Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY
May/June Index to Advertisers TCMS OfďŹ cers
Acute Care, Inc. .................................................30
President Thomas D. Siefferman, M.D.
Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D., MTS Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reect the ofďŹ cial position of TCMS. Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Katie Snow at (612) 362-3704.
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May/June 2011
AmeriPride...........................................................27
President-elect Peter J. Dehnel, M.D.
ClassiďŹ ed Ad .......................................................29
Secretary Edwin N. Bogonko, M.D.
The Davis Group .............. Inside Front Cover
CrutchďŹ eld Dermatology................................21 Fairview Health Services .................................29
Treasurer Melody A. Mendiola, M.D.
HCMC .................................................................19
Past President Ronnell A. Hansen, M.D.
Healthcare Billing Resources, Inc. ................. 2 Lockridge Grindal Nauen P.L.L.P. ...............21
TCMS Executive Staff
Kathy Madore....................................................... 1
Sue A. Schettle, Chief Executive OfďŹ cer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Assistant Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Katie R. Snow, Administrative Coordinator (612) 362-3704 ksnow@metrodoctors.com
Minnesota Epilepsy Group, P.A....................14 Minnesota Physician Services, Inc. ..............24 MN Org. on Fetal Alcohol Syndrome.......... 8 The MMIC Group .............Inside Back Cover MMIC Health IT ........... Outside Back Cover Pediatric Home Service .....Inside Back Cover Saint Therese.......................................................14 U.S. Army ............................................................31 Welcyon/Fitness After 50................................16
For a complete list of TCMS Board of Directors go to www.metrodoctors.com.
Winona Health ..................................................31
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MetroDoctors
The Journal of the Twin Cities Medical Society
CONTENTS VOLUME 13, NO. 3
2
Index to Advertisers
4
LETTERS
M AY / J U N E 2 0 1 1
Myth vs. Reality. Fact vs. Fiction Correction
5
IN THIS ISSUE
Don’t Get Mad, Get Data! By Gregory A. Plotnikoff, M.D., MTS
6
PRESIDENT’S MESSAGE
Law of Unintended Consequences is Just that, a Law! By Thomas Siefferman, M.D. Page 9
7
TCMS IN ACTION By Sue Schettle, CEO
9
COLLEAGUE INTERVIEW
Patricia F. Walker, M.D., DTM&H GOOD DATA...BAD DATA
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s Good Data: The Provider Peer Grouping Example By Edward P. Ehlinger, M.D., MSPH
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s Erroneous Facts, Spurious Data and Policy Dogma: Critical Thinking Required By Buz Cooper, M.D., as told to Gregory A. Plotnikoff, M.D., MTS
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s Transparency in Physician Cost and Quality By Jim Guyn, M.D.
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s Ensuring Credibility in Minnesota’s Health Care Quality Measures By James Chase
Page 13
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YOUR VOICE
An ACO Analysis By Robert W. Geist, M.D.
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New Health Care CEO: Kenneth H. Paulus, President and CEO, Allina Hospitals and Clinics
26
West Metro Medical Foundation
27
Obesity Prevention Coalition is Launched
28
WMMS Alliance—The End of a 100-year Era
29
In Memoriam New Members Career Opportunities
32 Page 28 MetroDoctors
LUMINARY OF TWIN CITIES MEDICINE
Owen H. Wangensteen, M.D. The Journal of the Twin Cities Medical Society
On the cover: Data can be used in many forms. But, how good or valid is it? Several authors describe their work. Articles begin on page 13. May/June 2011
3
LETTERS
Myth vs. Reality. Fact vs. Fiction The Sunday, March 6, 2011 Star Tribune carried a superb article on property taxes in Minnesota, and who carries the brunt of this burden. Answer — suburban homeowners. The article got us thinking about another major Minnesota issue, and the beliefs surrounding this program, its application and administration. That program is Medicaid. What if there was a “Voss Report” (the title of the property tax study prepared by the Minnesota Department of Revenue) for this program, the cost of which now totals $7 billion per year of federal and state monies, according to a report issued by Minnesota’s major health care plans and providers?
Much in the news today are various state governmental proposals to reduce this ever-expanding category of health care expense: s Decrease payments to physicians, longterm care facilities and hospitals s Decrease benefits to recipients s Increase eligibility requirements s Decrease covered services s Impose co-pays for some services While any, all or some combination of these solutions might be appropriate; a detailed study of the Minnesota Medicaid Program that could answer the following questions could prove very beneficial to all of
CORRECTION: Two lines were transposed in the chart accompanying the Minnesota and the Emerging ACO article by George Isham, M.D. in the March/April 2011 issue. This chart correctly reflects optimal diabetes control and the percent of patients who would recommend HealthPartners clinics.
TRIPLE AIM: Health Experience Affordability HealthPartners Clinics 42.5%
1.000 97.1%
97.6%
TOTAL COST INDEX
0.980
0.960
0.940
45%
35%
95% 25%
0.920 15% 9.0%
0.900
0.8952
4Q
04 1Q 05 2Q 05 3Q 05 4Q 05 1Q 06 2Q 06 3Q 06 4Q 06 1Q 07 2Q 07 3Q 07 4Q 07 1Q 08 2Q 08 3Q 08 4Q 08 1Q 09 2Q 09 3Q 09 4Q 09 1Q 10 2Q 10 3Q 10
0.880
Total Cost Index (compared to statewide average) < 1 is a better than network average
% Patients w/optimal Diabetes Control* * controlled blood sugar, BP and cholesterol (per ICSI guideline A1c changed from <7 to <8 in 1Q09 and BP control changed from <130/80 to <140/90 in 3Q10), AND daily aspirin use, AND non-tobacco user
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May/June 2011
% Patients “Would Recommend” HealthPartners Clinics
90% 5%
the residents of our great state — those who consume these services and those who pay for them: s Who are these people that utilize Medicaid dollars? s How did they become Medicaid recipients? s Why is Minnesota’s average cost per Medicaid enrollee the fourth highest in the country, even though Minnesota is 21st in population size among the 50 states? s How are the Medicaid dollars allocated, and why do the disabled and the children get approximately $2 for every $1 received by the elderly? s If some nursing homes have to close because of a funding shortfall, is this necessarily a bad thing? s Are long-term care policies the answer? s Should all of Minnesota’s Medicaid population be enrolled in managed care plans? s Is there a major role for mobile medicine and home-based primary care in the reduction of Medicaid expenditures? s What will happen to the State of Minnesota’s Medicaid program when Federal Assistance is cut? s Can reducing and/or eliminating fraud and abuse in the State Medicaid program significantly lower its cost? s Once people get on Medicaid, do they ever get off? In other words, has it become a permanent entitlement rather than a temporary assistance program? s Are alternative housing and day programs a viable alternative to the use of personal care assistants? To enact good public policy, we need to have evidence-based decision-making, a study along the lines of the “Voss Report” would certainly aid in moving our policy makers in that direction. As Joe Friday would say: “The facts madam, just the facts!” Peter R. Bartling, is a health care consultant in Plymouth, MN. Letters to the Editor and “Your Voice” opinion pages are encouraged. Please limit your writing to 750 words and email to nbauer@metrodoctors.com.
MetroDoctors
The Journal of the Twin Cities Medical Society
IN THIS ISSUE...
Don’t Get Mad, Get Data!
TEACHING IN A JAPANESE MEDICAL SCHOOL for six years taught
me the tremendous value U.S. medical culture places on quantitative data. In Japan imaging is used much more than quantified measurements to guide diagnosis and treatment. In the U.S., numbers are important and we favor the authority of measurements and quantities; e.g. we prefer to know there’s a 70 percent chance of successful surgery rather than “a good chance.” Mentor Nickie Lurie, M.D., taught me this great lesson: “Don’t Get Mad, Get Data!” Clearly, this is sage advice. But, I have added an amendment. As with surgical forecasting, the great challenge is not just to obtain data but to obtain good data. Researchers know that it is far easier to obtain bad data than good. Why? We are human and go looking for the key where the light is brightest — following the path of least resistance. We obtain a number we like and we pronounce it good. But is it valid? We physicians like summary statistics which simply and elegantly communicate a great deal of information. Examples include means, central tendencies, standard deviations, etc. However, we physicians must recognize that such statistics may hide as much as they highlight. This issue gives us the chance to ponder the challenges of recognizing and obtaining good data. Ed Ehlinger, M.D., Commissioner of Health, Jim Chase, Minnesota Community Measurement project, and Jim Guyn, M.D., medical director at Medica, give us the opportunity to review their reasoning and their current challenges — hopefully with good rather than bad data. How do we define the “normal” reference population and do we treat all patients on a bell curve similarly? Do clinical guidelines only treat the mean and not the tails? This can be problematic for physicians like Pat Walker, M.D., who treat minority culture populations (see page 9). Elsewhere in this issue, Buz Cooper, M.D. provides us with concrete examples of how summary statistics for public policy may harm physicians and patients. Specifically, he cites clinically relevant factors that have been hidden in summarized data used by policy makers (see page 15). Many Minnesota physicians are rightly wary of current attempts to quantify and grade “quality” and “efficiency.” We need to ask the
By Gregory A. Plotnikoff, M.D., MTS Co-editor, MetroDoctors
MetroDoctors
The Journal of the Twin Cities Medical Society
following questions to ensure that any analyses ses off patient care data are based upon “good data.” 1. Is the independent or explanatory variable able valid? Does the same outpatient ICD-9 code de fairly summarize variation in clinical severity and patient context? Is there any intra-observer and inter-observer reliability in coding? 2. Is the analysis more convenient than objective? Is there a variation in severity not captured by additional ICD-9 codes? Can the analytic algorithms handle the necessary number of accompanying ICD-9 codes? Or, is there an arbitrary cutoff of the number of applicable ICD-9 codes that restricts the complete picture? 3. Is the data from the right time frame? Is there a difference between an episode of care and a trajectory of care? 4. Does the patient matter? Are non-quantifiable values, including patient values, considered in the analysis? Should one size fit all? 5. Does the data truly matter? Are the “correct” outcomes being measured? What values, and whose values, define the “correct” outcomes? Who defines the “correct” outcomes? These questions will lead us to many policy considerations. Fundamentally, should the linear urgent-care model of episodic diagnosis, treatment, resolution be applied to care data for patients with chronic illness? Should quantified severity and life interference scores, such as the Brief Pain Inventory or Brief Fatigue Inventory, be included in analyses? Should some assessment of coping skills or social/environmental stressors be included? Should all process and outcome assessments also include measurement of any potential negative impact on existing finances, operations and culture? Finally, in this issue Marvin Segal, M.D., shares with us stories that demonstrate the greatness of Owen Wangensteen, M.D. (See page 32). He was world-renowned for so many reasons including development of gastric hypothermia for treatment of gastric hemorrhage. Relevant to our theme of good data/bad data, his superb outcomes supported the widespread use of this treatment. Only after a prospective, randomized controlled trial was it discovered that the great outcomes were due to the placebo effect of Dr. Wangensteen himself. Might this be the most important data of all?
May/June 2011
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President’s Message
Law of Unintended Consequences is Just that, a Law! THOMAS SIEFFERMAN, M.D.
