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Advocacy for Our Patients and the Profession

Nov/December 2001


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Doctors MetroDoctors

To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of HMS or RMS. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. E-mail: nbauer@mnmed.org. For advertising rates and space reservations, contact: 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.

MetroDoctors

VOLUME 3, NO. 6

NOVEMBER/DECEMBER 2001

2

“Payer Alert” Advises Members of Changes: HealthPartners Provider Agreement Contains Passive Amendments

3

HealthPartners Response to “Payer Alert”

4

LETTERS

4

Index to Advertisers

5

MN PERSPECTIVE

Bioterrorism Agents — What Clinicians Need to Know

8

FEATURE

Grassroots Organizations Joining Together to Resolve Inequities

12

Your Association — A Year in Review

16

Recap of the MMA Annual Meeting

17

MMA Awards

18

Challenges of the Past and Hope for the Future of Primary Care

20

The AMA — the Voice of Medicine in America

22

The Organized Medical Staff Section of the AMA

RAMSEY MEDICAL SOCIETY

23 24 25 26 27

President’s Message RMS Physicians are Leaders Applicants for Membership In Memoriam RMS Alliance HENNEPIN MEDICAL SOCIETY

28 29 30 31 32

Chair’s Report HMS Physicians: Leaders at Every Level New Members In Memoriam/Ollila Named Volunteer of the Year HMS Alliance

The Journal of the Hennepin and Ramsey Medical Societies

Advocacy for Our Patients and the Profession

BI Ag OTE en RR ts OR pa IS ge M 5

MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761.

CONTENTS

Nov/December 2001

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

On the cover: HMS and RMS members participate at the MMA Annual Meeting. Related articles begin on page 8.

November/December 2001

1


CONTRACT REVIEW

“Payer Alert” Advises Members of Changes HealthPartners Provider Agreement Contains Passive Amendments

Editor’s Note: In September, the following “Payer Alert” was sent to members by Virginia R. Lupo, M.D., chair, Hennepin Medical Society; Robert C. Moravec, M.D., president, Ramsey Medical Society; and Bradley Montgomery, president, Minnesota Medical Group Management Association. On the following page is the response received from HealthPartners.

H

HEALTHPARTNERS HAS RECENTLY sent out a letter to participating medical groups containing passive amendments (the “Amendments”) to its Referral Provider Agreement (the “Agreement”). These Amendments unilaterally

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November/December 2001

make significant changes to your Agreement involving, among other provisions, medical necessity, covered services, credentialing, confidentiality, quality assurance, and payment rates. While HealthPartners provided a copy of the proposed Amendments, it did not provide a redline draft of the amended Referral Provider Agreement, thereby making it more difficult to ascertain and analyze the changes to the Agreement. The letter, dated July 23, 2001 and postmarked July 30, 2001, provided a short amount of time — thirty (30) days — to respond to the changes before the Amendments took effect without a provider signature or other explicit approval.

MetroDoctors

The letter stated that “These passive amendments will be effective in 60 days unless written objections are received by HealthPartners within 30 days of your receipt of this letter.” It is not clear from the letter when the 60-day period commences. The Amendment document itself states that it is dated September 20, 2001 and that it is effective September 15, 2001. August 1, 2001 Minnesota Session Law Chapter 170 became effective requiring network organizations (PPOs, and Managed Care Organizations) to disclose contract amendments to providers. An amendment that alters the financial reimbursement or alters the written contractual policies and procedures governing the relationship between the provider and the network organization must be disclosed to the provider before the amendment or change is deemed to be in effect. While HealthPartners’ actions do not appear to violate this new law, we believe that HealthPartners’ actions do violate its spirit. Passive amendments, given with little or no reasonable time to review and analyze changes prior to implementation, appear to violate the public policy that the Legislature enacted just 90 days ago. The Metropolitan Medical Practice Forum contacted Rep. Jim Abeler and Sen. Dallas Sams, the authors of Chapter 170, who expressed shock and grave concern regarding this violation of the spirit of the newly enacted public policy protecting providers from passive amendments. Although it is unclear when the Amendments are to actually be effective, several steps in the amendment process clearly fall after the August 1, 2001 effective date for Chapter 170. At best, this is a very confusing situation prompted by an aggressive HealthPartners passive amendment process. If you want to clarify your rights and better understand how these Amendments will affect your group practice, you should send a written objection immediately to HealthPartners to preserve your rights under their passive amendment timeline. ✦

The Journal of the Hennepin and Ramsey Medical Societies


September 7, 2001 Bradley Montgomery, President, MN Medical Group Management Association Robert C. Moravec, M.D., President, Ramsey Medical Society Virginia R. Lupo, M.D., Chair, Hennepin Medical Society Dear Mr. Montgomery, Dr. Moravec & Dr. Lupo: This week, the MMGMA sent to its members a Health Plan Contract Alert that is critical of HealthPartners and its passive amendment process. The purpose of this letter is to respond to those concerns. We at HealthPartners highly value our relationship with physicians and medical groups. We want physicians to be comfortable with our contracts, and we work with them toward that end. When we mailed passive and regulatory amendments in July, it was intended to be an efficient, low-cost approach implementing administrative and regulatory requirements which offered medical groups an ample opportunity to have their specific questions or concerns addressed. As we said in our cover letter included with the amendments, the Medicare+Choice and Medicare Cost regulatory amendments are federal requirements for HealthPartners to be compliant with applicable Medicare laws and regulations. The passive amendment was used to implement a limited number of administrative changes to provider contracts. We understand that there might be some confusion regarding the effective date of the passive amendment. The confusion is a result of a clerical error in the passive amendment itself. We are sending a letter to physicians that clarifies that the passive amendment is effective 60 days after the provider received the amendment. This is consistent with both the passive amendment provision in our provider contract, as well as the cover letter that we included with the amendment. In the Health Plan Contract Alert, the MMGMA states that “[w]hile HealthPartners’ actions do not appear to violate [Chapter 170], we believe that HealthPartners’ actions do violate its spirit.” We strongly disagree with that statement. We believe our passive amendment process is consistent with both the letter as well as the “spirit” of Chapter 170. Chapter 170 states that changes to the provider contract must be disclosed to the provider, and if the change alters financial reimbursement or policies and procedures governing the relationship between the provider and the health plan, those changes must be disclosed to the provider before the change is effective. Chapter 170 does not address the number of days that the change must be disclosed prior to effectiveness. HealthPartners’ passive amendment process complies with these requirements since we give our providers 60 days notice prior to the effective date of the passive amendment. Moreover, our process goes beyond what Chapter 170 requires because we give our providers 30 days to review the amendment and object to HealthPartners if the provider has any concerns. If the provider objects within the 30 day period, the passive amendment does not become effective until the provider and HealthPartners mutually agree to the passive amendment terms. Therefore, to say that the HealthPartners passive amendment process violates the “spirit” of Chapter 170 is simply inaccurate. We also think it is important to keep in mind that from an administrative perspective, the passive amendment process is efficient and costeffective. HealthPartners has a large network of providers. The passive amendment process allows us to efficiently implement administrative changes to our provider contracts. HealthPartners has worked with medical groups using the passive amendment process in the past. Physicians are familiar with this process and it has worked well for both the provider and the health plan. In fact, we have received very few questions from physicians regarding this passive amendment. Nevertheless, as I have mentioned, HealthPartners will be sending a letter shortly to all providers that received the passive amendment clarifying the effective date and encouraging the providers to contact us if they have any questions or concerns regarding either the passive or regulatory amendment. We are disappointed that we did not have an opportunity to address your concerns prior to MMGMA mailing the Health Plan Contract Alert. In the future, if you have similar concerns or questions, we would appreciate the opportunity to address those concerns in a more collaborative manner. Sincerely, Babette Apland Vice President, Contracted Care

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

November/December 2001

3


LETTERS

Dear Editor: Dr. Ott’s Soapbox (July/August ’01) regarding health problems of people in Iraq and several letter writers’ responses raise some questions. Both sympathize with people’s suffering that was described by Dr. Ott. Both wrote that it wasn’t our fault that we have to support sanctions because Saddam is so bad. Supporters of sanctions argue that they’ve kept him in check. Is it our best moral choice to support sanctions which, along with Saddam’s actions, have caused so many to suffer and die? We already monitor his military development. Couldn’t we continue to do that, while easing sanctions gradually, reducing the suffering of innocents? ✦ Sincerely yours, Kevin M. Kelly, M.D.

