allow the provider tax to ﬂuctuate based on the projected revenue needs from the Health Care Access Fund.

removing the 30 day requirement for physical therapists to refer the patient back to the patient’s physician and allowing patients open access to physical therapists was introduced and received hearings in committee despite the fact that the license for physical therapists allows only evaluation and prohibits diagnosis by physical therapists. The bills, however, never made their way to the ﬂoors of either the Senate or the House.

The Omnibus Insurance bill was adopted although two provisions to provide universal health insurance and to allow for-proﬁt HMOs in Minnesota were not included. The bill does, however, require providers to have on premises an expand-

care approach to no-fault auto insurance coverage. The proposed

ed list of their top 50 procedures

and the average payment they receive from the payers for those services, the payments from public programs, and their charges to uninsured patients. Currently, providers are required to list their top 20 procedures. The Interpreter bill would have required the health plans to support the cost of providing interpreter services for their covered enrollees. Currently, some government programs and workers compensation cover some of the costs. The bill focused on interpreter standards, improvement in government reimbursement and adequate reimbursement from the health plans. The Minnesota Council of Health Plans opposed the bill as

MetroDoctors

Senator Linda Scheid once again held a hearing on her bill to impose a managed

legislation was thwarted by the agreement worked out with the Minnesota Chiropractic Association (MCA) to work with the insurance industry to develop legislation that will correct identiﬁed abuses such as the use of runners to recruit injured patients and to prevent the ownership of chiropractic clinics by non-chiropractors. Citizen’s League Study The Citizen’s League launched a study of medical facility expansion in 2005. Dr. Joseph Tashjian of St. Paul Radiology served on the committee and Dr. Kent Wilson of Midwest ENT offered testimony to the committee. In April of 2006, the Citizen’s League issued its report titled Developing Informed Decisions: Seeking Market Reforms to Advise Medical Facility Expansion. This study could be

the basis for legislative action in 2007. The Journal of the Hennepin and Ramsey Medical Societies

RMS Smoke Free Grants and Activities The Ramsey Medical Society continued its proactive campaign to support smoke free public policies. The Minnesota Part-

RMS Board Meeting

nership for Action Against Tobacco (MPAAT) awarded a grant renewal for $150,000 to RMS for the Dakota County Smoke Free Communities Partnership that will ensure continued

action in Dakota County to July 1 of 2007.

program. (See further details in the article on page 28.) Additional staff will be hired for these projects to build grassroots support in an effort to demonstrate the need for local clean air public policies. In addition to the programs in Dakota and in Washington Counties, RMS is involved with the Ramsey Tobacco Coalition working in St. Paul to support the implementation of the St. Paul Smoke Free ordinance to oppose the attempts to repeal the ordinance through a ballot referendum. Other RMS Actions The Ramsey Medical Society Board of Directors, led by Dr. James Jordan, RMS president, met in April and in February in a joint session with the HMS Board of Directors. The Ramsey Medical Society Executive Committee, chaired by Dr. Jordan, met in March and in May as well as with the HMS Executive Committee in March. The Ramsey Medical Society Foundation Board of Directors,

chaired by Dr. Robert Moravec, met in January and in March. The RCMS, Inc. Board of Directors, chaired by Dr. Peter Bornstein met in February and in May. The RMS Council on Professionalism and Ethics, chaired by Dr. Robert Geist, met in January, February and March. The RMS Council on Education Resources (CME), chaired by Dr. Anthony Orecchia, met in May. MetroDoctors

Ramsey Medical Society

Blue Cross and Blue Shield announced that the RMS application for the Partnership for Healthy Air in Washington County was accepted for the Communities for Healthy Air

The RMS Board of Directors met on Thursday, April 20, 2006 at United Hospital. Attorney Elizabeth Snelson gave a presentation on “Hospital Medical Staff Issues” for the members of the Board. From left front: Drs. Peter Bornstein, Christina Templeton, Frank Indihar, Elizabeth Snelson, J.D., Kim Viskocil, medical student, and Kathi Micheletti.