T
hroughout human existence, human actions on things around him has often had unanticipated results, both good and bad. And it has commonly been accepted that we can thank an American sociologist for the “Law of Unintended Consequences” (LAW) becoming a popular concept. Medicine, like any other human endeavor, is filled with examples both good and bad. I frequently joke with my veterinarian sister that if it were not for antiseptics, no one would allow her to operate on their pets. The intention of antiseptics was to clean surfaces, and its usage in the surgical field created a positive unintended consequence of making surgical treatments not only successful but also commonplace. More commonly, we come upon the negative results of certain interventions. In the news recently, there has arisen a clamor for justice in the obstetric world as the cost of progesterone injections will rise from $20 to $1,500 in order to give us a greater consistency and assurances of quality. Rightly, the obstetric community was worried about the varied quality and efficacy of commonly compounded preparations of progesterone. By giving the right to be a sole provider of FDA approved progesterone, KV Pharmaceutical Company can now charge whatever it wants and whatever the market will bear. Albeit, it is not a true marketplace, rather it is a very artificial government sponsored monopoly. Once more proving the adage that there are many great doctors in the world, but they are nearly all lousy at business and politics. To think that a government backed monopoly would charge a pittance for the medical-legal risks associated with pregnancy was poorly played on our part and a great day for the stockholders of said company. Multiple victims of the LAW here. Even in the halls of Washington D.C., our gracious American Medical Association was played like a fiddle. The AMA agreed to back the federal takeover of one sixth of the United States economy, under the “promise” of the dreaded Sustainable Growth Rate issue being finally fixed. The AMA failed to learn in school that you get what you want before you give away your reputation; the current administration received the official blessing from the AMA and the AMA got, well, nothing. Many physicians feel the AMA sold physicians out, and the AMA became the victim of the LAW. Even politicians at the top of their game are often “victims” of the law of unintended consequences; unfortunately, it is doctors and pharmacists that are paying for their mistake and are the true victims of the LAW. Congressional staffers included many annoying provisions in the crevices of Obamacare (Patient Protection and Affordable Care Act). One that has hit pediatricians and, subsequently, pharmacists, has been the provision that in order to use their funds from tax protected Health Savings Accounts and “Flex” Accounts to purchase Over the Counter medications (OTCs), a physician has to provide you with a prescription. The politicians were trying to take money spent on OTCs and add it to the federal accounts to hide some of the costs associated with Obamacare. But Americans are rightfully skeptical of the beast known as the federal government. Americans not only want to keep their money but many of them also need to keep their money. So, doctors have to either write prescriptions for OTCs, and pharmacists have to print up labels for OTCs, or both are refusing to and further alienating their patients or parents. And who pays for this time and effort? Some doctors are charging for it, or making the patients come in to the office and be seen to get the prescriptions, thereby increasing the cost of medical care. More upsetting it seems to the politicians, many patients are requesting prescription medications instead of using the less costly OTCs; think Nexium versus Omeprazole OTC as a common example. Once again, physicians, and non-physicians, like all humans before us, need to step back and think before leaping, passing judgment, pleading for legislation, demanding relief, and other actions. Remember, even the best of solutions can have unintended consequences. We need to stop whining about the other guy’s mistakes; instead, get rid of the error and look for a better solution.
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May/June 2011
MetroDoctors
The Journal of the Twin Cities Medical Society
TCMS IN ACTION SUE A. SCHETTLE, CEO
Community Engagement Director Joins Honoring Choices Minnesota
The financial support that TCMS has received from various community and health care funders to support the Honoring Choices Minnesota project has given us the opportunity to hire a full-time Community Engagement Director. Barbara Greene, MPH started with TCMS on February 28 and hit the ground running connecting with key individuals and organizations to explore opportunities for outreach and collaboration. Barbara specializes in multicultural hospice, palliative care and end-of-life training and education. She has worked professionally with national, state and local organizations to train physicians, nurses, social workers, chaplains, music therapists, board members and others on culturally sensitive end-oflife care for patients and families. Barbara has contracted with TCMS for two-three years focusing entirely on engaging diverse communities in the Honoring Choices Minnesota initiative. She can be reached at (612) 623-2899 or bgreene@metrodoctors.com. TCMS Has a New Executive Assistant
Andrea Farina joined TCMS March 21 serving as our executive assistant. Andrea has strong administrative and organizational skills which will be put to good use as she works to manage the metrodoctors. com website, assist in marketing and MetroDoctors
communications, database management and membership analysis as well as provide overall administrative support. We are really pleased to have her on board. Andrea can be reached at (612) 623-2885 or email at afarina@metrodoctors.com. TCMS Welcomes Eight New Board Members
Carolyn McClain, M.D., an ER physician with Emergency Physicians, PA; Matthew Hunt, M.D., neurosurgeon from the University of Minnesota Physicians; Lisa Mattson, M.D., ob/gyn from Allina Medical Clinic – Fridley; Cole Greves, M.D., perinatologist from Minnesota Perinatal Physicians; and Sanjiv Kumra, M.D., Child & Adolescent Psychiatry, University of Minnesota Physicians. Medical students Jessica van Lengerich and Laura Gorsuch have also been appointed to the board as well as MMGMA president-elect, Erik Crockett. TCMS Caucus
The TCMS Caucus will be held on Monday, May 2, 2011 at the Broadway Ridge Building — Conference Room D — 3001 Broadway Street NE beginning at 6 p.m. If you have ever wondered what happens at a caucus, this is your chance to explore the process. The Caucus is a meeting of TCMS members who have brought forward ideas or issues that they would like discussed at the Minnesota Medical Association. I strongly encourage you to attend the TCMS caucus and the MMA annual meeting in Duluth September 15 and 16. Please submit your resolutions in advance and RSVP to Andrea Farina at (612) 623-2885 or email her at afarina@metrodoctors.com. MMA Annual Meeting Changes
meeting. A Resolution Review Committee will review all resolutions submitted by the July 1 deadline and prepare a report of recommendations on how to manage each resolution. Reference Committee deliberations will begin on Thursday at 1:30 p.m. These changes are resulting from a report that was submitted and ultimately approved by the House of Delegates at the 2010 MMA Annual Meeting in Brainerd. Foundations Embark on Strategic Planning Retreats
The East Metro Medical Foundation and the West Metro Medical Foundation will independently embark on strategic planning retreats in mid 2011. When the East Metro Medical Society and West Metro Medical Society merged at the end of 2009 the Foundations of each organization remained intact. The merger allowed for the preservation of the assets of each of the Foundations while supporting the desire to continue to fund initiatives in the East Metro and West Metro communities separately. The strategic planning retreats will help to focus the mission and work of the Foundations for the next five years. Join the MetroDoctors Editorial Board
Interested in serving on the MetroDoctors editorial board? For more information contact Nancy Bauer, managing editor, (612) 623-2893 or nbauer@metrodoctors.com.
The MMA Annual Meeting will be held on Thursday and Friday, September 15-16 in Duluth with the functions of the opening session held electronically prior to the
The Journal of the Twin Cities Medical Society
May/June 2011
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You wouldnâ&#x20AC;&#x2122;t give a 3-year-old a drink, so why would you give one to an unborn child? As a physician, itâ&#x20AC;&#x2122;s your responsibility to let her know: the U.S. Surgeon General Advisory says no amount of alcohol is safe during pregnancy. Share 049: Zero Alcohol For Nine Months.
www.mofas.org
COLLEAGUE INTERVIEW
A Conversation With
Patricia F. Walker, M.D., DTM&H
P
atricia F. Walker, M.D., DTM&H served as the medical director at HealthPartners Center for International Health from 1988-2010. She attended Mayo Medical School and Mayo Graduate School of Medicine. She received her Diploma in Tropical Medicine and Hygiene from the London School of Hygiene and Tropical Medicine in 1997, and clinical tropical medicine as part of a Bush Foundation Medical Leadership Fellowship at Chiang Mai University in Thailand. She received her Certificate in Tropical Medicine and Travelers Health from the American Society of Tropical Medicine and Hygiene, and a Certificate of Knowledge in Clinical Tropical Medicine from the International Society of Travel Medicine. Dr. Walker is an associate professor, Division of Infectious Disease and International Health in the Department of Internal Medicine at the University of Minnesota, and the associate medical director of the Global Health Pathway. She chaired the State of Minnesota Immigrant Health Task Force from 2002-2004, and, she co-edited a medical textbook published in October 2007, Immigrant Medicine. She is currently pursuing a five-year Global Health Fellowship from the Medtronic Foundation and will be working at HealthPartners Research Foundation to translate best practices in refugee and immigrant health care to useful EMR tools for clinicians. She maintains an active practice in clinical care of refugees and immigrants. She speaks Thai and Cambodian.
How does the health of immigrants and refugees compare to other Minnesota populations? Most of the detailed data we have about the health status of immigrants applies specifically to refugees, and that data cannot be generalized to all immigrants. As you know, refugees must prove a “well-founded fear of persecution” in order to come the United States. Other immigrants are a larger and very diverse group including professionals, students, adoptees, as well as undocumented immigrants. Refugees account for 70,000 new migrants to the U.S. every year; legal immigrants another one million per year. Approximately 12 million illegal immigrants live in the U.S. — 4 percent of the population. We know a lot about the health status of refugees because of international screening which occurs under CDC auspices, as well as domestic refugee screening. Ninety-seven percent of refugees to Minnesota are seen for a new arrival screening examination within a few months after arrival here, and our screening protocols are considered a national best practice. Refugees do have a higher burden of certain infectious diseases including tuberculosis, hepatitis B carrier status and common intestinal parasites. Many refugees are healthy aside from treatable infectious diseases when they arrive. Unfortunately, the longer time they spend in the U.S., the more chronic non communicable diseases they develop.
The term “cultural competence” is applied to clinicians who work with patients of varying ethnic or cultural backgrounds. How is the notion of “cultural competence” relevant to your clinical work and training of clinicians? We cross many cultures in health care every day. We cross the culture of a male physician and female patient, literate provider and a patient with lower health literacy, race/ethnicity, and sexual preference, among others. As providers, we come to the encounter with the culture of medicine as well as our personal culture of origin influencing our beliefs and behaviors. Our patients may come to us with an entirely different belief system about health and disease. Cross cultural conflicts occur as a result. There are some very useful websites which can help providers learn a little bit about the history and culture of our patients’ country of origin and health belief systems. That being said, generalizing can wreck havoc in clinical settings. Your clinic may distribute handouts in Hmong for patients, for example, but older patients may not be literate, and their children may want handouts in English. The Institute of Medicine Quality Chasm report recommends redesigning the health care system around six qualities including providing care which is safe, timely, effective, efficient, equitable and patient centered. I like to think about (Continued on page 10)
MetroDoctors
The Journal of the Twin Cities Medical Society
May/June 2011
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Colleague Interview (Continued from page 9)
“patient centered care in the global village.” Because we cannot know everything about every patient from every culture, the fastest, most effective approach is to be curious, open minded, and to ask questions about health beliefs, practices, and patient treatment goals. We also all need to be aware about the implicit biases we bring to every clinical encounter.
Should physicians who serve minority populations be held to the same criteria for value produced as those who serve the majority population? Should the criteria be the same or different for defining value? Most quality improvement initiatives improve quality for all patients, but disparities gaps often widen in the process. Sending a “get your colonoscopy” reminder in the mail in English, for example, may not work for those patients with limited health literacy or English as a second language, even though it may be effective for English literate patients. There remains a very real risk that pay-for-performance initiatives will be harmful with clinics caring for large minority populations, and the seminal Institute of Medicine Unequal Treatment report warns us not to “dis-incent providers to care for safety net populations.” Physician payment systems should reward efforts which successfully reduce disparities gaps. Even those payment structures will not adequately address socioeconomic barriers which contribute to disparities experienced by minority patients. Straight salaries with a greater emphasis on patient feedback about quality, from the patient’s perspective, may be a more ethical payment system. The IOM Unequal Treatment report highlights that even after correcting for insurance and socioeconomic status, minorities experience health disparities, highlighting the complexity of the issue, and the contributions of health system barrriers and provider barriers, such as bias in medicine (www.implicit.harvard.edu). If value is defined by quality/cost, then more research is needed to demonstrate that providers with expertise in refugee and immigrant health care practice save the patient and our national health care system money. I have no doubt that this is the case, but documenting it with good studies would be a significant contribution to societal support for clinics that specialize in care for immigrants.