Nov./Dec. Index to Advertisers Allina Education and Research .............. 21 Allina Physician Recruitment ................ 32 Brainerd Medical Center ....................... 25 Classifieds ............................................. 16 Consulting Radiologists ....................... 10 Corporate Express (formerly US Office Products) ................ Inside Front Cover Dermatology Consultants ..................... 13 Financial Network .................................. 2 HealthPartners ...................................... 20 Hennepin Cty. Medical Center CME ..... 4 Methodist Hospital .............................. 13 MMIC .......................... Inside Back Cover Multicare Associates .............................. 26 RCMS Inc. ........................................... 22 Sally Bradford Realtor ........................... 14 U of M CME ............. Outside Back Cover Walser Auto .......................................... 11 Weber Law Office ................................. 15 4

November/December 2001

MARK

YOUR

CALENDAR

NOVEMBER 2001 7 Public Health Meets Clinical Practice: Eliminating Health Disparities 1.0 Hour Noon Lecture Pillsbury Auditorium, HCMC 29 – DEC.1 Annual Orthopaedic and Trauma Seminar Minneapolis Convention Center DECEMBER 2001 1 Defense Against Weapons of Mass Destruction: Hospital Provider Course Pillsbury Auditorium, HCMC 5

Geriatrics Dinner Lecture 1.0 Hour Evening Lecture St. Anthony Main, Minneapolis

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10th Annual Family Practice Update Ramada Inn, Bloomington

JANUARY 2002 28 – FEB. 4 Emergency Cardiology Conference Puerto Vallarta, Mexico We would like to better meet the educational needs of physicians in our region. If you have specific ideas or comments, please e-mail robin.hoppenrath@co.hennepin.mn.us or call us at the number listed below. The mission of Hennepin County Medical Center’s CME program is to provide organized, planned education activities to help physicians improve the delivery of medical care.

For more information, please call

HCMC Continuing Medical Education at (612) 347-2075. Fax (612) 904-4210. Toll Free 888-263-4262. www.hcmc.org

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies


MN PERSPECTIVE

Bioterrorism Agents — What Clinicians Need to Know

W

WITH THE RECENT SEPTEMBER 11, 2001 terrorist attacks against the World Trade Center and the Pentagon and the threats of bioterrorism, the intentional use of biological agents to cause disease, public health officials have been receiving a number of requests from health care providers regarding preparedness efforts. Early identification and recognition of patients ill with agents of bioterrorism are essential to reduce morbidity and mortality in the population. Prompt reporting of suspicious illness to the Minnesota Department of Health (612-676-5414) needs to be done when medical providers suspect that patients may be ill with disease due to bioterrorism. Although many biological agents might be used as a weapon, agents vary widely in availability, ease of dissemination, and lethality. There are many challenges in recognizing a bioterrorism attack. Symptoms may be delayed and their initial presentation may be non-specific (i.e., fever, cough, malaise). Medical providers are unfamiliar with many of these diseases. There is a great need for education of providers so that they will consider bioterrorism agents in their differential diagnosis. The U.S. Centers for Disease Control and Prevention and other working groups have indicated that the agents most likely to be used in bioterrorism include Anthrax, Plague, Smallpox, Tularemia, and Botulinum toxin. Following are brief descriptions and tables that summarize these five agents, with treatment and prophylaxis recommendations for adult patients. In the event of a biological release, it would be anticipated that these agents would be released via an aerosol; this would result in an in-

halational route of exposure. For more detailed information, including dosage information for pediatric patients, suggested references are included. Anthrax (Inhalational) Anthrax is caused by Bacillus anthracis, a rod shaped, sporulating organism. If this bacteria were to be weaponized, it would be in an aerosolized form, resulting in inhalation anthrax. Despite aggressive treatment with intravenous antibiotics and intensive care, mortality may still exceed 80 percent. Botulism Botulism is a rare but serious neuroparalytic disorder that can be classified into the following categories: foodborne, wound and intestinal (infant and adult). A nerve toxin that is produced by the bacterium Clostridium botulinum causes this paralytic illness. All forms of botulism can be fatal and are considered medical emergencies. A bioterrorist might choose to contaminate food with botulinum toxin or to aerosolize the toxin. Both exposures would cause similar illnesses and have a high mortality rate. Plague (Pneumonic) The causative agent of plague is Yersinia pestis, a nonmotile, gram-negative bacillus, sometimes coccobacillus. Pneumonic plague would result from inhalation of infected aerosol from an infected person or animal or from a bioterrorism release of an aerosol of Y. pestis. Mortality from pneumonic plague is very high (>80percent) if treatment is delayed.

BY REBECCA WEBER, R.N., M.S A N D R I C H A R D D A N I L A , P h . D . , M . P. H .

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The Journal of the Hennepin and Ramsey Medical Societies

Smallpox Smallpox is a rash forming illness caused by the Variola virus. Although smallpox was eradicated from humans in 1977, there have been allegations that rogue groups possess smallpox virus. Its intentional release in a bioterrorism event would be a crime against humanity. Historically, smallpox had a case fatality rate of 30 percent. The differential diagnosis for smallpox is chickenpox. The smallpox rash has centrifugal distribution with synchronous lesions appearing during a one-two day period and evolving at the same rate. The rash is maculopapular, then vesicular, and later pustular. Chickenpox has a centripetal distribution (greater concentration of lesions on the trunk rather than the face and extremities). Lesions are more superficial and appear in crops every few days and develop at different stages: papules, vesicles, pustules, and scabs. Chickenpox will burst if probed, and unlike smallpox, is never on the palms or soles. Tularemia Tularemia is a disease caused by the gram-negative coccobacillus Francisella tularensis. This agent could potentially be weaponized in an aerosol form resulting in a large number of cases of pleuropneumonitis with significant mortality. For a summary of the main topic areas being examined by the Minnesota Department of Health and the Domestic Terrorism Consequence Management Advisory Committee to direct preparedness efforts throughout the state, please refer to: Minnesota Medicine, August 2001, “Health Care Planning for Chemical and Biological Terrorism,� by John L. Hick, M.D., and Richard Danila, Ph.D., MPH. (Continued on page 6)

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Bioterrorism Agents (Continued from page 5)

Inglesby TV, Dennis DT, Henderson DA, et al. Plague as a biological weapon. Medical and public health management. JAMA. 2000; 283:2281-90.

References Biological Agents Inglesby TV, Henderson DA, Bartlett JG, et al. Anthrax as a biological weapon. Medical and public health management. JAMA. 1999;281:1735-45. Henderson DA, Inglesby TV, Bartlett, JG, et al. Smallpox as a biological weapon. Medical and public health management. JAMA. 1999; 281:2127-37.

Arnon SS, Schechter R, Inglesby TV, et al. Botulinum toxin as a biological weapon. Medical and public health management. JAMA. 2001; 285:1059-70. Dennis DT, Inglesby TV, Henderson DA, et al. Tularemia as a biological weapon. Medical and public health management. JAMA. 2001; 285:2763-73.

Vaccines CDC. Use of anthrax vaccine in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2000; 49 (No. RR-15). CDC. Vaccinia (smallpox) vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP), 2001. MMWR. 2001; 50 (No. RR-10). âœŚ

Agent: Anthrax Bacillus anthracis Clinical Presentation Incubation period: 2-5 days. Range: 1-6 days (may be >30 days). Initial symptoms are nonspecific with fever, dyspnea, cough, headache, vomiting, chills, weakness, abdominal pain and chest pain. This stage lasts from hours to a few days. The second stage develops abruptly with fever, dyspnea, diaphoresis, and shock. Cyanosis and hypotension progress rapidly; death sometimes occurs within hours.

Diagnosis Widened mediastinum on radiograph, with no infiltrates. Lab: Standard blood cultures show growth in 6-24 hours. Key culture characteristics include: large gram-positive spore forming bacilli, nonhemolytic, non-motile, catalase positive (Ref. MDH Lab).

Treatment

Prophylaxis

Ciprofloxacin 400 mg IV q 12 hours (or if strain is susceptible) Penicillin G, 4 million U IV q 4h. or Doxycycline 100 mg IV q 12 h. Switch to PO when condition improves. Treat for 60 days.

Ciprofloxacin 500 mg q 12h PO Or if strain is proven susceptible: Amoxicillin 500 mg q 8h or Doxycycline 100 mg q 12 h PO (Ref. JAMA 1999).

Transmission/ Infection Control Anthrax is not transmissible person to person.

Ciprofloxacin 500 mg PO BID or Ofloxacin 400 mg BID PO or Doxycycline 100mg PO BID or Penicillin VK 7.5 mg/kg PO QID or Amoxicillin 500 mg PO TID (Ref. MMWR 2000) Prophylaxis is for 60 days without vaccine. If vaccine is available, this duration could be shortened to 30-45 days with concomitant administration of 3 doses of vaccine at 0, 2, and 4 weeks.

Agent: Botulism Clostridium botulinum Clinical Presentation Incubation period: 18-36 hours (6 hrs-10 days). Acute, afebrile, symmetric, descending flaccid paralysis that always begins in bulbar musculature. Ptosis, diplopia, blurred vision, dysarthia, dysphonia, dysphagia are hallmark features. The extent and pace of paralysis may vary among patients.

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November/December 2001

Diagnosis Clinical diagnosis is the foundation for early recognition and response. Lab: Toxin production by culture isolates is confirmed by the mouse bioassay.

Treatment

Prophylaxis

Transmission/ Infection Control

Therapy consists of supportive care (mechanical ventilation) and passive immunization with equine antitoxin (trivalent A,B,E type antitoxin). Antitoxin should be given as soon as possible after clinical diagnosis.

Equine botulinum antitoxin, best to give before symptom onset; screen for hypersensitivity first.