RMS Caucus

RMS has been allocated 33 delegate positions for the MMA Annual Meeting of the House of Delegates on September 14 and 15 at the Minneapolis Convention Center. Dr. Charles Terzian, RMS past president, chaired a RMS caucus on Thursday, May 25 at United Hospital. The caucus meets to develop resolutions to sponsor at the MMA Annual Meeting. The RMS caucus met a second time on June 7, 2006 to ﬁnalize the resolutions that RMS will bring to the MMA Annual Meeting. Left from front: Drs. Dave Thorson, Todd Brandt, Stuart Cox, and Roger Johnson. Center: Charles Terzian, M.D., Chair. Right from front: Drs. Phillip Edwardson, Lyle Swenson, Vernon Sommerdorf, Robert Geist, and Ronnell Hansen.

RMS Senior Physicians Meeting Thursday, July 20, 2006 11:30 Social/Lunch • Speaker/Program to Follow Location: Bethesda Hospital (Board Room). 559 Capitol Blvd., St. Paul, MN 55103 Speaker: Carol Falkowski, director, Research Communication, Hazelden Foundation Carol Falkowski has monitored drug abuse trends at the local and national level for 20 years as part of an ongoing, drug abuse-monitoring network of the National Institute on Drug Abuse. Falkowski is author of the book “Dangerous Drugs: An Easy to Use Reference for Parents and Professionals.” In 2005 she produced two documentaries about methamphetamine in partnership with Twin Cities Public Television.

Topic: “Current Trends in Drug Abuse” —What Professionals Need to Know “What are the latest trends and issues in substance abuse? Whether purchased over-the-counter or under cover. What do these new, emerging drugs of abuse do, who uses them, and what’s new about them. How is drug abuse different today than in the past?”

Cost: $12.00 for lunch A notice will be mailed to RMS members age 62 and older or if retired prior to age 62. If you would like to attend and do not receive a notice, please call Katie Anderson at the RMS Ofﬁce at (612) 362-3704.

The Journal of the Hennepin and Ramsey Medical Societies

July/August 2006

RMSF Grants Awarded for Health Fairs

t. Paul’s Arlington and Highland Park High Schools each received a grant from the RMS Foundation to help them with expenses associated with the hosting of the Health Fair for St. Paul public school third graders. Arlington High School held the 2006 Health and Environment Fair on May 25 and 26. This was the second year they hosted this event. They educated over 600 third graders from 11 St. Paul elementary schools. There were over 60 total booths, 42 of which were health related. Five of these projects were presented by adults on various issues such as poison prevention, food feeler, food/health, dancing machine and exercise. There were four sessions total — two each day. The third grade students were given a Stamp/Sticker Book upon arrival to the fair and were encouraged

to get a stamp in their book from each of the stations they visited. The high school students really enjoyed working with the young third graders and the third grade teachers appreciated the involvement of the high school students.

Highland Park High School had 18 booths run by seniors from the Advanced Health Class and Psychology Class. They hosted 400 third graders on May 10 and 11, 2006. Some of the favorite booths were bike safety, ﬁtness, nutrition, and dance revolution.

Arlington High School had the third graders put a glow in the dark gel on their hands and then wash them with soap. The kids then put their hands in a box with a black light to show how many germs were still on their hands. Highland Park High School students are educating third grade students about poison prevention.

This display at Arlington High School was developed to show the third graders how much they can see when wearing a mask. The kids put on the masks and then had to bounce a ball on the ﬂoor. They found out that it was not easy to keep track of the ball when they were wearing a mask.

RMSF Receives Four Year Accreditation for CME

High school students at Highland Park High School show third grade students ways to stay ﬁt.