With the focus on evidence-based medicine, are we at risk for not serving minority populations well? Actually, I firmly believe there is a body of knowledge in refugee and immigrant health care — or care for globally mobile populations — and have spent my career working with colleagues around the world to define that body of knowledge. Utilizing the WHO definition of international migrant, 180 million humans live outside their country of birth. One billion people move around the world every year, and the speed of travel, combined with human mobility has resulted in an explosion of interest in clinical care, research and education in global health. St. Paul and HealthPartners have supported the Center for International Health for 31 years. The University of Minnesota has hundreds
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May/June 2011
of people involved in health disparities research. The Global Health Pathway in the Department of Medicine, (www.globalhealth.umn.edu) which I direct, is one of many examples of internationally recognized leadership in “global medical education” occurring from the U.S. to Canada to Europe and Asia. We have the world’s first online course in global health leading to accreditation by the American Society of Tropical Medicine and Hygiene. The good news is that there is much published in the field of global health daily. Dr. Bill Stauffer, my colleague at the University and HealthPartners, is leading the national CDC effort to design a rigorous set of recommendations for screening newly arrived immigrants based on country of origin, for example. Perhaps an even greater challenge, and the focus of my work the next few years, is how to translate that knowledge, much of it internet based, into rapidly available resources for answers to clinical questions “in the moment.” We just completed a one year grant funded by the Medtronic Foundation, with a focus on designing an education system in global health to address this issue. One of our survey findings was not surprising: most doctors have < 5-10 minutes to answer their clinical questions while seeing a patient. Particularly for the clinician seeing an ill Liberian or Hmong patient who may have no idea of diseases to consider in a patient from these countries, such point of care decisionmaking tools are critical to providing good care. In my experience, it is not that the answers aren’t out there — either electronically or via colleagues with expertise in tropical and travel medicine — it is that frightening category of “you don’t know what you don’t know” which results in poor patient outcomes. For example, recently I saw an older Nigerian man with hematuria and bilateral hydroceles, seen for more than one year by numerous colleagues without a clear diagnosis, who had both schistosomiasis and filariasis (elephantiasis). His doctors had used a non tropical differential diagnosis framework for his evaluation. I do not think it is a lack of evidence basis for minority health that is the issue in this case; it is the fact that medical education has not kept up with the pace of demographic change internationally, and that physician’s knowledge base and health delivery systems are not customized for specific patient populations.
What lessons have you learned about ensuring engagement of the patients you serve? What can you teach us about engagement? Critical to successful engagement is a genuine relationship with providers and care systems. First and foremost, we need to really care about our patients — they know when empathy and compassion are real, and when we don’t truly care about them individually. We need to be trustworthy, providing care which is culturally sensitive, safe and high quality. Engagement will only occur if those fundamentals are met. I had a Somali colleague who once said, “The first 15 minutes of an appointment with my Somali patients is spent on asking about the family” — and if that does not occur, the clinical encounter is unlikely to include an engaged patient. I have changed my Western sense of time with many patients as a result — I may see them more often, and keep working on mutually
MetroDoctors
The Journal of the Twin Cities Medical Society
established goals for a long time, rather than giving up asking about preventive health care, or starting insulin, or exercising. Patience and taking the long view may improve outcomes over time. Seeing patients more often is also helpful to keep them engaged. There are a few other things one can do: ask about your patient’s life story — what is it like growing up in the Rondo neighborhood in St. Paul? How did you escape from the Pol Pot regime in Cambodia? Most patients appreciate the caring behind such questions. Patients may also be more engaged if the environment celebrates or acknowledges their community: in artwork, prayer areas, and even patient educational materials. At HealthPartners Center for International Health we have four key principles designed to help us have engaged, healthier patients: 1) Your staff must reflect the communities you serve — we would not have credibility without that, and the work we accomplish together daily as a result is incredible. 2) Hire providers with expertise in refugee and immigrant health care — knowing how to conduct a refugee new arrival physical, or manage common psychiatric issues, for example. We look for providers with advanced degrees and experience in tropical and travel medicine, and who have worked internationally. 3) Use professionally trained interpreters — we have come a long way from the early days at St. Paul Ramsey with four interpreters to more than 80 interpreters at HealthPartners, across our care system. As a care system, we measure who was used as the interpreter, and “Use of family and friends” to interpret is our key quality measure. The Center for International Health has been at 2 percent use of family and friends for many years. 4) Provide multidisciplinary care — having psychiatrists, psychologists, social workers, primary care and medical home resources for safety net populations are critical to successful programs.
What have you learned from caring for the immigrant and refugee populations that can be translated to other Minnesota populations? Minority patients have many of the same needs and desires from us as providers and care systems as do majority patients. (After all, even the term minority is only relevant to geography.) They need to feel welcomed, honored, and respected. They need to know our work is all about them, not about us. They want prompt service, reliable communication and handoffs, and they want to know we are providing safe, high quality care. Because of previous negative experiences with the care system, they are aware of implicit bias in medicine and society, and how it may impact their care. We can learn a lot from immigrants about focus on family, hard work, respect for elders, and commitment to providing a good education for our children. Interacting with immigrant patients who make health decisions as a group is a good reminder for how we should interact with all of our patients: with a patient centered approach. I have come to appreciate human resiliency when thinking about the horrors many refugees have experienced before their arrival in the U.S. Resiliency is also a clinical useful construct when counseling any patient who has experienced loss.
The Dalai Lama has said that the fundamental goal of every human being is happiness. If we consider that in the context of our clinical work and care systems, it may help us be more truly patient centered in our care. It would help us work to understand differences in beliefs about informed consent, or end-of-life care, or to understand that definitions of happiness may be different for our patients than for us — thus achieving more success at negotiating shared treatment goals.
Use of the electronic medical record often involves time and effort by clinicians in the “inputting” of information. What information would a clinician record include regarding characteristics or the special medical needs of immigrants or refugees? And, would this be documented in a narrative or checklist format during the clinical interview, or at another time? There a few fundamentals which are critical to ask and record: race and ethnicity, as defined by the patient, which is something the literature refers to as “granular ethnicity.” “I am Guatemalan,” not Hispanic/ Latino, may be the way a patient prefers to self-identify. Second is preferred language for interacting with the care system. Third is country of birth. Country of birth is often a better proxy for disease risk than is race or ethnicity. For example, I saw a middle aged Asian American woman several years ago for an annual exam. Although she sounded as Midwestern as myself, she told me she had been adopted from Korea as an 8-month-old child. Knowing the prevalence of hepatitis B in Asia, I screened her and she was found to be a carrier — changing her preventive health care recommendations life long to include screening for hepatocellular carcinoma. She had been in a local care system her entire life without ever being tested for HBsAg; the CDC recommends screening for hepatitis B in all patients who were born in countries with HBV prevalence > 2 percent. In the history, clinicians should make it a habit to routinely ask, “Where are you from, and where have you traveled?” on a routine basis. Evaluating a patient with a fever without asking these two fundamental questions is not practicing evidence based care in today’s globally mobile populations. Incubation periods for many tropical infectious diseases, for example, are critical to developing a thorough differential diagnosis. In an ideally designed electronic medical record, race/ethnicity, language, country of origin and U.S. arrival date would all be able to be abstracted electronically. Health care organizations would routinely analyze key quality measures by demographic characteristics.
How do you see care provided for undocumented individuals, particularly ongoing primary care? A 2005 study by researchers from Harvard Medical School found that health care expenditures for U.S. immigrants were approximately 55 percent less than those of U.S. born residents. Although immigrants accounted for 10 percent of the U.S. population in 1998, they accounted for only 8 percent of U.S. health care costs. A report on the Kaiser (Continued on page 12)
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Colleague Interview (Continued from page 11)
network showed that communities with high numbers of Hispanics, immigrants and the uninsured actually had lower usage rates for emergency departments than communities with higher numbers of residents in these three groups. Undocumented individuals are a reality here in the U.S., providing a huge labor force and contributing to taxes. We should provide health care, including primary care, to undocumented individuals, both as a fundamental human right, and as sound public and global health policy.
Is there a system in place for monitoring care for patients with multiple drug resistant tuberculosis? How and who will do the tracking down of undocumented individuals who do not show up for follow-up? Public health programs at the local, state and national level monitor care for patients with tuberculosis, including those with drug resistant disease. Resources are devoted to tracking patients across state and national boundaries in order to provide more consistent, continuous care. A U.S. – Mexico TB cross border initiative is such an example; an innovate program which acknowledges the reality that patients travel, and their TB care and records should travel with them to improve their outcome, and reduce the problem of resistant disease developing.
What are some common mental health conditions prevalent in a refugee or immigrant population? How do you address mental health issues with patients and families when in many cultures there is no term for “mental health” or when discussion of this subject is taboo? Major depression, anxiety and PTSD are relatively common in many refugee populations who often have experienced years of severe deprivation and trauma, including the loss of family, home and country. Minnesota is home to an estimated 20,000 or more victims of torture, and
many immigrant women have experienced rape as a war crime. Georgi Kroupin, psychologist at the CIH, comments that because refugees have had an experience of normal life before war and political displacement, therapeutic interventions may be more successful than with U.S. born patients who may come from family systems with generations of strife, chemical dependency and incarceration. Mental illness is stigmatized world wide. One therapeutic approach is to normalize the feelings patients may be having: fear, anxiety and depression are all normal responses to the abnormal situation which our patients have experienced. Focusing on resiliency: “how did you survive to get here?” and the future is also helpful. Many refugees poignantly tell us that they feel they have given up their lives for their children. A primary care recommendation to see psychiatry or psychology should focus on symptom relief as opposed to diagnoses.
What is the best way to refer patients to the Center for International Health? We provide consultative services in cross cultural care, psychiatry, psychology, and tropical medicine, as well as primary care. HealthPartners Appointment Center can help arrange appointments at the appropriate location and with the right provider: (952) 967-7978, or visit our website at www.healthpartners.com.
What are the greatest challenges ahead in serving immigrant and refugee needs at the Center for International Health? Have changes in immigration policy since 9-11 affected the volume of services that you deliver through the clinic? We need to redesign our care system to be more patient centered. To do so for patients whose language and cultures are so diverse is challenging. Equally challenging is dealing with bias in medicine, and providers without either adequate training or access to educational resources at the point of care. Underlying it all, the economic stressors of caring for the underinsured are always a threat to high quality care for immigrants.
How will immigrant health be integrated into the new health plan legislation (Accountable Care Act)?