Not transmissible person to person.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies


Agent: Plague Yersinia pestis Clinical Presentation Fever, cough, chest pain, and hemoptysis. Severe pneumonia 1 to 6 days (usually 2-4 days) after exposure, progresses to fulminant pneumonia and death without early treatment. Prominent gastrointestinal symptoms, including nausea, vomiting, abdominal pain and diarrhea, might be present.

Diagnosis Cardinal clinical sign would be hemoptysis. Radiograph: patchy or consolidated bronchopneumonia. Lab: Gram stain of sputum or blood may reveal gramnegative bacilli or cocobacilli. Other key culture characteristics include: lactose negative and urea negative (Ref. MDH Lab). Cultures of sputum, blood or lymph node aspirate would grow 2448 hours after inoculation.

Treatment

Prophylaxis

Transmission/ Infection Control

Treat exposed who have fever or cough immediately with antimicrobials for presumptive pneumonic plague. Preferred: Streptomycin 1 gm IM BID or Gentamicin 5 mg/kg IM or IV QD or 2 mg/kg loading dose followed by 1.7 mg/kg IM or IV TID. Alternative: Doxycycline 100mg IV BID or 200 mg IV QD or Ciprofloxacin 400mg IV BID.

Recommended for anyone who was in close contact (i.e., less than or equal to 2 meters) with confirmed or suspected patients that have had <48 hours of antibiotic therapy. Doxycycline 100 mg PO BID or Ciprofloxacin 500 mg PO BID.

Transmissible person to person by droplet. Isolate patient first 48 hours of treatment and until clinical improvement occurs. Special air handling not necessary. Health care workers should wear masks; masks on patients during transport.

Prophylaxis for 7 days

Treat for 10 days

Agent: Smallpox (Variola major) Clinical Presentation Incubation period: 12-14 days (range 7-17 days). End of 12-14 day incubation period, high fever, malaise, prostration, headache and backache. A maculopapular rash develops in mouth and pharynx, followed by lesions appearing on face, progressing to hands, forearms, then spreading to trunk and legs. The rash becomes vesicular, then pustular.

Diagnosis Differential diagnosis must be made to rule out chickenpox. Lab: Electron microscopic examination of vesicular or pustular fluid or scabs.

Treatment

Prophylaxis

Transmission/ Infection Control

Supportive care is the mainstay of smallpox therapy with aggressive treatment of secondary infection.

Vaccine up to 4 days after exposure offers some protection.

Smallpox spread by droplet nuclei, direct contact, and contaminated clothing and bedding. Most infectious from onset of rash, through first 7-10 days. Transmission begins with rash and lasts through convalescence, until scabs fall off. Ongoing transmission is a critical factor; therefore, strict adherence to airborne and contact precautions are necessary.

Treatment

Prophylaxis

Transmission/ Infection Control

Preferred Streptomycin 1 g IM BID or Gentamicin 5 mg/kg IM or IV QD (continue treatment for 10 days). Alternative Doxycycline 100 mg IV BID (continue treatment for 1421 days) or Ciprofloxacin 400 mg IV BID (continue treatment for 10 days). May switch to oral antibiotics when clinically indicated.

Preferred Doxycycline 100mg po BID or Ciprofloxacin 500 mg PO BID

Not transmissible person to person.

Vaccine up to 4 days after exposure offers some protection.

Agent: Tularemia Francisella tularenis Clinical Presentation Incubation period: 3-5 days (range 1-14 days). Abrupt onset of fever, chills, mylagia and headache. This would progress in some patients to pharyngitis, bronchiolitis, pneumonitis, pleuritis, hilar lymphadenitis. Complications of untreated infection may lead to sepsis and inflammatory response syndrome.

MetroDoctors

Diagnosis Infiltrates on radiograph, may have pleural effusions. Lab: Direct exam of secretions, exudates or biopsy specimens using direct fluorescent antibody or immunohisto-chemical stains. Other key culture characteristics include: Poorly staining, tiny gram negative coccobacilli, slow growing, requires cysteine, oxidase, urea and nitrate negative (Ref. MDH Lab).

The Journal of the Hennepin and Ramsey Medical Societies

November/December 2001

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FEATURE STORY

Joining Together —

Grassroots Organizations to Resolve Inequities

“If you think being small means powerless, you’ve never been in bed with a mosquito.” Sidewalk Art, Macalester College

In our democracy it is important for physicians to understand what their opportunities are in order to “change the system.”

W

WHY SHOULD PHYSICIANS BE INVOLVED in their local medical society? The short answer to this question is for the good of their patients and for their own good. The object of all our professional activities should be to deliver optimum medical care to our patients and to improve the public health of our communities. While these are noble objectives, the complexity of our current medical care environment makes it crucially important for physicians to understand the environment in which they work and, as importantly, understand how they can influence their environment to improve deficient circumstances and correct wrongs. The professional landscape in which we participate is initially driven by our professional education and the ethical codes by which we abide. Our education is impacted by state and federal legislation and our ethical codes require continuing scrutiny to make sure that applications are appropriate for our moment in time. Our professional environment is impacted as well by state mandated licensure, federal overview, and a necessity to maintain proficiency mandated by CME requirements. City, county, state, and federal laws and regulations, will impact our individual practice settings, whether clinic-based or hospital-based. The web of laws and regulations is such that it is almost certain that each physician will encounter at least one circumstance in the course of their career — a burdensome regulation that requires correction, an inappropriate legislative initiative, or an unworkable statute that requires correction. The question then becomes one for each individual physician. How can I correct this inappropriate or inequitable situation? It is easy to forget that we live in the United States of America, a representative democracy in which competing interests occur in nearly all areas in which government and regulatory authorities have a necessity to reconcile competing interests. In our democracy it is important for physicians to understand what their opportunities are in order to “change the system.” The first stage in “Changing the System,” is to recognize the problem. This might occur in any one of our daily activities but requires consideration within some collective group that could be a clinic working committee or a county medical society. It is important to refine particular issues in a group process to make certain that any particular issue has sufficient breadth and severity to justify the work needed to affect change. Physicians individually may feel quite powerless to alter or modify the health system in the United States. Groups of physicians, however, with substantial motivation, can in fact

BY KENT WILSON, M.D.

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November/December 2001

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies


bring to bear sufficient consideration to alter significant inequities and have very substantial effects on the health care system. The tools for resolving inequities often involve the legal and legislative systems. Group activity is very important in the efforts to influence legislation. The Ramsey and Hennepin Medical Societies are the grassroots organizations that are available to develop concerns, formulate solutions and raise both the issues and the solutions to the state level such as the Minnesota Medical Association. It is common for many issues to originate at the county society level, be carried to the state, and then on to the national level at the American Medical Association. Redress of significant issues may require the use of legal challenges and these are generally beyond the means of individual physicians and, therefore, require group action such as state or national medical societies, including specialty societies when the issue is specialty specific. My own career beginning as a delegate from the Ramsey Medical Society, serving as president of my state specialty society, and then moving on to the Minnesota Medical Association where I subsequently was elected president, was largely driven by issues and a curiosity and drive to learn how inequities and injustices could be eliminated. When I first became a RMS delegate to the MMA House of Delegates in the early 1980s it was clear that the development of managed care and the application of its principles had some downside aspects that were of great concern to physicians. The concern was sufficient enouth that I had the privilege of chairing the MMA Commission on Competition in Health Care that studied the evolving health care environment of the early and mid-eighties and arrived at a number of conclusions. One of the conclusions was that fourth parties, in what had previously been considered a three party system, played a substantial role in determining the economics of health care. Today, the role of fourth parties is old news, but at that time, the conclusion was new and timely. Other conclusions were adopted, including the federal anti-trust regulations employed to prevent independent physicians from collectively bargaining with the rapidly developing managed care organizations and placing physicians in an extremely weak negotiating position. Initiatives emerged from the study that included resolutions in the AMA House of Delegates from Minnesota and later, from California, calling on the AMA to study collective bargaining options for physicians and to seek changes in the federal anti-trust statutes that would allow physicians to organize for negotiating for reasonable negotiating purposes. Texas has recently adopted state law that allows limited collective bargaining and the Campbell bill introduced in the U.S. House of Representatives is an example of proposed federal legislation allowing physician collective bargaining.

It is common for many issues to originate at the county society level, be carried to the state, and then on to the national level at the American Medical Association.

(Continued on page 10)

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

November/December 2001

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Grassroots Organizations (Continued from page 9)

An example from my own experience in which a professional society as well as the state medical association and the AMA became involved in an issue, is the Blue Cross and Blue Shield of Minnesota Value Health System of prior authorization for surgery initiated in 1990. The system was protected by

copyright, and review criteria were not readily available to either practicing physicians or patients. The organization that developed the criteria did not employ a Minnesota licensed physician. There were sufficient concerns on the part of my fellow otolaryngologists that we believed we needed to oppose the implementation of this program. Since we were small in numbers, we

Consulting Radiologists, Ltd. Introduces New Physicians Consulting Radiologists, Ltd. is pleases to announce the association of Gwen Nazarian, M.D., Juris Purins, M. D. and Michael Vendrell, M. D. Dr. Nazarian earned a medical degree from Mayo Medical School. She was the Outstanding Resident at the University of Michigan and performed a fellowship in cardiovascular and interventional radiology at the University of Minnesota. Dr. Nazarian has been a practicing radiologist for seven years and is currently at Abbott Northwestern Hospital.