Blue Cross Selects RMS Proposal for Partnership for Healthy Air in Washington County

lue Cross announced on May 26, 2006 that the RMS proposal for the Partnership for Healthy Air in Washington County was selected as one of 11 proposals to promote clean indoor air policies in communities in Minnesota. The Communities for Healthy Air is a Blue Cross initiative and is part of Prevention Minnesota, a long-term Blue Cross initiative. The RMS proposal was selected after undergoing a two-part expert review process. The budget and contract agreement with Blue Cross are now being developed. The 28

July/August 2006

Partnership will be launched this summer in Washington County with the hiring of staff to implement grassroots community assessments and organizing. Physicians, clinics, and hospitals interested in working to achieve healthy air in Washington County are urged to participate in the Partnership for Healthy Air in Washington County. Please contact the RMS ofﬁce at (612) 362-3704 if you wish to join the Partnership.

MetroDoctors

n May 30, 2006 the MMA Committee on Accreditation and CME announced that the Ramsey Medical Society Foundation was granted continued, full accreditation for four years effective May 25, 2006. “As chair of the Council on Education Resources (CME) I am very proud of receiving full accreditation from the MMA. This is quite a distinction for RMS as we join a handful of county societies in the entire U.S. to be accredited as a CME provider,” said Dr. Anthony Orecchia. The Ramsey Medical Society Foundation sponsors the Annual Winter Medical Conference and local conferences on identiﬁed education needs of interest to the local medical community. The Ramsey Medical Society includes physicians of all specialties. If you are a physician member of RMS and you are interested in serving on the Council on Education Resources, please contact the RMS ofﬁce at (612) 362-3704.

The Journal of the Hennepin and Ramsey Medical Societies

CHAIR’S REPORT JAMES A. ROHDE, M.D.

“Healing Hands for Haiti”

BY THE TIME THIS APPEARS in print,

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

I will have returned from my second trip to Haiti. In January 2005 I joined 18 other Midwesterners (a few from Iowa and Wisconsin) who made up the Minnesota team of “Healing Hands for Haiti.” Along with 11 other teams, we take turns visiting Port-au-Prince where our clinic sees and treats persons with disabilities. This time I will be joining one of the Salt Lake City teams. I have always wanted a mission to add to my more routine practice. Medical missionaries were my inspiration when I was a child and got me thinking about medicine as a vocation. In medical school, at the University of Michigan, I had the opportunity to spend ﬁve months at Mount Silinda Mission on the eastern border of Rhodesia (now Zimbabwe). I returned to Rhodesia after my internship and worked in two other mission hospitals. During the same time, I visited numerous rural clinics. This was the beginning of my awareness and an interest in family medicine at the University of Michigan. After a year as a surgical resident at Hartford, I found the University of Minnesota Family Medicine Department and Clinic where I did two years of training. In 1975 I joined John Beecher, M.D. in forming the Meadowbrook Family Care Clinic. During that ﬁrst year I was invited to join Courage Center as a staff physician for the residence. I was interested and willing to take on the mission of learning to care for persons with disabilities. Except for three years in the late 1990s, when I took time off and helped start an organization called “AXIS Healthcare,” I have been on staff at Courage Center until just recently. I have made my last set of rounds at Courage Center to devote more time to “Healing Hands for Haiti” and an occasional round of golf. Courage Center is one of the top organizations in Minnesota for its reputation and creativeness. Two particular organizations have spun off of the Courage Center Residence. One is Accessible Space Incorporated (ASI) that has

HMS-Board Members

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

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

Jack G. Davis, Chief Executive Ofﬁcer Sue Schettle, Director, Marketing & Member Services Kathy R. Dittmer, Executive Assistant

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The Journal of the Hennepin and Ramsey Medical Societies