Become a Delegate TCMS needs 116 delegates at the MMA Annual Meeting, Sept. 15-16
Submit a Resolution Attend the TCMS Caucus May 2 at 6 p.m. To register or learn more, visit www.metrodoctors.com or call (612) 623-2885
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I believe the Center for International Health, as well as many other clinics taking great care of refugees, has been a medical home for refugees for 30 years. In her beautifully illustrated book about the Center, My Heart It Is Delicious: the Story of the Center for International Health, author Biloine Young captures the feeling of relief and safety which many of our patients feel when they walk through our doors. I hope that Accountable Care Organizations can achieve the goal of providing patient centered care in the global village; immigrant health and the health of the nation are at stake. This Colleague Interview has been shortened due to space limitations. A complete version and references are available upon request. Contact nbauer@metrodoctors.com. MetroDoctors
The Journal of the Twin Cities Medical Society
Good Data ...Bad Data
Good Data: The Provider Peer Grouping Example
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ata is one of the basic tools of both medical care and public health. In the clinical setting, data from the history, physical exam, laboratory and radiological procedures help identify and define the extent of an individual’s problem. These data also help evaluate the progression of disease and the effectiveness of various interventions. On the business side of medical care, encounter and claims data form the basis for reimbursement of services provided. They also have the potential to help evaluate the health care delivery system and measure the quality and cost efficiency of the health care delivery system. In the domain of public health, data help identify and provide a common understanding of the issues, problems and concerns that exist in our society while also highlighting opportunities for improvement. Public health data help stimulate action for program and policy development and help evaluate what works and what doesn’t. Because the quality of medical care contributes significantly to the health of our society, medical and claims data are also important public health data. If we are going to help individuals be healthier and make progress toward a healthier society, good data is essential. But what makes data good? Is it just the classic statistical characteristics of “reliability and validity”? Or are there other characteristics that must also be included in the definition of good data? At the Minnesota Department of Health (MDH) we have multiple sources of individual and population-based data and use data in multiple ways. Because of that, not only do we understand how critically important good data is, but we also know from experience that what makes By Edward P. Ehlinger, M.D., MSPH
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and reduce costs. PPG will be a powerful tool to create more transparency about how much we pay for health care and the quality we are buying with those dollars. For PPG to be a beneficial resource for all Minnesotans, it must provide useful and meaningful information to all users. There are two critical pieces to accomplish this: accurate raw data and sound analysis. Together, these pieces of PPG showcase important qualities of good data and good data-use. To be “good” from an MDH perspective, data must be: s #OMPLETE s #ONSISTENT s 3ECURE s 4RANSPARENT s -ETHODOLOGICALLY 3OUND s 2ELIABLE AND 2OBUST data “good” goes far beyond just reliability and validity. One of our current initiatives, the Provider Peer Grouping (PPG) system, is an excellent example of the importance of good data and a demonstration of the characteristics of good data. As part of Minnesota’s bipartisan 2008 health reform law, Provider Peer Grouping was created to evaluate health care value through a composite measure of the cost and quality of health care providers’ services. Minnesota is the first state in the nation to develop a comprehensive system to support decision-making based on health care value. According to the health reform legislation, public employers and health plans will be required to use information generated by PPG to develop and offer health care products that create or strengthen incentives for people to choose high-quality, low-cost providers. Consumers can then use this information to make more informed health care choices. Providers can use the information to improve their quality
The Journal of the Twin Cities Medical Society
Complete. The raw data used in the PPG system data set is the most complete for calculating cost that exist in the United States, covering Medicare, Medicaid, self-funded and fully insured sources. As of February 2011, 62 payers had submitted more than 923 million records to the PPG system, covering an estimated 85 percent of total enrollees in the Minnesota health care market. Consistent. Given the volume and comprehensiveness of the PPG data set, it has been an important and challenging task to ensure that the data is consistent. MDH has worked closely with payers, third-party administrators (TPAs), HMOs and others to make sure we understand the unique nuances of the data. This effort has helped ensure that the data is consistent and uniform across sources.
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Good Data ...Bad Data Good Data (Continued from page 13)
Secure. PPG data is de-identified to ensure that individual patients cannot be identified. Additionally, the storage and use of the information complies with nationally accepted standards and practices for health data security. Transparent. MDH has worked hard to ensure transparency in the development of PPG. An advisory group of stakeholders developed the framework for the analysis. MDH also established a “rapid response team” of stakeholders who can canvass their respective organizations and provide feedback on analytical issues that arise, such as patient attribution or risk adjustment. MDH also holds monthly stakeholder conference calls to provide updates on the development of PPG. Methodologically Sound. MDH and our stakeholder partners have also focused on the need to ensure that the methodologies behind PPG are established, tested, and replicable. In developing the analysis, we are building on methodological work that has already been done in the community and research world.
Minnesota Epilepsy Group is the largest and most comprehensive epilepsy program in the Midwest. As a regional referral facility, we are the recognized leader in treating epilepsy and other seizure-related conditions in patients of all ages, from infants to the elderly. We also offer comprehensive neuropsychological assessment for a broad range of acquired or developmental neurological conditions in both adult and pediatric patients. Adult Epileptologists Deanna L. Dickens, MD Julie Hanna, MD Patricia E. Penovich, MD James R. White, MD (Now seeing patients in Hudson, WI) Pediatric Epileptologists Jason S. Doescher, MD Michael D. Frost, MD Frank J. Ritter, MD
Appointments (651) 241-5290 225 Smith Avenue N St. Paul, MN 55102 www.mnepilepsy.org
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Functional Neuro-Imaging Wenbo Zhang, MD, PhD Neuropsychologists Elizabeth Adams, PhD Robert Doss, PsyD Ann Hempel, PhD Donna Minter, PhD Gail Risse, PhD
Reliable and Robust. The PPG data collection and analysis also ensure consistency, so that outliers or small changes to the data do not dramatically change or skew the results. Developing PPG has been a complicated process, but MDH is committed to making it a useful tool that our community will embrace. We and our partners have taken a thoughtful and collaborative approach to building the system to assure that we are gathering good raw data and creating an analytical framework that makes theoretical and practical sense. The first set of PPG information will be sent to providers in the summer of 2011 and publicly reported in the fall. Bad data is worse than no data at all because it can lead to program and policy decisions that do not accurately and effectively address the real issues. However, good data, if used properly, can help us move toward our goal of a healthier society. PPG is an important asset to help us do that. PPG is an example of good data at work for Minnesotans. Edward P. Ehlinger, M.D., MSPH, is the Minnesota Commissioner of Health. MetroDoctors
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Erroneous Facts, Spurious Data and Policy Dogma:
Critical Thinking Required Richard (Buz) Cooper, M.D. is a Professor of Medicine and senior fellow in the Leonard Davis Institute of Health Economics at the University of Pennsylvania. During almost 50 years as a physician, he has practiced hematology and oncology, conducted experimental hematology research, directed a cancer center (at Penn), been dean of a medical school (at the Medical College of Wisconsin) and led a health policy institute (also at Wisconsin). Over the past 15 years, his efforts have been focused on critical issues in health care policy related principally to projecting the demand for physicians and other health care professionals and understanding the future dimensions of the health care system. He blogs on health care reform issues at www. buzcooper.com. In this article, Buz Cooper, M.D., challenges us Minnesotans to reconsider the conventional thinking or dogma associated with medical policy that follows from both erroneous facts and spurious data. To illustrate these, he shares two stories from his time as dean of the Medical College of Wisconsin in Milwaukee. I became passionate about ensuring high quality data in health policy research after being drawn into AAMC policy considerations during the Clinton Health Plan. The question everyone wrestled with: How many doctors would we need? What data would guide or direct the answer? The Clinton administration was predisposed to restricting the training of physicians based on the widely-held belief that we were training too many and that there soon would be a vast surplus in the year 2000. This conclusion stemmed from projections made By Buz Cooper, M.D., as told to Gregory A. Plotnikoff, M.D., MTS
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by the federal Bureau of Health Professions and endorsed by the committee that advises the government on such matters, the Council on Graduate Medical Education (COGME). However, when I examined the data, I discovered that the projections were made on the assumption that the population would not grow much beyond the level in 1990. That made no sense. So I called the Census Bureau to inquire how such an error could have been
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support a philosophic belief that there were too many specialists, and like-minded academics quoted the numbers to policy makers. And that’s what led to the cap on residency training positions supported by Medicare that was put in place in 1997 and remains to this day. Well, the year 2000 came and went, and there was no physician surplus. In fact, in 2004 COGME changed its policy statement to reflect the fact that there would actually be a shortage,
Being a good doctor means being meticulous in interpreting clinical data. The same applies to health care data. Be careful. Be skeptical. And be honest.
made. They told me that before the 1990 census they believed that population growth would slow, but after the census they realized that they had been wrong and “would I like their current projections?” Of course, I said yes, and when I plugged them into the calculations, the picture changed dramatically. It showed that there would be a shortage (not a surplus) beginning about 2005-2010. You might think that the Bureau of Health Professions would have corrected their error. But that was not their response. Instead they constructed a new projection model in which, rather than over-projecting supply, they under-projected demand and arrived at the same surplus as before. There would be 100,000 too many physicians in 2000. The data were fudged. The whole thing was a sham. Government planners had created phony numbers to
The Journal of the Twin Cities Medical Society
as I had projected a decade earlier. But then the second wave of data fudging swept across America — the Dartmouth Atlas of Health Care. The Dartmouth folks concocted a crazy map of health care based on hospital referral regions. For example, the region called “Minneapolis” extends all the way into Wisconsin, and St. Paul is a separate region. Based on their data, they concluded that many areas of the country waste health care resources and that it’s because there are too many specialists there. This is a repeat of the old paper by Victor Fuchs that the amount of surgery in a community correlates with the number of surgeons. But Dranove found, using the same methodology, that the number of deliveries correlates with the number of obstetricians. Cause and effect? (Continued on page 16)
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Good Data ...Bad Data Erroneous Facts (Continued from page 15)
The Atlas says that Milwaukee is a high use region. On the surface, that is true. But there’s more to the story. While I was dean of the Medical College in Milwaukee, leaders of the business community, many of whom sat on our board, were very concerned about the rising costs of health care. A consulting group had documented that in comparison to Minnesota or Iowa, the health care costs in Milwaukee were significantly higher. The board and the business community challenged me to explain why spending was different. So I critically examined the data from many different perspectives. I ultimately discovered that patients living in the poorest ZIP codes used much more health care. This could more easily be seen in Milwaukee because it is a very segregated city with sharp income demarcations by zip code. When carving out the poor communities, costs for the remainder of Milwaukee were the same or even better than
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elsewhere in Wisconsin and Minnesota. The added health care spending in Milwaukee was attributed to patients living in a narrow poverty corridor: extraordinary differences, 3-4-5 fold, were seen. Clearly, when comparing health care in different areas or regions, the underlying culture of poverty must be taken into account. But the Dartmouth folks categorically say that poverty does not contribute to geographic variation in health care. That’s like saying that snow doesn’t contribute to slippery roads — it’s all due to the asphalt. Why poverty? Poverty is associated with more disease, decreased coping skills and weaker social networks. And poverty is geography. So it should not be surprising that health care utilization and spending follow geographic patterns. A second major problem with the Dartmouth Atlas is that it’s an atlas of Medicare, not of total health care, and Medicare spending. As Minnesotans know, Wennberg and his Dartmouth collaborators showed that Minnesota’s Medicare spending is among the lowest in
the nation. Per-capita spending per Medicare enrollee in Miami is almost 2.5× as great as in Minneapolis, even after adjusting data for age, sex and race. However, what is not widely known is that Minnesota’s total health care spending per capita is among the highest in the nation. How could this be? The problem is that there is no positive correlation between total health care spending per capita and Medicare spending. States with better employer-sponsored care, better Medicaid coverage and fewer uninsured spend less through Medicare. At the end of the day, health care spending is a black box, and all sources contribute. So places like Florida, Alabama, Mississippi, Louisiana, Texas, Arkansas and Oklahoma spend a lot through Medicare but not much else. It’s the opposite for Minnesota. This fact is crucial to recognize in evaluating data restricted to only the Medicare population. In fact, when those who are underinsured and have a high burden of disease reach Medicare age, they tend to fully avail themselves of insurance, yet
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the outcomes are poor, because the underlying effects of life-long poverty remain. The result is that Medicare expenses are terribly skewed; they reflect the distribution of poverty in America. Compare the social conditions of the poor in Minneapolis with those of the South Bronx. There really is no comparison. The original leader of this Medicare Atlas group, Jack Wennberg, is a Dartmouth professor who started his career studying variation in Maine and New Hampshire of particular treatments where no clear guidance existed, such as prostate cancer. He noted that regions tend to cluster around different treatments. He documented the obvious: practice patterns differ regionally. Physicians, of course, knew this. This is why it was so valuable to learn different approaches in different communities. Physician mentors traditionally encouraged training in different cities: it was valuable to learn of such differences and that such differences are not nefarious but interesting and important. Wennberg and others chose to focus on these differences from an economics perspective. They argued that correlation was actually causality: the correlation between hospital beds and admissions actually meant that increased hospital beds result in increased admissions. The correlations between surgeons and surgery meant that surgeons cause surgeries. They adopted terms from economic reasoning such as “supplier-induced demand” and “supply sensitive services.” These statements are presumed to be causal relationships even without evidence. However, obstetricians do not generate deliveries any more than the presence of snow plows generates snow fall. Despite this, tremendous, widespread and well-funded efforts went into proving this theory. Yes, self-generating business was true in pockets. However, Bob Evans, Vancouver, demonstrated that these tend to be self-correcting. Moral equivalency squashes overuse. What was seen in pockets was extended to include the entire United States. The Wennberg group, with funding from the Robert Wood Johnson Foundation, the Federal government and the insurance industry produced a map of the nation, based not on Metropolitan Statistical Areas (MSA), but on where patients receive their care. They identified 306 such areas termed Hospital Referral Regions (HRR).