Dr. Purins, M.D. earned dental and medical degrees from the University of Minnesota. He performed residencies in diagnostic radiology at Wilford Hall Medical Center in San Antonio, Texas and internal medicine at Abbott Northwestern Hospital. He served as a physician for nine years in the Air Force and currently practices at Cambridge Medical Center.

Dr. Vendrell was a Commander in the United States Public Health Service and most recently served as chief radiologist for the Indian Health Service in the Bemidji area. He earned a medical degree from the University of Texas and preformed residencies in diagnostic radiology and internal medicine and was a fellow in gastrointestinal, interventional and vascular radiology at George Washington University.

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November/December 2001

MetroDoctors

decided we needed to collaborate with both the MMA and the AMA. Ultimately, this conflict resulted in the state and national development of widely published specialtybased criteria for surgical intervention in a variety of circumstances for quality assessment purposes. Those of us who held office in organized medicine in the early 1990s had the opportunity to participate in the very farreaching actions of the Minnesota Legislature that resulted in the enactment of MinnesotaCare. MinnesotaCare is not the last reform of the health care system and it is crucially important that physician organizations such as the Ramsey and Hennepin Medical Societies, the MMA, and the specialty societies remain actively involved. The concerns of physicians and their patients must be represented as reforms are made to improve health care and to change the economic factors. The skills that are required to work in a complex legislative or regulatory health care environment are not customarily taught in medical school. Training for survival in this environment is readily available in the Ramsey and Hennepin Medical Societies and in the MMA where physicians collectively assess the need and collectively act to correct the problem through legislation or through the regulatory process. Leadership training in assessment of issues, communication skills, group process, and legislative action are available to all members. Physicians who become involved find a very dynamic and rewarding process that empowers them to achieve their goal. Concerned physicians who are willing to spend some of their time to work collectively to improve health care through their professional organizations best serve the interests of patients and of physicians. For the sake of all physicians and their patients, I hope Minnesota physicians continue to play an active role in the Ramsey and Hennepin Medical Societies and in their other professional organizations. â&#x153;Ś The Journal of the Hennepin and Ramsey Medical Societies


2002 MeMber benefit— neW! Ramsey & Hennepin Medical Societies A HASSLE-FREE Automotive Discount Buying Service

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“You get the best price up front — no need to negotiate from the sticker price, no hidden charges or hassles and you’re eligible for all manufacturer’s incentives” • • • •

Convenience is key: We will get you the best price and locate the right vehicle for you, your employees, or family members * Enroll your clinic or practice and all your employees will receive special pricing Great factory financing and leasing Trade-ins welcome RV’s Too! Ford Explorer

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Huge selection of • Camry • Maxima • Lincoln • Taurus • Le Sabre • Intrepid • Caravan • Mazda

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Huge collection of SUVs & Trucks available • Toyota Highlander • Nissan Extera • Ford Explorer • Lincoln Navigator • Chevy Tahoe • Jeep Grand Cherokee

Contact HMS/RMS at 612-362-3705 for your personal ID card or contact Ty Reed at 612-272-1385 or e-mail treed@walser.com for these Special Pricing Programs MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

November/December 2001

11


Your Association — A Year in Review Highlights of the activities of 2001

Editor’s Note: To our loyal members (and others): If you have ever questioned “What has my county medical society done for me lately?” the following compilation of one year’s activities should help convince you what an incredible deal your dues investment is. The staff and physician volunteers accomplish an unbelievable amount of good work on behalf of you physicians and the community we all serve. Yet, we still have colleagues who don’t belong, and don’t contribute. (Young physicians, in particular, are often said to be reticent.) That’s unfortunate for everyone. If you agree with me, please seize the moment and share this list with one or two colleagues. And take a moment to call and thank the medical society staff. Richard J. Morris, M.D.

of health care, to observe, firsthand, physicians doing what they do best—caring for their patients. Medical Student Activities • • • •

JOINT HMS/RMS EFFORTS: Credentialing The Hennepin and Ramsey Medical Societies successfully provided a six-month bridge to the medical community by continuing the credentials verification services to physicians until the Minnesota Joint Purchasing Coalition finalized its national search and contract with CredentialOne.

Referral Provider Agreement. These notices are intended to provide physicians and clinic administrators with information on changes being made to provider contracts and to educate members on the contract provisions. Successes at the legislature in 2001 relating to health care providers and consumers include: 1) Passive contracting limitations; 2) Mandatory disclosure of contract changes (effective Aug. 1, 2001); and 3) Provider options to decline and later participate in new categories of medical service.

• •

Winter Medical Conference •

Membership Considerable effort has been placed on membership marketing and retention this year. Personal phone calls and face-to-face meetings with clinic administrators and physician leaders are resulting in a reversal of the trend in membership decline.

Quarterly Meetings with Health Plan Reps

Fair Contracting Coalition

Community Internship Programs

12

In partnership with the Medical Group Management Association, HMS and RMS produced and distributed payer contract “Alerts” on two BCBS contract amendments and most recently a HealthPartners

November/December 2001

Leadership of the HMS, RMS and MMA meet quarterly with representatives of the major health plans for the purpose of dialogue and information sharing.

Two community internship programs were cosponsored by HMS and RMS, providing the opportunity for key members of the public who may affect or influence the purchase or delivery

MetroDoctors

Connections – A physician/medical student mentoring program; Shadow a Physician – Medical students observe physicians in various specialties; Lunch ’n Learn – Educational speakers and lunch are provided to 200+ students; 1st Year Welcome Picnic – First year medical students are introduced to organized medicine; White Coat Ceremony – Cross pens and kudos mark this event; and Dinner Program for medical students and their significant others – “Escape Fire,” a video by Dr. Donald M. Berwick, was viewed and discussed at the Shoreview Community Center.

The Moon Palace on the Mayan Riviera south of Cancun was the venue for the 2001 HMS/RMS Winter Medical Conference. Sixteen hours of CME were offered in addition to warm temperatures and sunny skies. Join us for the 2002 Winter Medical Conference, March 9-16, Royal Caribbean Cruise. Contact Doreen Hines @612-3623705 or dhines@metrodoctors.com for more information.

MetroDoctors and website •

Now in its third year of publication, MetroDoctors continues to offer timely and thought-provoking articles, editorials, and articles on the business of medicine.

The Journal of the Hennepin and Ramsey Medical Societies


â&#x20AC;˘

www.metrodoctors.com is the HMS/RMS website with links to each society, the MMA and other organizations.

Accountable Provider Networks HMS and RMS continue to support and monitor the development of alternative health insurance products. AMOM (Advocates for Marketplace Options for Mainstreet) is leading these efforts. Metropolitan Hospital Physician Leadership Forum HMS and RMS have continued their commitment to meet with physician leaders in the metropolitan area. Chiefs of staff, medical directors, and other physician leaders are invited four times a year to come together to share concerns and to hear speakers on issues that are common to physician leaders in the Twin Cities area. (Continued on page 14)

DR. MALINEE SAXENA was born in Romford, England and lived in India and Canada. She went to high school in Brookings, South Dakota. She graduated with a B.A. in physiology and child psychology from the University of Minnesota. Her medical degree was obtained in 1997 from the University of Minnesota Medical School. She then went on to complete her Transitional Internship at Hennepin County Medical Center in 1998. Dr. Saxena completed her Dermatology residency at the University of Minnesota where she served as Chief Resident in 2000-2001. She currently resides in St. Paul with her husband, Jeff.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

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

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

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

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

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

Eagan Office Suite 220 1185 Town Centre Dr. Eagan, MN 55123 (651) 251-3300

November/December 2001

13


Year in Review (Continued from page 13)

HENNEPIN MEDICAL SOCIETY ACTIVITIES:

Shotwell Award Two awards were given this year. Paul Quie, M.D., University of Minnesota pediatrician with specialization in infectious diseases; and Gordon Sprenger, CEO of Allina, were presented with a Spritz sculpture, the symbol of the Shotwell Award. Charles Bolles-Bolles Rogers Award Edward A. L. Spenny, M.D. received the annual Charles Bolles-Bolles Rogers award recog-

Marine on St. Croix

communities. An early success is the development of a single record for student health information created by a work group focused on improving communication between school nurses, physicians, and families.

nizing his commitment to medicine and his love of the profession. Ethical Accountability Guidelines Following three years of research and refinement, the HMS Ad Hoc Ethics Committee produced, “Ethical Accountability Guidelines for Physicians in our Changing Healthcare Environment.” This document was created in response to member concerns about challenges to the physician-patient relationship and the independence of physician clinical judgment and ability to be effective patient advocates. AMA Guidebook Under the leadership of A. Stuart Hanson, M.D., HMS physicians and experts throughout the country are producing a guidebook for the AMA on “Guidelines for Diagnosing and Treating Workplace Abuse in Medical Care Organizations.” This guidebook is the ninth in a series on abuse published by the AMA.