helped meet the need for accessible housing. ASI was started in 1978 with six duplex-type facilities housing six disabled individuals each. This has grown now to 83 sites in 24 states with 16 more under construction that will increase its presence to 28 states. Currently, 1647 adults with physical disabilities and seniors get their housing through ASI. There are another 68 affiliated sites where ASI provides services. In the late 1990s, another organization called AXIS Healthcare started as Chris Duff partnered Courage Center with Sister Kinney in an attempt to provide coordination of the care of the disabled. The first few dozen patients came out of my practice, as I was their first Medical Director. Since then, they have moved on to an organization that serves 650 clients and is growing monthly. Thus, the last 30 years have given me the confidence in taking care of people with disabilities. This was translated during my first trip to Haiti in providing medical backup for the physical medicine rehabilitation leader Dr. Steve Fisher who works out of Hennepin County and Regions Hospitals. Our clinic in Haiti provides physical therapy, occupational therapy, and particularly prosthetic work. It also includes a pharmacy, a wheelchair fitting and repair service, and many other aspects of caring for the disabled. My upcoming trip will go far beyond the first one in its scope as I will be traveling to such areas as Leogane and also Cange, the clinic of Dr. Paul Farmer. Paul is the Harvard physician featured in the book Mountains Beyond Mountains. We will also be doing some work in a village near the Dominican Republic border that requires a one hour donkey ride to finish the trip. Most of these visits will be (Continued on page 31)

July/August 2006

Hennepin Medical Society

HMS-Ofﬁcers

HMS NEWS

HMS Caucus Gets Ready for MMA Annual Meeting

he physician delegates of the Hennepin Medical Society met on Wednesday, May 24, 2006 at the HMS Caucus to discuss various resolutions that were brought forward by HMS physician members. The HMS caucus is chaired again this year by Carl Burkland, M.D., family physician from the Parkview Medical Clinic in New Prague. Dr. Burkland guided the sometimes-lively discussion on the resolutions in an effort to gain consensus from the physician delegates. The next opportunity to discuss the resolutions will be at the Minnesota Medical Association’s annual meeting in September where HMS will hold another caucus prior to the resolutions being introduced to the various MMA reference committees for further consideration.

Call for Delegates

physicians and medical students are needed for the Hennepin Medical Society’s Delegation to the Minnesota Medical Association’s Annual House of Delegates Meeting. HMS will reimburse delegates $100 for parking and transportation expenses at the MMA Annual Meeting. Thursday-Friday, Sept. 14-15, 2006 Minneapolis Convention Center

Visit www.metrodoctors.com. On the left side of the screen, click Hennepin Medical Society. The last topic listed, “MMA House of Delegates Annual Meeting Information,” provides more information. If you have any questions or want to be a delegate, contact Kathy Dittmer at (612) 623-2885, or kdittmer@mnmed.org.

July/August 2006

Some of the resolutions presented this year include asking MMA to: • Lobby insurance companies to increase the conversion factors for those clinical practices that have fully implemented electronic medical records and electronic prescribing. • Advocate for increasing excise tax on beer, wine and spirits to keep pace with inﬂation, and to educate the media and public about the appropriateness of increasing the alcohol excise tax in order to adequately fund the real health impact costs of alcohol use by Minnesotans. • Introduce and support legislation that prevents health insurance plan discrimination against maternity carveouts. • Introduce and support legislation that requires pharmacies to dispense FDA approved medication for emergency contraception after receiving a valid prescription from a physician. • Introduce and support legislation that requires all Minnesotans to be covered by a very basic health care coverage plan. • Recommend removing sugar-added pop (non-diet pop, sports drinks), and sugaradded juices from vending machines and hospital cafeterias, and replace them with healthier options. To read about these resolutions, and others, that were brought forward at the May 24, 2006 HMS caucus, visit our Web site at www.metrodoctors.com. If you have an idea for a resolution, it isn’t too late. Please contact Sue Schettle, Director of Marketing and Member Services for HMS at (612) 623-2889, or e-mail her at sschettle@metrodoctors.com.

From left: John Larsen, M.D., Vice Speaker of MMA House of Delegates; Paul Kettler, M.D., HMS President; Carl Burkland, M.D., HMS Caucus Chair; and Jack Davis, CEO of HMS discuss caucus proceedings prior to the start of the HMS Caucus.

John Larsen, M.D., HMS member and Vice Speaker of MMA House of Delegates, addresses the HMS caucus on May 24, 2006. Dr. Larsen sought input in the MMA’s focus on health care reform.