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From this came their famous assertion: there is a causal relationship between the number of physicians in a given area and the dollars expended for health care. More physicians lead to more health care spending, especially among specialists. Based on my experiences, I believe that we physicians ought to be very careful in accepting policy findings that seem counter-intuitive. Some may be correct. But the two examples above were totally wrong, and they have totally distorted policy as it relates to training physicians. Politics and political philosophy drive the data, and that’s not science. From the first story, we can see that an erroneous fundamental assumption will lead to an erroneous conclusion. Politics may drive the acceptance of the erroneous assumption. From the second story, we can see that faulty reasoning includes mistaking correlations for causality. Again, such findings may be used to advance a political agenda. To stimulate thought, let me share with you contrarian data. My policy research group took the 306 HRRs and divided them up into five regions. The lowest spending quintile includes Minnesota and are the rural regions which extend from the west of Milwaukee to the Pacific Ocean including Iowa, Nebraska, Colorado, excluding larger cities. The result is a low spending area because of no poverty ghettos. This region’s demographics are unusual. Only 0.5 percent of the population is African-American, compared with 14 percent elsewhere, and only 10 percent are Latino, compared with 18 percent elsewhere. And while poverty exists in the rural Midwest and West, it exists at a much lower rate and rarely exists in anything resembling a poverty ghetto, as it does in major metropolitan areas. In comparison, seven Southern states from Texas to Florida account for the highest expenditures. Poverty there is also the highest in the nation and minorities comprise a larger portion of the population. Eliminating the rural Midwest and West and the seven Southern states results in minimal geographic variation in health care expenditures. We found that high Medicare spending areas are of two kinds: a) big cities with large populations of both affluent and poor residents, and b) the poor South. The bottom line: more poverty in the South and less in the
The Journal of the Twin Cities Medical Society
rural Midwest and West is the principal factor governing the observed geographic differences in service use. We also found that Medicare spending is a spurious measure for total health care expenditures. Here is what concerns me most: all concrete measures, such as hospital readmissions, are much higher in poor populations than affluent populations. The Dartmouth group asserts that their data proves physician supply drives expenditures. Actually, they are looking at only part of the picture: they are looking at Medicare data because it is easiest to do so. They are not looking at total health care spending by region and they are not looking at the incredibly important confounder of poverty. And here is our greatest challenge: all factors which lead to higher utilization and poorer outcomes are overwhelmed by demographics. To truly make comparisons, we must stratify by demographic characteristics. But our Medicare demographics are rather crude: black/white, zip codes, etc. In fact, race and ethnicity are invalid predictors of socio-economic status. And, for the Medicare population, so is zip code. Furthermore, for retirees as for students, income is not a measure of poverty that impacts health care spending. Retiree income does not correlate with education and supportive social networks. As a result, there can be no adequate and valid risk adjustment for comparisons. What sounds like good data turns out to be bad data that can be used for political and/ or economic agendas. Does this twist on reason also apply to other issues in medicine? Yes, and that is why we physicians ought to be aware of the limitations of this data. Are process measures a valid way to assess quality? In fact, process measures do not correlate with true clinical outcomes. Does more health care spending truly lead to worse outcomes? In fact, regions with higher total health care expenditures per capita have better outcomes (although outcomes are worse where there is more Medicare spending per enrollee). Being a good doctor means being meticulous in interpreting clinical data. The same applies to health care data. Be careful. Be skeptical. And be honest.
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Good Data ...Bad Data
Transparency in Physician Cost and Quality Medica Premium Designation Program Provides Individual Quality and Cost Evaluations
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edical consumers and health plan sponsors increasingly are demanding information about physician cost and quality as individuals are expected to pay a greater share of the cost of their health care. To meet that need, Medica began sharing quality and cost ratings for individual physicians in its online provider search tool on January 19, 2011. Dubbed the Medica Premium Designation Program, the tool is the next evolutionary phase of care and cost information to be made transparent to consumers. The program uses a star rating system. If a physician meets quality measures they receive one star; if they also meet cost-efficiency benchmarks they receive a second star. Those who don’t meet either measure receive no stars, while those who don’t have enough qualifying claim data will be designated as not having enough data to assess. Premium Designation uses evidencebased, medical society, and national industry standards with a transparent methodology and detailed data sources to evaluate physicians across 20 specialties. In order to be eligible for the program, a physician must have an active contract as a Medica network physician, hold a medical license without sanctions, practice in one of the evaluated Premium Designation specialties, and be board certified in the specialty they practice. Premium Program Methodology
On a broad scale, Premium Designation evaluation for quality compares a physician’s observed practice to a national rate among other physicians who perform like services. An example of this would be determining if a woman within By Jim Guyn, M.D.
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child-bearing age has a claim within the review period for a Pap test during a visit with a primary care physician. National benchmarks are used for each individual quality measure to set expected performance for that measure. Physicians are measured relative to their peers rather than at an absolute threshold. To reflect the reality that more than one physician can appropriately provide certain services, measures may be attributed to more than one physician. The statistical methods behind the program have been evaluated and judged to be sound by third-party experts. Premium Designation, which was developed and is administered by Ingenix, uses software tools such as the latest versions of Symmetry EBM Connect®, Symmetry Episode Treatment Groups® and Procedure Episode Groups®, which allow precision for assessing episodes. We realize Minnesota primary care providers have moved beyond claims data and process measures to outcome measures like those provided through Minnesota Community Measurement. Unfortunately, there are few outcome measures available for specialists. The tools we selected have the most detailed claims data analytics available for both primary care and specialty care. While quality is the primary measurement — based on the community’s commitment to evidence-based practice — Premium Designation also includes an evaluation for cost efficiency. This component of the program compares a physician’s observed episode costs to the risk-adjusted costs of their peers in the same specialty and market. Importantly, physicians must first be designated for quality in order to be designated for cost efficiency. Premium Designation quality and costefficiency evaluations incorporate adjustments for case mix and severity of illness where
appropriate. Case-mix adjustment accounts for the differences in the types of cases each physician treats and severity adjustment accounts for the degree of disease the patient has. For quality, case-mix adjustment is at the measure level using a benchmark result based on the national average for each measure. For example, patients with diabetes may expect to have a retinal exam at a lower rate than a blood test due to the higher effort required. Using a benchmark rate for each measure takes this into account. Evidence-based medicine (EBM) measures apply regardless of severity of a patient’s condition so process measures are not severity-adjusted. That being said, certain EBM measures may adjust for severity through the clinical exclusions. For cost efficiency, case-mix and severity adjustments are accomplished by comparing the same type of episodes by creating comparable sets of episodes. For a given specialty, a set consists of all episodes that share the following characteristics: condition, treatment indicator, severity level, and pharmacy benefit, when available. The division of episode sets into base conditions and treatment indicators accomplishes case-mix adjustment. The division by severity level accomplishes severity adjustment. The pharmacy benefit is included to adjust for otherwise equivalent episodes for patients when there is pharmacy information. The entire set of episodes forms the benchmark used when comparing an individual physician to his or her peer group. (More details are outlined in the Premium Designation Program Detailed Methodology at medica.com/premium.) Program Implementation
Medica considered the impact on the physician community before Premium Designation was made public. Throughout 2010, Medica
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employed several communication methods to discuss the launch of the program. Part of the implementation process included a review period to allow physicians the opportunity to examine their results prior to public display. Beyond that time frame, a reconsideration process is in place for physicians to appeal any results they believe are inaccurate. Because Medica updates program data constantly, a physician’s information will be corrected in a timely manner, if warranted. Approximately 10,000 physicians in 20 specialty areas were reviewed. About 70 percent of the 10,000 physicians achieved the quality ranking, a testament to the outstanding quality of physician care available to Minnesotans. That’s far better than physicians rated in any of the other 144 markets where Premium Designation is in place. Another 22 percent of physicians had “not enough data to assess” — i.e., they did not meet the minimum number of episodes to make an evaluation statistically significant. Finally, 7 percent of physicians did not receive one or two stars.
assessment summary; an overview of opportunities for quality conditions and cost-efficiency categories; and practice cost-efficiency information in varying levels of detail. Some provider systems and individual physicians have told us that they intend to utilize Premium Designation as a quality improvement tool. Patient Impact
Premium Designation ratings are available for members to view on the Find A Doctor search tool on medica.com. The website contains detailed information for members on which physicians were evaluated and the criteria that was used for evaluation. Medica tells its members that the Premium Designation results are a guide to be used as one of many factors to consider in choosing a physician. Medica is committed to empowering patients with information as they make their health care decisions. Medica
recognizes there are many factors that may be considered when patients choose their physicians. Main Street Medica, which displays site-level cost and quality details, is another tool Medica provides its members to guide them as they are choosing health care providers. Medica believes the effort to bring greater transparency on cost and quality to patients is working. Over time, it can also contribute to making care even better. On the day Premium Designation was launched, visits to Find A Doctor on medica.com experienced 10 times the normal volume. Dr. Guyn joined Medica in September 2006 as the medical director focusing on Provider Relations. Since joining Medica, much of his focus has been on primary care redesign and payment reform. A graduate of the UCLA School of Medicine, he is a board certified family practice physician.