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University of Minnesota Medical School Admissions Committee HMS is proud to have a designated seat on the U of M Medical School Admissions Committee. Roger Becklund, M.D. currently fills this position. Park Nicollet-Tri County Health Committee HMS is participating in a group of health care, school and community representatives in the southwestern suburbs to identify and discuss needs and potential solutions to measurably improve the health of children, families, and

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Public Health Advisory Committee Doug Price, M.D. has been appointed as the HMS representative to the Minneapolis Department of Health & Family Support, Public Health Advisory Committee. Drs. Walter Wilder, Mary Hroscikoski, and Julia Joseph DiCaprio have served as past representatives. Hennepin Medical Foundation The philanthropic arm of the Hennepin Medical Society, the Hennepin Medical Foundation provides annual gifts to community organizations and projects approved by the Board of Directors, and scholarships and loans to medical students. The Foundation also serves as the fiscal agent for the Thomas W. and Mary Kay Hoban Scholarship, the Eitel Fund (Mpls. Surgical Society), the Peppard Fund, and the International Health Care Fund. Senior Physicians Association Paul Bowlin, M.D. serves as the 2001 president of the Senior Physicians Association, an organization of 400+ retired physicians who gather quarterly for the purpose of socialization and education. Hennepin Medical Society Alliance HMS proudly supports the HMSA and many of their public health activities, most notably Body Works, the health education fair for third graders, and the HIV/AIDS Education Folder, distributed to more than 200,000 middle grade students statewide.

The Journal of the Hennepin and Ramsey Medical Societies


RAMSEY MEDICAL SOCIETY ACTIVITIES:

Community Service Award Recognizes the positive contributions RMS physicians make in their communities. This year, Wayne Thalhuber, M.D., was honored with the award at the RMS Annual Meeting held at the North Oaks Golf Club in North Oaks, MN. Dr. Thalhuber was recognized for his leadership in organizing hospice care and for serving the needs of patients who have end of life care needs.

Community Internship Program – Macalester College In March of 2001, RMS members were offered the opportunity to host an upper division student or faculty member from a Health Care Policy Analysis class from Macalester College. Each intern spent four hours with two physicians to experience first-hand the delivery of health care at the point of patient contact with their physician.

Commendation for Service Joseph L. Rigatuso, M.D., was recognized at the RMS Annual Meeting for: his years of service representing East Metro physicians on the MMA Board of Trustees; his years of service as a RMS delegate in the MMA House of Delegates; and, his service on the RMS Board of Directors. RMS Alliance Activities RMS supports many joint projects with the RMS Alliance. Please see the RMS Alliance news for a project summary. Caring Hearts for the Homeless RMS and the Alliance worked with HealthEast to secure needed medical and hygiene supplies for the homeless in Ramsey County by co-sponsoring the Caring Hearts for Homeless People supply drive. Twenty-three clinics participated, 45 churches and many, many volunteers. Nearly $57,000 worth of donated goods (two tons of supplies!) were received and dispersed to Health Care for the Homeless clinics, Listening House, and Safe Zone.

MetroDoctors

Senior Physicians Paul J. Dyrdal, M.D. is the current President of the RMS Senior Physician Association. The Association currently has more than 350 senior physicians. The RMS Senior Physicians meet four times per year to hear from speakers and to socialize. Most recently, the Senior Physicians enjoyed lunch and a tour of the Weisman Art Museum at the University of Minnesota with the HMS Senior Physicians. RMS Foundation Reorganization The RMS Foundation supports charitable, educational and scientific projects. Recently, the Bylaws were revised and a new Board of Directors was appointed. The Board members are now focusing on creating a vision statement, a mission statement, and a strategic plan. The Board is enthusiastic and inspired to rejuvenate the RMS Foundation.

RMS Accreditation RMS is submitting an application to the Minnesota Medical Association Committee on Accreditation and CME to become a CME accredited entity. By virtue of this accreditation, RMS will be able to offer its members accredited CME courses throughout the year, in addition to the Winter Medical Conference. Orientation for Clinic Employees RMS offers semi-monthly seminars for clinic employees and special interest seminars on medical issues whenever needed. The orientation generally touches on areas such as continuous quality improvement, risk management, medical records, patient relations and health care in 2001. The seminars are always well attended and very well received. ✦

WEBER LAW OFFICE

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MICHAEL J. WEBER, J.D. • Former Attorney for the Board of Medical Practice • Over Six Years as an Assistant Attorney General

612-296-8080

University of Minnesota Medical School Admissions Committee

www.weber-law.com

Terrance Capistrant, M.D., is the dedicated representative of RMS on the Admissions Committee. Members of the Admissions Committee devote many hours to reviewing applications for admission to the medical school and in decision-making meetings.

“Committed to the Best Legal Outcome Possible Through Diligence and Resourcefulness!”

The Journal of the Hennepin and Ramsey Medical Societies

November/December 2001

15


Recap of the MMA Annual Meeting

T

THE PRESENCE OF THE Hennepin and Ramsey Medical Society members was truly noted at the MMA annual House of Delegates meeting September 19-21 in St. Cloud. Blanton Bessinger, M.D., RMS member, concluded his term as MMA President and passed the presidential medallion to Peter Amadio, M.D., Rochester. Robert Meiches, M.D., HMS member and MMA Board Chair, awarded Carolyn McKay, M.D., HMS member, the Distinguished Service Award. In addition, several HMS members were elected to officer positions. They included: Gary Hanovich, M.D., President-Elect, Michael Ainslie, M.D., re-elected Treasurer, and David Estrin, M.D., re-elected Secretary. J. Michael Gonzalez-Campoy, M.D., Ph.D., RMS member, was narrowly de-

feated in the ballot for Vice-Speaker of the House. A number of the HMS and RMS members served on reference committees and many physicians provided testimony on the resolutions being considered. Below is a list of the resolutions submitted by HMS and RMS. Please refer to the MMA website: www.mmaonline.net/ about/annualmeeting.cfm for information on the action taken on these resolutions. • Resolution 100: AMA Federation Unity Project. • Resolution 102: Electronic Medical Records. • Resolution 106: Disaster Preparedness. • Resolution 204: Point of Care Lab Choice. • Resolution 205: Commercial Tanning of Minors.

• • • • • • •

• •

Every picture tells a story…

• • • • •

…unless you don’t have one.

The Hennepin and Ramsey Medical Societies, in conjunction with Invizeon, can help tell your story. Invizeon’s photography team will be in the Minneapolis area December 3-21, and in the St. Paul area January 7-18, taking color digital photos of society members for the 2002 print directory and on-line physician locator. Photography sittings will conveniently take place in local hospitals in the metropolitan area. An Invizeon representative will be calling society members beginning in early November to schedule your free photography appointment.

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Resolution 206: Repeal State Sales Tax on Topical Sunscreens. Resolution 207: ICD-9 Codes. Resolution 208: Drivers Cellular Phone Policy. Resolution 209: Patient Noncompliance Factor. Resolution 210: Health Professional Educational Use of Provider Tax Funds. Resolution 301: Global Risk Sharing Contracts Between Health Plans and Physicians. Resolution 302: MMA to Cosponsor a Community Conference to Discuss the Next Generation of Health Care Delivery and Financing Systems. Resolution 303: Reimbursement for Treatment of Obesity. Resolution 304: Standards to Protect the Quality and Privacy of Patient Care in Contracts Between Health Plans and Physicians. Resolution 305: Health Screening of Minnesota Offenders. Resolution 306: Patient Protection with Fairness in Health Care Contracts. Resolution 307: Critical Care Reimbursement. Resolution 308: MMA Support for Consumer Driven Health Care Reform. Resolution 405: Uniform Machine-Readable Coding of Pharmaceuticals. Resolution 406: Task Force to Study the Approprite Mental Health Evaluation of Children. ✦

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The Journal of the Hennepin and Ramsey Medical Societies


McKay Receives MMA Distinguished Service Award

C

Ramsey Medical Societies. To 200 first and second year medical students, she spoke of the pride she has in being a physician and the value of organized medicine for the profession. She wore her white coat as an indication of her love of medicine. ✦

CAROLYN J. MCKAY, M.D., a pediatrician at

Staub Pediatric Clinic, received the 2001 Minnesota Medical Association (MMA) Distinguished Service Award, the highest honor bestowed upon a colleague by the MMA. In presenting the award, Robert Meiches, M.D., MMA Board Chair, recited Dr. McKay’s accomplishments, including serving as the Commissioner of Health for the City of Minneapolis, director of the Maternal and Child Health Division of the Minnesota Department of Health, and a consultant to the WIC program. She also served on the state Crime Victims Reparation Board, the Children’s Home Society of Minnesota Board, and currently serves on the state Health Technology Advisory Committee. Dr. McKay has represented Minnesota physicians as a delegate to the American Medical Association since 1992 and on the Smoke-Free Coalition Board. She has been actively involved in public health and preventive medicine at the MMA and throughout the world. Dr. McKay is a graduate of the University of Minnesota Medical School and completed

50-Year Members

Dr. McKay accepts MMA’s Distinguished Service Award.

her residency in pediatrics at Cleveland Metropolitan General Hospital and the University of Colorado Medical Center. In addition, she received a master’s degree in public health from Johns Hopkins School of Hygiene and Public Health. Recently, Dr. McKay participated in a University of Minnesota Medical Student “lunch ’n learn” organized by the Hennepin and

Hamann Receives President’s Award

P

PAUL R. HAMANN, M.D., HMS member, was

awarded one of the MMA’s President’s Awards. This award is presented to those members of the Association who have made outstanding contributions in service but have never been recognized by the MMA for their dedication and commitment. Dr. Hamann was a delegate to the MMA House of Delegates and served as the MMA vice president in 1996 and 1997. He serves on the Minnesota Physician Support Committee, and the Committee on Administration and Finance. ✦ MetroDoctors

Dr. Hamann (right) receives the President’s Award from Dr. Blanton Bessinger.