Paul Pentel, M.D., internist/medical toxicologist from HCMC, presents his resolution to the HMS Caucus.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

HMS Chair’s Report (Continued from page 29)

HMS is Awarded Three Additional Grants

that HMS was involved with in Minneapolis, Hennepin County, Edina, Golden Valley and Bloomington. The grant from BCBS begins in July Sue Schettle 2006 and has three phases. The ﬁrst phase focuses on planning and building and can last up to 18 months. Each of the next two phases are subject to renewal by BCBS. The total project could last for 3½ years. If you live or practice in Scott County and want to be involved at some level in this project, please be sure to contact Sue Schettle, HMS Director of Marketing and Member Services/Tobacco Prevention Coordinator, at (612) 623-2889, or e-mail her at sschettle@ metrodoctors.com.

HMS Quit and Win

sing grant dollars from the Minnesota Department of Health, HMS funded the 2006 Quit and Win program administered by the University of Minnesota and Boynton Health Services. This contest is designed to encourage college students to stop smoking by

Ed Ehlinger, M.D., medical director of Boynton Health Services, and Jack Davis, CEO of HMS, stand with three of the winners of the Quit and Win program for 2006.

MetroDoctors

offering them an attractive incentive. Of the 616 college students who participated, 73.2 percent reported that they were smoke-free for the entire month of April. Boynton Health Services will administer Quit & Win on eight additional college campuses in the fall of 2006 with funding from Blue Cross and Blue Shield of Minnesota.

Ed Ehlinger, M.D., medical director of Boynton Health Services, and Jack Davis, CEO of HMS, present college student Kari Peterson with the grand prize—a $3,000 gift certiﬁcate.

The Journal of the Hennepin and Ramsey Medical Societies

HMS Has Updated its Web Site — www.metrodoctors.com

lease take some time to visit our new Web site to learn about the work that we are doing on behalf of our members. We understand how vital it is to let our members know about the work that we’re doing, so we’ve spent some time over the last few months updating the content and functionality of our Web site, together with the Ramsey Medical Society. If you know there is a meeting that is coming up, but you don’t know where it is — refer to our Web site. If you know that we’re working on a particular issue, but you don’t recall exactly everything that you’d like to know, it’s all there. If you have feedback that you’d like to give to us about a particular issue, or ask us to check into something on your behalf — there is a place for that, too. Visit us at www.metrodoctors.com July/August 2006

Hennepin Medical Society

ennepin Medical Society is pleased to announce that we have been awarded three additional grants by two organizations that will allow us to continue our secondhand smoke policy work in our service area. Two of the grants are from the Minnesota Department of Health, totaling $30,000, and they are to be used to conduct public opinion polls in Scott County and Carver County in 2006. The results of the public opinion polls will be shared with elected ofﬁcials, business leaders and others as they consider enacting smoke-free policies in their communities. HMS also received confirmation that we have been awarded a grant maximum of $250,000 from Blue Cross and Blue Shield of Minnesota under its newly created Communities for Healthy Air effort. The focus of this grant will be on Scott County, and will follow the same methodology as the campaigns

general medicine and will not speciﬁcally involve rehabilitation but will provide us with a broader view of the medical care needs of Haiti. An interesting fact is that over 8 million people live in Haiti. They account for 2 percent of the births in the Caribbean area. On the other hand, they account for 19 percent of the deaths among children under age 5. This gives them a child mortality rate of well over 100 per 1,000. Hopefully with a new popularly elected government again in place, and the support of organizations such as ours, and the surrounding countries of the Caribbean and North America, Haiti will start making the progress that is long overdue. All physicians, and indeed all humans, need a mission that carries them beyond the daily task of life. I will take plenty of pictures to document some of the more interesting work that we will be involved with when I am in Haiti so that I can report to you in a future article in MetroDoctors. If any of you have a chance at the upcoming MMA meetings to talk to me, I would be glad to personally relate my experiences.

In Memoriam

HMS Hoban Scholarship Event

ormer Chief Executive Ofﬁcer of Hennepin Medical Society, Thomas W. Hoban, together with his wife Mary Kay, were in town recently to take part in the 2005 Hoban Scholarship Event. The Thomas W. and Mary Kay Hoban Scholarship was established by the Hennepin Medical Foundation to honor and recognize the 25-years of service that Mr. Hoban provided to the Hennepin Medical Society.