Physician Impact
Since the program was implemented, physicians have provided considerable feedback on it — mostly that they would have liked longer to review the data (this step actually continues to be available through the reconsideration process). Medica has received several specific comments and suggestions from physicians about their data, too. Many have been changes to demographics such as specialty updates, board-certification updates, provider termination updates, and updates to primary place of service. Physician comments on program criteria have also resulted in program updates in some cases. In addition to physician ratings provided for consumers, another goal of Premium Designation is to provide actionable information for practice improvement. The program provides physicians with access to information on how their clinical practice compares with national and specialty-specific measures for quality, and with local cost efficiency benchmarks in the same geography. In addition to receiving individual designation results and underlying data and calculations, physicians also receive a summary of potential areas of additional care management. Reporting includes an individual
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The Journal of the Twin Cities Medical Society
May/June 2011
19
Good Data ...Bad Data
Ensuring Credibility in Minnesota’s Health Care Quality Measures
A
t Minnesota Community Measurement (MNCM), we recognize that in order for our measures to have impact, they must be meaningful, credible and reliable. The first step to achieving these goals is our measure development process. Our measure specifications are taken from evidencebased guidelines produced by the Institute for Clinical Systems Improvement (ICSI). The specifications are reviewed by both a technical committee, with clinical expertise in the area being measured, and also by our Measurement and Reporting Committee, which includes multiple stakeholders who can evaluate if the measures will be both meaningful and useful. We also have a public comment period that helps us get information from provider organizations on whether the measure design will actually work in practice. We also strive to use measures that have been endorsed by the National Quality Forum to ensure that we are meeting national standards. The NQF has recently endorsed five measures that have been developed in Minnesota including our optimal diabetes, depression care, and optimal vascular care measures. Once the measure specifications have been approved, we go to great lengths to ensure that the results in our reports are reliable and valid. One of the ways in which we maintain reliability is to use large data sets. For measures that use health care claims, we get data from all health plans in the state. The data reporting structure is reviewed annually and the health plans all follow standard technical measurement specifications. In 2010, for the cervical
By James Chase
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May/June 2011
cancer screening measure, we were able to report on 152 medical groups representing over 200,000 patients enrolled across 10 health plans. In addition, we only publicly report results if at least 30 patients are represented for a medical group so we are able to calculate acceptable confidence intervals around the result. For measures that use clinic site data, clinics submit data on their total population of patients or a sample. Eighty percent of clinics submit data on their entire patient population. In 2010, 128 medical groups representing 573 clinics submitted data for the Optimal Vascular Care measure. Data from these clinics represented over 95,000 patients with ischemic vascular disease. We also ensure consistency by using standardized measure specifications and instructions for clinics on how to collect and report data, implementing an upfront denominator certification process, and developing field warnings and error programming that occur upon file upload to MNCM’s secure data portal. The upfront denominator certification process ensures that all clinics identify their patient population in the same way during the same time frame. For patient experience survey measurement, MNCM creates criteria for which patients can be included in the survey sample frame relying heavily on the recommended parameters from the national Consumer Assessment of Healthcare Providers and Systems (CAHPS) Consortium. Survey participants then use a certified vendor to fairly and accurately select the patients and conduct the survey. Survey vendors have substantial experience generating this information using the criteria
specified. The survey data is then aggregated and analyzed using CAHPS Consortiumspecified methods. In 2010, MNCM began reviewing subsets of randomly selected patients to look for potentially missing patients who should be included in the sample frame. MNCM also employs an extensive data validation process for all measures that are publicly reported. Validation processes involve quality checks of files from health plans and clinics for accuracy. Current year rates and eligible patient population volume are reviewed for discrepancies compared to prior years. For data submitted directly from clinics, we also conduct on-site audits comparing data submitted against the medical record to ensure accuracy. All clinics that submit data to MNCM are subject to an on-site audit. In addition, we
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The Journal of the Twin Cities Medical Society
have a comment period that allows clinics to ask questions and raise concerns about their results. This process encourages dialogue that fosters transparency and trust. It has become an important step in the validation process that has increased our credibility with clinics and, on occasion, has led to the identiďŹ cation of legitimate data issues that have allowed us to improve our processes. If clinics have an ongoing concern about their results after MNCM investigation, they have the option of submitting a formal appeal. The Quality Audit Committee of the Board is responsible for developing policies and procedures that support valid and reliable data. They review the validation ďŹ ndings and address appeals from clinics for all measures that are publicly reported. Ultimately, the most important test of any measure is whether the information is used by clinicians to improve their care, by payers in their contracting, and by patients to help them make decisions. In Minnesota we have had success in getting our measures used by all stakeholders, but there are growing expectations that we will do more to develop measures that apply across settings of care, that use new sources of data from patient surveys, that address cost as well as quality, and that recognize the underlying population risks and co-morbidities. These new efforts will bring new challenges in ensuring credible and reliable data, while at the same time balancing the burden of data collection and analysis. We will only be able to meet these challenges by building on the collaboration we have established between patients, clinicians, health plans, and employers. James Chase is the president of Minnesota Community Measurement, a non-proďŹ t organization whose mission is to improve the health of the community by publicly reporting information on health care quality. He has over 20 years of experience in health care management and is a faculty member with the ISP Health Administration program at the University of Minnesota. Mr. Chase is the chair of the board of Network of Regional Healthcare Improvement and is a board member of the Institute of Clinical Systems Improvement.
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MetroDoctors
The Journal of the Twin Cities Medical Society
May/June 2011
21
YOUR VOICE
An ACO Analysis: Gatekeeping and Violations of Anti-trust and Anti-fee Splitting Laws When you look carefully at an Accountable Care Organization (ACO), you can see a mini-HMO. Double-speak is meant to cover up the transfer of the gatekeeper role from the mega-HMO to the mini-ACO corporation, as well as the loss of patient protection laws. For example, the managed care industry and policy maker rationale for change is that irresponsible providers (read doctors) profiteer “every time they do a procedure,” when incented by “piecemeal” fees paid for each service. Culprit Economics. The industry cure of “irresponsibility” touted in the 1970s was to redirect the venal incentives of “sick care” into a societal good of “well care.” HMO corporations on fixed budgets and providers on fixed annual capitation payments would be incented to profit from “health maintenance.” Better “prevention” would control costs, but if failing to do so, they would be punished financially. By the 1990s the corporate managers understood that, “health maintenance,” “prevention,” and “quality” were only sloganeering and that raising premiums was simpler than politically dangerous Draconian rationing of care. Cost inflation remained unabated, while doctors rebelled against fixed capitation payments that threatened clinic financial viability. Today, the new federal Patient Protection and Affordable Care Act (aka ObamaCare) law touts a version of the same cost control cure. The self-styled “payers” — managed care corporations and government agencies — need only pay those accepting underwriting risk, by which means the provider “culprits” can be coerced into being “accountable” corporate or state gatekeepers. The ACOs would have a fixed global budget determined by their annual capitation fee rate bid at “payer” auctions of the insured lives (people) to be serviced. The frenzied creation of “at risk” ACOs is the result. What’s wrong with this culprit economic mythology, sloganeering, and transfer of the gatekeeper role from the mega “payers” to mini-ACO corporations, and what problems will this bring? Econ 101. First, the abrupt onset of unrelenting inflation was not due to an acute epidemic of avaricious behavior, “poor quality care,” or fraud and abuse causing too much “sick care,” while the venal providers hid some magical prevention of disease in the medical closet. Sudden inflation arose after 1965, a tipping point in time, when tax-free health insurance was acquired by 85 percent of Americans (workers and the official old, poor, and disabled). The subsequent economic problem is that tax subsidies led to buying coverage
of even affordable and expected expenses (low co-pay insurance) and the appearance of “free” care that drives demand inflation. As subsides transferred enormous amounts of money into the medical sector, the response was a remarkable change in the medical market basket. New technology in the hands of a skilled workforce dedicated to the interests of patients dropped population mortality rates at all ages. Second, the prescription of government price-fixing of services and creation of powerful managed care corporations motivated by profits to ration “free” care, failed to control costs for decades, because the problem was and remains demand inflation. Third, doctors have no control from the bedside over popular political tax subsidies that drive demand, nor over population quality statistics, which for the most part reflect poverty and cultural status. Doctors can solve patient problems, but cannot solve the problems of a managed “free” care system gone awry. Population Budgets and Violations of Law. Yet total population costs are the measures that policy makers propose to “incent” ACOs and clinics to be efficient gatekeepers for the “payers” under the guise of “bonuses” to be earned by “quality” statistics of a few patients with a few headline diseases. ACOs are a “back to the future” prescription to “transform” the failed 3rd party managed care insurance system of government price-fixing and of profit driven mega corporation gatekeepers into a system of mini “provider” gatekeepers sharing rationing of care profits (“gainsharing”) with the 3rd party “payers.” It is ironic that to legalize ObamaCare ACO implementation, the “Patient Protection” law requires federal waivers of patient protection laws. These are FTC waivers for ACO violations of anti-trust law (mergers of colluding providers) and CMS waivers for violation of federal self-referral (Stark) laws and state anti-fee splitting laws (“gainsharing”). Patients need protection from mega and mini 3rd parties seeking to profiteer from inducing or coercing clinicians into gatekeeper “shared” profiteering contracts. Ultimate Problems with ACOs. The pretext of a social good (the ends of cost control and quality) is touted to justify questionable means (people auctions and gatekeeping doctors). This is how professionals and professional medical organizations can be forced into losing their claim of patient and public loyalty, and how patients can lose the protection of law.
By Robert W. Geist, M.D. rgeistmd@comcast.net
Letters to the Editor and “Your Voice” opinion pages are encouraged. Please limit your writing to 750 words and email to nbauer@metrodoctors.com.
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MetroDoctors
The Journal of the Twin Cities Medical Society
New Health Care CEO: Kenneth H. Paulus, President and CEO, Allina Hospitals & Clinics Editor’s note: MetroDoctors continues to highlight newly named health care executives. Each CEO has been asked to outline his/her vision and challenges for their organization as well as offer some personal insights.
Ken Paulus became Allina Hospitals & Clinics’ president and chief executive officer (CEO) in 2009. He moved into that leadership position after serving as chief operating officer (COO), responsible for the operations of Allina’s 11 hospitals, specialty operations and clinic groups (Allina Medical Clinic, Aspen Medical Group and Quello Clinic). He has led numerous growth initiatives, including a number of joint ventures, partnerships and acquisitions. Before joining Allina in 2006, Paulus was president and chief executive officer of Massachusetts-based HealthOne Care System, one of the nation’s largest physician organizations and a teaching and research affiliate of Harvard Medical School. Prior to that he was chief operating officer of Boston-based Partners Community HealthCare, Inc., and chief operating officer of Alta Bates Medical Resources in Berkeley, California. Mr. Paulus is a Wisconsin native and University of Minnesota graduate.
Tell us about yourself. How did you get to where you are today? I grew up in the grocery business; my father was a manager for the Red Owl, which was later acquired by SuperValue. I worked union jobs to put myself through college. Two of those summers I worked as an apprentice meat cutter — it was hard labor but I learned a lot of important life lessons.
How has your personal experience shaped your vision for improving health care, and your leadership approach for Allina? I can see now that my retail experience will come in handy in the very near future. My father used to tell me and my siblings that “the customer is always right.” That didn’t matter much in health care before — patients were lucky to have access to our expertise. The future looks to be much different, with greater focus on patient empowerment and service. MetroDoctors
The Journal of the Twin Cities Medical Society
Your wife is a nurse. How has she helped shape this vision? My entire family is in the health care business. My wife is a nurse, and my five siblings are also in health care, including a family physician, nurse practitioner, clinical psychologist, social worker and an occupational therapist. They remind me regularly that the health care industry revolves around caregivers and patients — not insurance and administration.