The Journal of the Hennepin and Ramsey Medical Societies

The Minnesota Medical Association annually recognizes its members who have given 50 years of service to the practice of medicine. The following HMS and RMS members were among those recognized: Wallace E. Anderson, M.D. James R. Bergquist, M.D. Charles V. Carlson, M.D. H. Mead Cavert, M.D. Henry W. Cohen, M.D. Edward P. Donatelle, M.D. Robert A. Dornbach, M.D. Evan S. Ellison, M.D. N. L. Gault, M.D. Suzanne Grant, M.D. William H. Houlton, M.D. Edward A. Johnson, M.D. Charles F. Kelly, M.D. Jeanette K. Lowry, M.D. John E. Middlebrook, M.D. John B. O’Leary, M.D. Konald A. Prem, M.D. Robert F. Premer, M.D. Arthur B. Quiggle, M.D. Harley J. Racer, M.D. Alexander E. Ratelle, M.D. Byron H. Roberts, M.D. Kenneth B. Romness, M.D. Gregory A. Schissel, M.D. Franklin D. Sidell, M.D. Donald Bjork Swenson, M.D. Albert L. Walonick, M.D. Harold Wexler, M.D. ✦ November/December 2001

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Challenges of the Past and Hope for the Future of Primary Care

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THE 1990s WERE A TIME of upheaval in U.S. health care. A market-driven system was controlled by government, insurers, and employers while the input of patients and physicians was limited. Managed care business practices caused frustration and ill will, as well as time and income pressures among physicians. The press reported deteriorating morale and career dissatisfaction among physicians. The effect was felt in Minnesota, forcing professional physician organizations to deal with the changing marketplace. In 2000, the Hennepin and Ramsey Chapters of the Minnesota Academy of Family Physicians (MAFP) recognized that health plan reimbursements in the Twin Cities area had fallen significantly behind the increased cost of doing business. Both independent and system-owned primary care clinics were losing money unless the physicians’ compensation was significantly reduced or they significantly increased their work for the same pay. Family physician compensation from 1995 to 2000 was flat and fell behind inflation and productivity increased. The net effect has been a demoralizing loss of income per work RVU produced. Health plans increasingly shifted the risks to independent practices. One clinic faced a situation where the health plan declared that new contracts would place clinics at 80-90 percent risk, versus a 20 percent risk with the old contracts. Practices were offered contracts on a “take it or leave it” basis — a difficult choice when this represents 25 to 30 percent of the clinic’s business. Health plans also began pricing products below actual costs as evidenced by health plan internal communications. The plans were un-

der considerable financial stress due to increased patient demand, increased cost of new technology as well as other costs, such as 21 percent annual increased drug costs. They significantly increased their premiums but did not increase the dollars going to primary care doctors enough to even cover increased costs. From 1996 through 2000, a primary care clinic averaged 4 percent increases in revenue per year from the health plan, but watched utilization expenses increase by an average of 12 percent per year. This occurred at a time when the clinic risk share increased from 20 to 70 percent. Clinics were increasingly expected to assume risk without control over the pricing of the product. Also, healthier patients were being removed from the risk pool through employers’ self-insurance that meant patients covered by health plan contracts suffered from more complex illnesses and used health care services more often. These events were having a significant economic impact on practices, family physicians and their patients (i.e., the sale of clinics, clinics being closed, physicians being laid off or leaving practices, loss of continuity of care, expense of transferring patient records, etc.). The income of established physicians in independent clinics has been reduced in order to offer competitive salaries to new physicians, and primary care physicians needed to see more patients in less time or increase clinic hours in order to offset the financial impact. It appears that an average family physician in the Twin Cities metropolitan area averaged 28 hours per week of clinic patient contact in 1995. Presently, family physicians spend 32 to 36 hours or more a week in the clinic. This has given rise to a change in the hospital practice of many family

B Y R I C H A R D M . G E B H A RT, M . D . Vice President, Minnesota Academy of Family Physicians

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physician groups. It is now common for groups to share hospital coverage using a “clinic rounding physician” or admit patients to a “hospitalist.” 1999 data from large clinic systems in the Twin Cities showed significant losses in their primary care sites. Losses in some systems were in the $50,000/FTE physician range. Independent practices were equally affected with six figure losses at some clinics. The MAFP recognized that optimal primary and preventive care is best provided by physicians without time limits, financial constraints, or burnout. The Hennepin and Ramsey Chapters planned two focus groups to discuss these issues and hopefully identify ways that practices had addressed them. Last spring, 35 physicians from both sides of the river took part in the focus groups facilitated by faculty from the University of St. Thomas. Participants were invited from a variety of practices. The following is a summary of the issues discussed. Besides reimbursement issues directly relating to health plans, physicians discussed coding for complex patients, reimbursement for time spent supervising care by others and formulary changes, and the impact of open-access scheduling and using hospitalists. Another issue was the need for research data, not just for evidence-based practice, but also to show the value-added to clinics by primary care physicians. Concern was expressed over the growth of urgent care clinics and how they change the way health care is being delivered, the changing image of family practice and medical students and residents comfort with practicing the whole spectrum of primary care. The physicians who planned the focus groups had hoped for descriptions of some successful ideas that practices have implemented. Unfortunately, the focus groups confirmed the individuality of the practices and the challenges

The Journal of the Hennepin and Ramsey Medical Societies


of addressing both economics and practice styles. What may work well in one practice setting would not necessarily transfer to another practice with a different mix of specialties, patients or payment sources. Further, some practices may be hesitant to share information with “competing” practices because such sharing might be perceived to be counter to anti-trust laws. Currently underway at the MAFP are plans to address this crisis. It is deemed urgent to maintain the viability of family practice in the following ways: • address the issue of adequate reimbursement and education on appropriate coding for outpatient care for individuals with complex medical illnesses; • gather information on practice models, the cost of doing business and reimbursement by payer that will help physicians to select the most successful business models; and • develop an ongoing program of communications that seeks to identify and publish clinical and business models which physicians have used to successfully address reimbursement issues, staffing inadequacies, quality of care issues, and continuity of care. The MAFP is also concerned about the impact the issues described above is having on

MetroDoctors

interest in the medical profession in general and student interest in family practice. Both the number of applications to medical school and the number of U.S. medical students applying to family practice residencies have fallen in recent years. (See the chart below). Nationally, the number of students applying to match in family practice residency programs has been declining the last five years. In Minnesota, an average of 26 percent of graduating students from the University of Minnesota entered family practice over the last three years, which is down from 30 percent three years ago. Of the 2001 graduating class, only 20 percent matched in family practice. In addition, the rural residency programs in Waseca, Duluth, St. Cloud and LaCrosse, WI, had fewer students match than last year. The MAFP is committed to looking at issues of student interest and recruitment and start asking “why?” One reason may be the increasing medical school debt of almost $100,000 per student that may deter them from applying to medical school. Along with that, students may be selecting specialties other than family medicine because those specialties have higher salaries allowing students to pay off their loans faster. A positive counterbalance to the negative is that happy physicians precepting

The Journal of the Hennepin and Ramsey Medical Societies

medical students in successful practices make the best recruitment poster. Results from informal surveys by the MAFP show that faculty, mentors and preceptors rank first as influencing specialty choice among students. Plans are underway to develop a conference that will gather key players together to look at the future of health care and family practice in Minnesota. Participants will gather information and brainstorm ideas for addressing the following: • Medical student interest; • Definition of family medicine (what does it add to the system?); • Attitudes of current practitioners regarding practice issues — style, call schedule, generations, training, etc.; • Patient and consumer needs and their impact on system design; • Collaboration in provider teams, who’s on the team, complementary medicine, etc.; and • Vision of the future for family medicine. Of course, the MAFP believes that family medicine has played, and will continue to play, a key role in the future of health care in Minnesota. We expect that not only our members will benefit from this process, but that the patients and the system will benefit even more! ✦

November/December 2001

19


The AMA — the Voice of Medicine in America

T

THE AMERICAN MEDICAL Association’s House of Delegates serves as the major voice of medicine in America. This is accomplished by the AMA’s pluralistic and democratically elected House of Delegates, its comprehensive and consensus-building approach to federal legislative activity, and the multi-faceted activities that directly impact the individual physician’s practice of medicine. The importance of the individual physician member and the county society is most noted BY FRANK INDIHAR, M.D. AMA Delegate, Minnesota

in the AMA’s policy-making body, the House of Delegates. The major portion of the House of Delegates is derived from the democratic election of delegates sponsored by counties from across the United States. These county-sponsored individuals are elected at statewide association conventions. As a result, these delegates remain responsive to the issues of individual physicians, their counties, and their states. Specialty societies also elect delegates whose representation is more parochially directed as national representatives of their specialty to single, specialty specific items. This focus often deters these specialty societies from serving the pluralistic house of