The Hoban Scholarship funds are managed by the Hennepin Medical Foundation, which grants scholarships on an annual basis. Awards are provided to selected applicants pursuing graduate level education in health care management/administration and nutrition. This year’s event was held on Tuesday, May 16, 2006 at the Edina County Club.

From Left: Thomas W. Hoban, Mary Kay Hoban, and 2005 scholars: Debra Thingstad Boe, Anna Henry, Sue Schettle, Jennifer Dobratz, Kara Mitterholzer, Darla Morris-Preble (past scholar) and H. Thomas Blum, M.D.

Dr. Richard Streu, President of the HMS Senior Physicians Association and Kevin Smith, president and chief executive ofﬁcer of the Minnesota Opera.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

July/August 2006

RONALD E. CRANFORD, M.D., died on May 31. He was 65. As a medical-ethical consultant and neuroethicict, Dr. Cranford was involved with numerous landmark right-to-die cases in the United States and served as an advisor and a consultant to several national commissions on right-to-die issues, including deﬁning death and persistent vegetative state, as well as ethical issues regarding the terminally ill. Dr. Cranford was a professor of neurology at the University of Minnesota Medical School, and senior physician and assistant chief of neurology at Hennepin County Medical Center. He was the recipient of the Shotwell Award in January 2006. Dr. Cranford joined HMS in 1976. WILLIAM DANIEL KELLY, M.D., died on May 13 at the age of 83. Following in the footsteps of his father and uncles, he chose to become a medical doctor and in 1946 graduated second in his class from the University of Minnesota Medical School. He then served two years in the U.S. Army Medical Corps, including one year in Japan. Upon returning to the U.S., he developed an interest in medical research and in 1955 he obtained a Ph.D. in physiology. Thereafter, he conducted pioneering research in organ transplantation at the University of Minnesota, where he established the kidney transplant program. Notably, he led the team of surgeons that performed the ﬁrst successful pancreas transplant in the world. In 1966 he joined a private practice of cardiovascular and thoracic surgeons. He retired in 1991. Dr. Kelly joined HMS in 1968.

HMS Senior Physicians Association he HMS Senior Physicians met on Tuesday, April 25 at the Zuhrah Shrine Center in Minneapolis. Mr. Kevin Smith, president and chief executive ofﬁcer of the Minnesota Opera was the guest speaker. Mr. Smith provided the retired physicians with an overview of what it takes, ﬁnancially and artistically, to run a theatre production. A lively discussion followed. If you are interested in learning about upcoming Senior Physician events, please contact Kathy Dittmer at (612) 623-2885, or e-mail her at kdittmer@metrodoctors.com.

WILLIAM H. CARD, M.D., 82, died on April 8 at the Sherman Home, Hospice of the Valley in Phoenix, Arizona. He received his medical degree from the University of Minnesota. After internships and residency at HCMC and the Armed Forces Institute of Pathology, he joined the U.S. Navy Medical Corps. After serving ﬁve years, he concluded with the rank of Lt. JG. Dr. Card established a private practice, which he nurtured for 35 years. He served from 1956 to 1989 on the staff at MMC, Fairview and Southdale Hospitals. As a member of the American Urologic Society, he received the Distinguished Service Award in 1974. Among his other ofﬁces, he served as a professor at Hennepin County General Hospital and as president of the Midwest Section of the AUA. In his retirement, Dr. Card committed himself to further study at Scottsdale Mayo. Dr. Card joined HMS in 1951.

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Membership Advantages for Physicians and their Practices NEW I.C. System

is a Minnesota (St. Paul) based company specializing in full-service revenue cycle management solutions for the health care industry. They are now offering RMS members effective, ethical, and cost effective solutions to collecting debts, improving cash flow and reducing costs. For more information and a no-obligation price estimate, please contact I.C. System directly at 1-800279-3511 and let them know you are a RMS member.

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

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

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

Call RMS at 612-362-3704 for details.

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