How do you handle the inter-hospital rivalry within Allina as each organization vies for the spotlight? Do you have a favorite child? All of the operating entities at Allina are equal. Each has a very special role, and we would not be complete without them. The regional hospitals are generally the sole caregivers of a community, tertiary hospitals are market leaders in complex care, and our community hospitals serve as lynchpins between these two worlds.
What are the biggest challenges in your job? Rewards? The biggest challenge is doing more with less. Reimbursements from state and federal health care programs are steadily declining, and there is no relief in sight. Also, as the recession persists, we are seeing increasing amounts of charity care and patients covered by government programs that do not cover our costs. A few years ago, the percentage of patients at Allina covered by government health programs was about 35 percent. Our current business is closer to 60 percent government representation. That puts serious pressure on our finances, let alone the bureaucracy that comes with government programs. I also worry about how much of our (Continued on page 24)
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New CEO (Continued from page 23)
Proceeds from MPS help to support the operations of TCMS. Please consider our business partners listed below as you look to reduce your operational costs.
physician’s time we waste with administrative stuff. Not only is it a misuse of intellectual capital, but it isn’t in the best interest of our community. The biggest rewards for me are twofold. First, seeing patients at Allina served in ways that substantially improves their lives and health. We are blessed to have some of the best caregivers in our nation working with our organization, and it is humbling to work for and with them. I also get great rewards from working for and with our employees. I am on a mission to avoid layoffs at all costs, and to provide our staff a steady and reliable job. That is especially important to families during this persistent recession we find ourselves in.
What is your impression of ACOs? What will it take for this new model of service to succeed? The ACO terminology is overused and misunderstood. To me, it means the health care industry must take responsibility for the quality of care, and also the cost of health care. It’s that simple, and yet very complicated.
Allina is embarking on developing a “clinically integrated network.” How does this fit into Allina’s overall strategy? We have made an important commitment to our community of physicians to put them in a position to lead us into the future. The network is the platform by which we will do this. It also is the vehicle that we will use to partner with independent physicians. These caregivers, in conjunction with the strength of our employed and affiliated physicians, have a unique opportunity to create a virtual care system that will lead the market in patient outcomes. I am pretty excited about the possibilities, and particularly excited about getting there while respecting the interests of independent physicians.
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The ambulatory world and hospital-based world seem to be at odds with each other, or at least have competing priorities for resources, capital, etc. How do you balance those two sides of care delivery? The growth of care delivery that is efficient and easily accessed by patients makes a lot of sense to me, and should be supported by increased investment. That will mean continued growth of physician practices, ambulatory care, and outpatient services. That said, there will continue to be a need for very high quality inpatient care that is well managed, highly standardized, and closely integrated with the overall system of care. We will need both as we all age into our retirement years.
One of the challenges of future health care delivery is going to be keeping people out of the hospital to help reduce costs. Hospital systems, on the other hand, have huge investments in facilities/fixed structure that depend upon patient volume to remain financially viable. How do you reconcile the two? The investment in what I would call the “optimal health” of our
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communities presents a great opportunity for innovation and even better, higher quality care. To be incented to keep a population healthy is a lot more interesting and rewarding than reimbursement for activity. Will this create excess capacity for hospitals? It is too early to tell, but I do like the idea of collaborating to avoid significant duplication of assets. We owe it to our community to find ways to work together to avoid this problem. Recently, Allina and Children’s Hospital agreed to co-venture a mother/baby pavilion on the Children’s campus. This avoids a significant investment in an aging facility at Abbott Northwestern that would have been much more expensive. I am convinced there are a number of like opportunities whereby we can lower cost and also better serve the community.
Allina needs a large number of qualified, experienced and well-trained staff to maintain its current operations. Do you see any workforce issues, especially with primary care and emergency department clinicians, in the next several years that we should try to prepare for at this point? The time has finally come to recognize primary care physicians for the incredible work they do coordinating the care of patients. Their cognitive abilities have been greatly undervalued in the current system, and I expect this to improve. Unfortunately, the training pipeline will lag the resetting of relative value, and we are likely to see a shortage of primary care for at least five years. Ideally, the health care leaders in Minnesota would come together to support an increase in the funding for primary care training programs, and make this a priority for our region.
What will be the role of independent nurse practitioners in primary care? We expect advanced practice clinicians (nurse practitioners, physician assistants, others) to play an increasingly important role on the health care team. That said, we have a strong belief that the primary care physician should and will serve as the leader for that team.
There has been a recent trend toward a high level of diverting ambulances away from Allina-based emergency departments. Does Allina currently have a plan to increase staffing levels or address other factors that are allowing this to happen? We are not aware of such diversion activities from Allina emergency departments.
It appears that Allina is focusing its efforts and resources primarily on the west metro. What are Allina’s overall plans for the east side of the metro area as other health systems expand their market penetration?
Recent changes in the East Metro regarding Allina’s relationship with Lakeview Hospital and the dissolution of St. Paul Heart Clinic has occurred. With the loss of that as a referral source, what is Allina’s plan to enhance its presence in the East Metro? We don’t anticipate any changes to specialty relationships or patient integration due to the change to St. Paul Heart. Twenty of the 32 St. Paul Heart physicians have joined United Hospital and will continue to provide cardiovascular patient care without interruption. We also are expecting overall growth of the cardiovascular program, and have offers out to two additional cardiologists to provide improved access to the community.
Cancer care is very expensive. What efforts are underway to coordinate the expensive equipment, services, etc. vis-àvis the current state of competition? The growth and development of the Virginia Piper Cancer Institute, in partnership with Minnesota Oncology, is our chief strategy to improve care and financial outcomes for the patients we serve. We subscribe to the theory that the right care, provided at the right place, at the right time is the best means to accomplish those goals. Ultimately, that means providing access to treatment protocols that are consistently applied to patients with a cancer diagnosis regardless of where they are treated. By coordinating care in this fashion, we believe costs will come down, and outcomes will actually improve.
Please describe Allina’s “Backyard Initiative.” Have you been able to demonstrate improved health status of the neighborhood? If so, how? The Backyard Project, and also the Heart of New Ulm effort have been great learning experiences for Allina. While we have indeed made measurable progress against our goals, the more important lesson has been in the building of community partnerships. That concept was not a strength of ours, and we will remedy that partially through what we learn from these initiatives.
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Our plans are to serve the entire metropolitan area of the Twin Cities equally and comprehensively, and also to continue to build strong partnerships with communities outside of the metro area. MetroDoctors
The Journal of the Twin Cities Medical Society
May/June 2011
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West Metro Medical Foundation Support for medical education and community health programs provided the impetus for creating the Hennepin County Medical Foundation (now West Metro Medical Foundation) in November 1964. It was Richard D. Schmidt, M.D. established as a 501(c)(3) philanthropic organization with broad general purposes to advance, foster, and promote medical science, education, and public health. Its activities over the years include granting scholarships to medical students, providing support to community programs and projects, and offering award recognition to outstanding physicians and community leaders. The West Metro Medical Foundation (WMMF) serves as the philanthropic arm of the west metro district of the Twin Cities Medical Society (named as a result of the merger of the East Metro and West Metro Medical Societies on January 1, 2010.) The initial funding for the foundation came through estate giving and proceeds from a mass rubella immunization program. Funding today continues through memorials, estate gifts and the annual solicitation of the medical society membership and west metro community hospitals. The WMMF has the honor and privilege as serving as the executor of two awards and recognitions. s
#HARLES "OLLES "OLLES 2OGERS !WARD â&#x20AC;&#x201D; An engraved sterling silver Revere Bowl is given to a physician, who, in the opinion of the members of the selection committee, by reason of his/her professional contribution on the basis of medical research, achievement or leadership, has become the outstanding physician of this and other years.
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3HOTWELL !WARD â&#x20AC;&#x201D; Dedicated service to mankind; signiďŹ cant breakthrough in some form of research or signiďŹ cant contribution to the ďŹ eld of medicine; and innovations and/or improvements in health care delivery make up the criteria for selecting the award recipient.
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In 2010, grants to the following community programs and scholarships totaled nearly $15,000: s #LARION #ASE #OMPETITION Â&#x2C6; STUDENT driven, interdisciplinary educational competition to build a better, safer health care system. s -INNEAPOLIS #RISIS .URSERY Â&#x2C6; SUPPORT FOR Pediatric Assessment and Medical Management program. s (ONORING #HOICES -INNESOTA Â&#x2C6; A METro-wide advance care planning program, funding to support faculty training and education. s -INNESOTA 6ISITING .URSE !GENCY Â&#x2C6; FUNDing for two health and safety initiatives: portable cribs, mobility strollers and infant carriers; new bedding to address bed bugs, and new bedding for palliative and hospice clients. s --! &OUNDATION Â&#x2C6; SUPPORT FOR THE )NITIAtive for Access â&#x20AC;&#x201D; Health Care in Minnesotaâ&#x20AC;&#x2122;s Cities campaign.
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3UB 3AHARAN !FRICAN 9OUTH AND &AMILY 3ERvices in Minnesota â&#x20AC;&#x201D; support of the childrenâ&#x20AC;&#x2122;s program, Ijole, providing a wide range of life enriching and educational activities. s 4HOMAS 0 #OOK 3CHOLARSHIP Â&#x2C6; MEDICAL student scholarship. For more information on the West Metro Medical Foundation or to make a donation, please contact Nancy Bauer, Twin Cities Medical Society, at nbauer@metrodoctors.com or (612) 623-2893. 2011 Board of Directors Richard D. Schmidt, M.D., chair E. Duane Engstrom, M.D. Paul R. Hamann, M.D. Elisabeth Hurliman, M.D., Ph.D., resident Chris J. Johnson, M.D. Burton S. Schwartz, M.D. Carrie A. Terrell, M.D. Joseph M. Tombers, M.D. Sue Schettle, CEO, Twin Cities Medical Society
Thank you to the following physicians for your 2010 donation to the West Metro Medical Foundation: Arnold Adicoff, M.D. Bonnie K. Adkins-Finke, M.D. Rolf L. Andreassen, M.D. Howard J. Ansel, M.D. Thomas R. Arlander, M.D. Daniel R. Baker, M.D. Lee H. Beecher, M.D. Peter J. Benson, M.D. Peter J. Boardman, M.D. David L. Bowlin, M.D. Paul F. Bowlin, M.D. Louis A. Buie, M.D. Joseph M. Cardamone, M.D. Robert D. Christensen, M.D. James S. Cole, M.D. James L. Craig, M.D. Grant Cravens, M.D. James C. Dahl, M.D. J. Timothy Diegel, M.D. Robert E. Doan, M.D. Dale T. Dobrin, M.D. Edward P. Ehlinger, M.D. Eisenstadt Allergy & Asthma, LLP E. Duane Engstrom, M.D. Richard L. Engwall, M.D.
David L. Estrin, M.D. Richard J. Frey, M.D. Vincent F. Garry, M.D. Reinhold O. Goehl, M.D. Stanley M. Goldberg, M.D. Alberto Gonzalez, M.D. Paul R. Hamann, M.D. Joseph I. Hamel, M.D. A. Stuart Hanson, M.D. John N. Heinz, M.D. Kristen E. Helvig, M.D. John L. Howell, M.D. Charles S. Hoyt, M.D. Gerald D. Jensen, M.D. Charles R. Jorgensen, M.D. David L. Justis, M.D. Laurel A. Krause, M.D. Arthur K. Larson, M.D. James R. Larson, M.D. G. Patrick Lilja, M.D. Maurice L. Lindblom, M.D. John H. Linner, M.D. Virginia R. Lupo, M.D. Richard C. Lussky, M.D. James C. Mankey, M.D.