Every Month

Cardiology Today 

NOVEMBER 2001

Fall - Winter Programs

2001-2002 For further information contact Continuing Professional Development

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20

November/December 2001

FEBRUARY 2002

February 28 - March 1

Sixteenth Annual Family Medicine Today 

APRIL 2002

December 6 -7

Fourteenth Annual Burn and Wound Care Today 

MARCH 2002

The Challenges of Aging In A New Century November 2

Twenty-Third Annual Cardiovascular Conference 

Sponsored by HealthPartners Institute for Medical Education

Second Tuesday of the Month

Second Annual Women's Health Conference: 

DECEMBER 2001

medicine. It is only an umbrella association such as the AMA that can effectively be a voice for all physicians at a federal level. The House of Delegates’ unique composition positions it, via its legislative committee, to uniquely build consensus regarding those issues that demand a response at the federal level. Think of coding and documentation issues, reimbursement issues, Federal mandates, EMTALA rules, fraud and abuse regulations and investigations. These are a few of the examples that directly impact the individual physician. It is only an organization, like the AMA, that can be effective in influencing federal policy. Due

March 14 -15

Twentieth Annual OB/GYN Conference 

April 25 -26

Second Annual Depression Conference 

May 3

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies


to its lobbying presence and respect in Washington D.C., the AMA is effective in influencing federal legislation and policy. The AMA, in addition to its legislative and lobbying efforts, has many other facets that directly impact the life of the individual physician and the community. The compilation of the rules of ethics that govern our professional behavior are promulgated by the AMA’s Council of Ethical & Judicial Affairs. The voice of young physicians, residents, and medical students are heard and heeded by their active participation in the House of Delegates and Board of Trustees. They are effective advocates for issues that are of particular interest to them and reflect the concerns of America’s medical future. Well-researched position papers on scientific affairs affect our daily practice of medicine and the AMA’s sponsorship and participation on the JCAHO regulates and directs our hospitals across America. The Council on Medical Education deals with the national issues regarding medical education and serves as a clearinghouse for data analysis, educational trends and needs, and medical school affairs. Public health issues, including thoughtful treatises on terrorism and the medical profession’s responsibility to combat the effects of chemical weapons, are also a major impetus of your AMA. The AMA recognizes that it is not a perfect organization. It is, however, vital, changing, and ever-evolving. Efforts are underway to make the organization more responsive to its grassroots base and better reflect the needs of its members and the communities it serves. Membership issues are of prime concern and many solutions have surfaced, including making it a “no-dues” organization to evolving into an umbrella, convening body that does not develop separate policy. All of these solutions have obvious detriments, but the ongoing discussions will lead to an eventual innovative solution. Governance of such a large, multifaceted, policy-making and lobbying body is always under scrutiny. It is apparent that enhanced communication from the AMA to its constituent members is necessary to publicize its good work. The AMA is your grassroots based organization. The AMA needs your membership, support, participation, and involvement so it can continue to represent each individual physician most effectively. ✦

MetroDoctors

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November, 2001 5

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The Journal of the Hennepin and Ramsey Medical Societies

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®Allina Health System

November/December 2001

21


The Organized Medical Staff Section of the AMA

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THE ORGANIZED MEDICAL Staff Section (OMSS) is one of several sections in the AMA. The criterion for membership is being a part of an organized medical staff. These organized staffs include hospitals, clinics, independent physician associations (IPA’s) and other organized physician groups. Thus, virtually all physicians are eligible. Representatives and alternates from each organized group meet in a National Assembly

twice a year just prior to the meeting of the House of Delegates. Any group may send a representative to the National Assembly. There, resolutions are debated and passed as is done at other levels, or they may be referred on to the House of Delegates. Historically, over 90 percent of the resolutions that the OMSS Assembly sends to the House of Delegates result in becoming AMA policy.

B Y K E N N E T H W. C R A B B , M . D . , FA C O G S t a t e C h a i r, M i n n e s o t a O M S S

RMS Membership ValueAdded Advantages for Physicians and their Practices ➣ Office Supplies Corporate Express (formerly US Office Products) • 651-639-4757 50-75% discount on a full-range of office supplies and office furniture. Free delivery. Email: gary.petro@cexp.com www.corporateexpress.com

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Products and Services Offered to RMS Members by RCMS, Inc. For more information call 612-362-3704. 22

November/December 2001

MetroDoctors

The Mission of the AMA-OMSS The OMSS will lead and assist grassroots physicians, individually and in groups, to organize and reclaim their role as medical leaders and advocates for excellence in patient care, professionalism, and the integrity of the patient-physician relationship by providing practical educational forums, focused policy development, and grassroots support through the Federation. The OMSS carries out its mission by providing a direct and ongoing relationship between the AMA and medical staff organizations. The Section debates issues and develops policy that influences the complex and rapidly changing environment within which our nation’s hospitals and other delivery systems operate. Specifically, the AMA-OMSS: 1. Develops and nurtures medical staff leadership within the policy-making structure of the AMA, as well as state and county medical associations. 2. Provides a forum to discuss timely and often controversial issues, solve problems, and avoid polarization of medical staffs. 3. Identifies the implications of future trends, and the role of medical staffs individually and collectively. 4. Serves as a clearinghouse for issues pertinent to medical staffs. 5. Provides medical staff leaders with a contact point to receive timely information, as well as AMA source materials and services. I would encourage elected representatives from every hospital, group practice, IPA and any other organized physician group to attend the National Assemblies. The next one will be November 29 - December 3 in San Francisco. The next Annual meeting will be in Chicago, June 13-16, 2002. ✦

The Journal of the Hennepin and Ramsey Medical Societies


PRESIDENT’S MESSAGE ROBERT C. MORAVEC, M.D.

From Where I Sit… RMS-Officers

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

RMS-Ex-Officio Board Members & Council Chairs

Brenda Andrewson, Alliance Co-President Brent R. Asplin, M.D., AMA Young Physician Section Blanton Bessinger, M.D., MMA Past President Kenneth W. Crabb, M.D., AMA Alternate Delegate Paul J. Dyrdal, M.D., Sr. Physicians Assoc. President Stephen P. England, M.D., Community Health Council Chair Robert W. Geist, M.D., Ethics & Professionalism Council Chair *Michael Gonzalez-Campoy, M.D., Education Resource Council Chair Frank J. Indihar, M.D., AMA Delegate William E. Jacott, M.D., U of MN Representative Matthew D. Layman, M.D., AMA Delegate for American Society of Anesthesiologists Jean London, Alliance Co-President Melanie Sullivan, Clinic Administrator *Lyle J. Swenson, M.D., Public Policy Council Chair *Russell C. Welch, M.D., Communications Council Chair *Also elected RMS Board Member RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive Officer Doreen M. Hines, Membership & Web Site Coordinator Sue Schettle, Director of Marketing & Member Services

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The Journal of the Hennepin and Ramsey Medical Societies

6.

Continued focus by physicians on the successes of their own specialties and niches rather than system transformation. The patient safety effort must overcome each of these barriers to be successful. Many physicians strive to meet the goal of high quality and safe care by focusing on each individual patient and providing the best possible care to each individual. However, in a complex adaptive system (see 2nd IOM Report “Crossing the Quality Chasm”, Appendix B), even the bestintentioned individual efforts have the potential to lead to error and cause harm. Successful systems improvement can enhance individual performance, but individual physician performance will not be sufficient to improve systems. All physicians must be included in the systemwide initiative. Physicians must take ownership and responsibility of all aspects of this problem and help develop a full-spectrum effort. This effort should continually focus on how patients perceive and experience their care in our hands. As physicians aspire to regain legitimacy as responsible stewards and ethical leaders in health care, we must accept responsibility to reduce error and improve on care delivered. To this end, we must devote time, energy and resources to develop the strategies, tools and methods needed for success. The barriers cited above are high and much is at stake. They are all resolvable, though, by keeping the patient as our top-of-mind priority. Physicians who are interested in improving quality of health care would profit from reading Crossing the Quality Chasm, published this year by the National Academy Press for the Institute of Medicine. The book is available by visiting the home page at www.nap.edu. ✦

November/December 2001

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Ramsey Medical Society

Kimberly A. Anderson, M.D., Specialty Director John R. Balfanz, M.D., Specialty Director Victor S. Cox, M.D., Specialty Director Charles E. Crutchfield, III, M.D., At-Large Director Thomas B. Dunkel, M.D., MMA Trustee Michael Gonzalez-Campoy, M.D., At-Large Director James J. Jordan, M.D., Specialty Director Kathryn M. Klingberg, M.D., Resident Physician Charlene E. McEvoy, M.D., At-Large Director Ragnvald Mjanger, M.D., Specialty Director Kenneth E. Nollet, M.D., Ph.D., At-Large Director Paul M. Spilseth, M.D., At-Large Director Stephanie D. Stanton, Medical Student Lyle J. Swenson, M.D., MMA Trustee Charles G. Terzian, M.D., Specialty Director Jon V. Thomas, M.D., At-Large Director David C. Thorson, M.D., Specialty Director Russell C. Welch, M.D., At-Large Director