MetroDoctors
Harry W. Mixer, M.D. Deane C. Manolis, M.D. Anne M. Murray, M.D. Frederick Muschenheim, M.D. Duane L. Orn, M.D. Mark L. Ostlund, M.D. Sotirios A. Parashos, M.D. James J. Pattee, M.D. Mary H. Pennington, M.D. William E. Petersen, M.D. Richard A. Pfohl, M.D. Frank S. Rhame, M.D. Patrick J. Scanlan, M.D. Richard D. Schmidt, M.D. Martin A. Segal, M.D. Richard K. Simmons, M.D. Michael D. Smith, M.D. Edward A. Spenny, M.D. Tierza Stephan, M.D. Farrell S. Stiegler, M.D. Jack L. Strobel, M.D. Marc F. Swiontkowski, M.D. Joseph M. Tombers, M.D. Robert M. Wagner, M.D. Richard C. Woellner, M.D.
The Journal of the Twin Cities Medical Society
Obesity Prevention Coalition is Launched
You will be surprised how little it costs to: • Promote Your Professional Image • Build Patient Confidence • Reduce Employee Turnover • Increase Office Efficiency
T
he Twin Cities Obesity Prevention Coalition is in full swing with the goal of advocating for the passage of obesity prevention resolutions in local metro communities. The first Coalition meeting was held in November with the goal of having all the partners meet, come up with a coalition name and develop next steps for the work in Bloomington. Because the goal is to have many communities pass these resolutions, the Coalition will be expanding over time to reflect the communities where the work is happening. Current Coalition members include Catalyst, Rainbow Health Initiative, American Heart Association, APPEAL, Welcyon Fitness after 50, American Diabetes Association and Bloomington Public Health. Physicians are a critical piece to the advocacy efforts and there are currently a dozen TCMS members who volunteered to participate. They will be writing letters to the editors, attending one-on-one meetings with decision makers, attending community coalition events, providing testimony at hearings, publicly supporting the coalition and being trained in media communications. The Twin Cities Medical Society physician volunteers are Dr. Louis Ling, Dr. Courtney Jordan Baechler,
By Jennifer Anderson, M.A.
MetroDoctors
Dr. Thomas Kottke, Dr. Frank Rhame, Dr. Sanjiv Kumra, Dr. Peter Dehnel, Dr. Stephanie Stanton, Dr. Thomas Siefferman, Jessica van Lengerich, medical student, Dr. Chris Reif and Dr. Claudia Fox. A second Coalition meeting was held the end of February where the group discussed building the Coalition and support from the community as well as communication venues to promote the effort. Watch for the Coalition’s presence at community events across the metro this spring and summer. We will be educating the public on the risk factors for obesity, importance of good obesity prevention policies and how they can help bring successful policies to their community. The Coalition will be recognizable by the new logo that was created by Enoch Peterson, an independent graphic designer residing in St. Paul. Regular updates of Coalition work will be posted on metrodoctors.com and you can follow us on Facebook. If you’re interested in supporting the Twin Cities Obesity Prevention Coalition, please contact Jennifer Anderson at (612) 362-3752 or janderson@metrodoctors.com.
The Journal of the Twin Cities Medical Society
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May/June 2011
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WMMS Alliance
The End of a 100-year Era
H
ow do you say “thank you” for 100 years of support, partnership, collaboration and friendship? The West Metro Medical Society Alliance members wish to thank every medical society member for all each of you have done to help us make a difference in the health of our community. After 100 years of dedication to the mission of “educational and charitable partnership with others (notably physicians) to promote the health and well-being of its members and the community through education, advocacy and service,” the West Metro Medical Society Alliance (originally the Hennepin County Medical Society Auxiliary) has closed its books for good. Reflecting societal changes and an aging membership, the Alliance was no longer able to remain a vital and active organization. The Board voted last November to dissolve both the Alliance and the Philanthropic Alliance. In May, 2010, a lovely 100th anniversary celebration was held to commemorate hundreds of projects, programs, initiatives and most of all, the thousands of Alliance/Auxiliary members, who have worked tirelessly in service to others since 1910. Through the entire hundred years, Alliance members worked alongside our physician spouses to promote the profession of medicine. And for 100 years, the medical society gave generous support — monetary, staff and most of all encouragement — to the Alliance. During this century of service Auxiliary/ Alliance projects reflected society: the first project (1910) was to purchase hospital gowns for patients at Hopewell Hospital. Each decade saw efforts to improve health in such diverse areas of need as Glenwood Hospital’s tuberculosis program; rolling bandages and collecting
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medical instruments during WWII; initiating a Community Health Day to educate high schoolers about drugs; participating in school hearing and vision screenings; piloting a project for newborn hearing at Fairview Southdale Hospital; purchasing equipment for General Hospital’s newborn intensive care ambulance; sending medical supplies to East Africa; educating more than 60,000 third graders over a 20 year period during the Body Works health fair; distributing more than 300,000 HIV/ AIDS education folders to middle schoolers; and raising more than $1,000,000 for local hospitals, medical student scholarships, and health-related organizations and agencies.
It is sad to see such a valuable organization cease its work, but Alliance members are proud of the legacy they leave behind and grateful to the West Metro Medical Society for 100 years of support and friendship. We simply say, “Thank you from the bottom of our hearts!” Co-Presiders: Mary Anderson Martha Arneson Dianne Fenyk Diane Gayes Eleanor Goodall Trish Vaurio
Alliance members celebrate 100 years. From left: Diane Gayes, Dianne Fenyk, Trish Vaurio, Marlene Engstrom, and Mary Anderson.
MetroDoctors
The Journal of the Twin Cities Medical Society
In Memoriam RAYMOND C. BONNABEAU, JR., M.D., Ph.D. died on February 26, at 77 years of age. He was in the class of 1959 at the State University of New York Medical School. He specialized in general and thoracic surgery and then spent nearly 30 years in the U.S. Army, serving overseas and in various posts around the country before retiring as a Major General. Dr. Bonnabeau was later a physician at the Minneapolis VA Hospital and considered it a great privilege to treat veterans. He also taught at the University of Minnesota as a clinical professor of surgery and worked alongside Dr. C. Walton Lillehei in groundbreaking work in heart surgery. ROBERT W. REIF, M.D., age 89, died on February 7 surrounded by his family. Dr. Reif
was a U.S. Army veteran, a former state legislator and both a state and national VFW Surgeon General. He graduated from the University of Minnesota Medical School in 1950 and practiced family medicine in White Bear Lake. JOHN S. RYDBERG, M.D., passed away February 22, 2011, at the age of 79. Dr. Rydberg graduated from the University of Minnesota Medical School, and practiced anesthesiology at the U of M and later at Mercy and Unity Hospitals. He joined TCMS in 1964. HENRY P. STAUB, M.D., 91, died on March 8, 2010. Dr. Staub left Germany at the age of 22 to escape persecution. He received his medical degree from the University of Illinois, completing an internship and residency in
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Minneapolis. He started a pediatric practice in NE Minneapolis. In 1967 he joined the U of M Dept. of Pediatrics where he helped found Pilot City Health Center and served as its acting medical director. Dr. Staub left Minneapolis in 1970 to join the pediatrics faculty at SUNY Buffalo, Meyer Memorial Hospital, and Marshall U Dept. of Pediatrics in Huntington, WV. He returned to Minneapolis in 1983 to enter private practice and eventually started the Staub Pediatric Group. NORMAN F. STONE, M.D., passed away January 26 at the age of 91. Dr. Stone graduated from the University of Minnesota Medical School in 1945 and practiced as a radiologist. He joined TCMS in 1948.
See Additional Career Opportunities on page 30.
Jane E. Flad, M.D. Bloomington Lake Clinic Family Medicine Ishani Jhanjee, M.D., MBBS Multicare Associates of Twin Cities Family Medicine Matthew L. Stiles, M.D. Associated Anesthesiologists, PA Anesthesiology Lea H. Uzochukwu Ekochir, M.D. Allina Medical Clinic Internal Medicine
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MetroDoctors
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May/June 2011
31
LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.
OWEN H. WANGENSTEEN, M.D. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.
VOLUMES HAVE BEEN WRITTEN about Dr. Owen Wangensteen (1898-1981). They’ve dealt mainly with his widely chronicled clinical, scholarly academic, administrative and research accomplishments. Graduating first in his U of M medical class, he later earned his Ph.D. and at age 31 became the first full-time head of the Surgery Department — a position held for over 37 years. There, he created and nurtured a milieu that encouraged wide-ranging achievements by his colleagues, his students and himself … including: naso-gastric suction for bowel obstruction treatment, the heart lung by-pass machine, the first open heart surgery, the first cancer detection center, a variety of intestinal tract cancer techniques and assorted uses for gastric balloons such as peptic ulcer hypothermia treatment. His students included Drs. Shumway and Barnard who performed the first human heart transplants, and 38 academic surgical department chairs. He authored over 900 medical publications, headed the American College of Surgeons and established the University’s Historical Biology and Medicine Library. Dr. Wangensteen’s countless honors and lasting legacies are truly iconic. But, what was he really like? Approachable? Understanding? Humorous? Sympathetic? In the summer of 1960, a starry-eyed junior medical student found out while spending three weeks on Purple Surgery with “The Chief.” The student closely witnessed Dr. Wangensteen delicately explaining to a patient, rapidly succumbing to an antibiotic induced Staphylococcal pseudo-membranous colitis, the urgent need for an enema which would infuse fecal effluent from another patient to her. She agreed; her bowel flora was replenished; she recovered. A gastric cancer patient of Dr. Wangensteen, Mr. “Boone,” was having a large, unwieldy photosensitive coated balloon positioned into his stomach by a surgical resident for imaging purposes. The patient, in an agitated state of discomfort induced panic, forcefully yanked
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the rubber inserting tube, lodging the partially inflated balloon firmly up into the back of his throat. His trachea became obstructed. He unsuccessfully gasped for air. The resident was unable to manually budge the balloon in either direction. The student stood transfixed … figuratively paralyzed. Finally, the equally frightened resident reached for his ever-present bandage scissors and cut the tubing. There followed a mighty audible “swoosh” as the balloon shot swiftly downward, thus relieving the respiratory distress and easing the bluish hue on the unfortunate patient’s lips. Acute tragedy averted; but what would become of the balloon? We were pleased to report to “The Chief” three days later on rounds that the balloon had finally appeared in a bed pan. With a wry and knowing smile, Dr. Wangensteen asked the medical student to place the following message in the progress notes: “Mr. “Boone” has passed the balloon quite soon.” I complied with his request. The student scrubbed with “The Chief” on a complex and lengthy right colon procedure. The aching boredom of holding retractors — as his talented hands gently positioned mine first above by the liver, then below in the pelvis — while towering at his side, remains a vivid memory … even 50 years later. As the last successful stitch was taken and he stripped off his gloves, he turned to me and said, “Thank you, Doctor, I could have never done it without your help.” The student’s question had been answered … arguably the greatest surgical teacher of his time was much more than just a scholar; he was a gentleman of the highest order — blessed of humor and good grace.
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The Journal of the Twin Cities Medical Society
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