I

IT’S PRETTY OBVIOUS to many (myself included) that the issues of patient safety and its ramifications of error disclosure, systems redesign, computerized order entry, e-prescribing, error measurement and others will require multifaceted approaches and solutions. It is incumbent upon all physicians to participate in these process improvements and to take a leadership role in most of them. However, the past experiences of physicians and their role and participation in health care improvement, along with the current chaotic environment of health care delivery systems (physician care included), does not bode well for chances of quick success. Most large health care delivery systems have taken significant first steps toward improvements in patient safety. These have been driven as much by the new JCAHO standards on patient safety as by a recognition of the huge impact of errors on cost of care, community health concerns, and organizational peer pressure. These efforts will fall short of their goal unless physicians are engaged and take on active leadership roles in their development and implementation. Significant barriers still exist that will forestall physician participation: 1. Tension between voluntary physician participation in committees and work groups and their clinic and personal productivity and income; 2. Lack of trust between facilities/health care delivery systems, and physicians; 3. Increased competition between facility outpatient care systems and free-standing care systems that are physician owned; 4. Lack of shared culture and continued reliance on blame-centered review, both by delivery systems and by regulatory agencies; 5. Resistance of physicians to accept care processes and designs that they have not played a key role in. This seems related to a potential loss of autonomy on the part of physicians; and


RMS Physicians are Leaders They are Your Contacts When Action on Issues is Needed

Frank Indihar, M.D.

Kenneth Crabb, M.D.

Matthew Layman, M.D.

Brent Asplin, M.D.

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November/December 2001

SEVERAL RMS MEMBERS are representing physicians at the national and the state levels of organized medicine ensuring that the collective voices of physicians in the East Metro area are heard when positions are taken on issues and when policy and program decisions are made by governing bodies. At the national level, Dr. Frank Indihar, the medical director at Bethesda Rehabilitation Hospital, has served as a delegate to the American Medical Association House of Delegates since 1996. Dr. Kenneth Crabb, Advanced Specialty Care for Women, has served as an alternate delegate to the American Medical Association since 1996. Dr. Matthew Layman of Twin Cities Anesthesia also serves in the AMA House of Delegates representing the American Society of Anesthesiologists. Emergency medicine is represented in the AMA Young Physicians Section by Dr. Brent Asplin of HealthPartners. Dr. Robert Moravec, medical director for HealthEast Care, Inc., the current RMS and RMS Foundation president, serves as chair of the Committee for Recognition and Review of the Accreditation Council for Continuing Medical Education, the national committee that oversees CME. Dr. Moravec also chairs the MMA Patient Safety Task Force. Several RMS physicians represent physicians at the state level. Dr. Blanton Bessinger, director, Child Advocacy and Child Policy, Childrenâ&#x20AC;&#x2122;s Hospitals and Clinics, is the past president of the Minnesota Medical Association (MMA). Drs. Thomas Dunkel of St. Paul Internists and Lyle Swenson of St. Paul Cardiology represent East Metro physicians on the MMA Board of Trustees. Two RMS physicians chair MMA standing committees. Dr. Jon Thomas, Ear Nose & Throat Specialty Care of Minnesota, P.A., chairs the MMA Communications Committee. Dr. Thomas also was appointed to the Minnesota Board of Medical Practice earlier this year. Dr. Michael Gonzalez-Campoy, the Aspen Medical Group, chairs the MMA Committee on Minority Affairs. RMS Past President, Dr. John Gates, of the Minnesota Epilepsy Group, chairs the RMS delegation of 27 physicians in the MMA House of Delegates. â&#x153;Ś

Robert Moravec, M.D.

Blanton Bessinger, M.D.

Thomas Dunkel, M.D.

MetroDoctors

John Gates, M.D.

Michael GonzalezCampoy, M.D., Ph.D.

Jon Thomas, M.D.

Lyle Swenson, M.D.

The Journal of the Hennepin and Ramsey Medical Societies


R M S U P DAT E

Applicants for Membership

John T. Murphy, M.D. University of Minnesota Family Practice Stillwater Medical Group, P.A.

Kenneth Rosenblum, M.D. Yale Medical School Emergency Medicine Mendota Health Care

Mark E. Myers, M.D. University of Minnesota Diagnostic Radiology St. Paul Radiology, P.A.

Bijan Shayegan, M.D. New York Medical College Pediatrics Stillwater Medical Group, P.A. (Continued on page 26)

Dermatology, Family Practice, Gastroenterology, General Surgery, Internal Medicine, & Neurology

Douglas L. Best, M.D. University of South Carolina Diagnostic Radiology/Vascular & Interventional Radiology St. Paul Radiology, P.A.

There are immediate openings at Brainerd Medical Center for the following specialties: Dermatology, Family Practice, Gastroenterology, General Surgery, Internal Medicine, and Neurology.

Todd D. Brandt, M.D. Vanderbilt University Urology Metropolitan Urologic Associates, P.A. Charles W. Bransford, M.D. University of Minnesota Internal Medicine Stillwater Medical Group, P.A. Ted D. Cox, M.D. Washington University Pediatric Radiology/Diagnostic Radiology St. Paul Radiology, P.A. Bruce F. Dennison, M.D. Medical College of Wisconsin - Milwaukee Otolaryngology Stillwater Medical Group, P.A. Michael L. Douglas, M.D. East Tennessee State University Family Practice/Geriatrics East Metro Family Practice - Gorman Clinic Laura J. Hedlund, M.D. University of Minnesota Radiology/Vascular and Interventional Radiology St. Paul Radiology, P.A.

MetroDoctors

Ramsey Medical Society

Active Joseph C. Ardolf, M.D. University of Minnesota Internal Medicine Stillwater Medical Group, P.A.

BRAINERD MEDICAL CENTER, P.A. • • • • • •

42 Physician independent multi-specialty group Located in a primary service area of 50,000 people Almost 100% fee-for-service Excellent fringe benefits Competitive compensation Exceptional services available at 162 bed local hospital, St. Joseph’s Medical Center

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CALL

COLLECT TO

ADMINISTRATOR:

Curt Nielsen (218) 828-7105 or (218) 829-4901 2024 South 6th Street Brainerd, MN 56401 bmc@brainerd.net www.brainerdmedicalcenter.com

The Journal of the Hennepin and Ramsey Medical Societies

November/December 2001

25


New Members (Continued from page 25)

Gene C. Stringer, M.D. University of Minnesota Family Practice Stillwater Medical Group, P.A. Rolf P. Ulland, M.D. University of Minnesota Obstetrics & Gynecology Stillwater Medical Group, P.A. Thomas A. Weber, M.D. University of Minnesota Obstetrics & Gynecology Stillwater Medical Group, P.A. David J. Weil, M.D. Washington University Hand Surgery Metropolitan Hand Surgery Associates

1st Year in Practice April D. Abrahamson, M.D. University of Minnesota Internal Medicine/Geriatric Medicine HealthEast - Midway Clinic

Multicare Associates of the Twin Cities offers physician-owned, multispecialty clinics in Roseville, Blaine and Fridley. Currently, positions are available for BC/BE physicians in the following departments: Family Practice Internal Medicine OB/GYN Excellent salary/benefits package includes paid insurance, flexible benefits plan, 401K, profit sharing, continuing medical education. Shareholder status potential after one year.

Contact: Jeannine Schlottman Administrator 7675 Madison St. NE Fridley, MN 55432 763-785-3338 www.multicare-assoc.com

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November/December 2001

John C. Foley, M.D. Ophthalmology Progressive Eye Care Associates, P.A. Ephraim M. Ghide, M.D. Jimma Institute of Health Internal Medicine/Pathology Allina Medical Clinic - Coon Rapids Andrew S. Hartigan, M.D. Medical College of Wisconsin - Milwaukee Diagnostic Radiology/Interventional Radiology St. Paul Radiology, P.A. M. Obinna Nwaneri, M.D. University of Nigeria Hematology/Oncology/ Internal Medicine Minnesota Oncology Hematology, P.A. Malinee Saxena, M.D. University of Minnesota Dermatology Dermatology Consultants, P.A.

Resident Sudha M. Chadalawada, M.D. A.P. India Family Practice Ramsey Family Physicians Clinic

Ty D. Weis Brian A. Weisenberg

Transfer into RMS — 1st Year Practice Keith H. Wittenberg, M.D. Boston University Diagnostic Radiology St. Paul Radiology, P.A. Transfer into RMS — Resident Kyle J. Butkiewicz, M.D. Mayo Medical School Anesthesiology Associated Anesthesiologists, P.A. Transfer into RMS — Student (University of Minnesota) Christine S. Albrecht Jeanine L. Brunclik Neal F. Campbell Jason J. Caron Lisa M.L. Dryer Natasha A. Hamann Sheri W. Haroldson Maren E. Olson ✦

In Memoriam

Kurt M. Isenberger, M.D. Medical College of Wisconsin Emergency Medicine Regions Hospital

JOHN G. BULS, M.D., died August 15 at the age of 56. He graduated from the University of Melbourne in Australia in 1968. Dr. Buls was board certified in Colon and Rectal Surgery. He was currently a partner of Colon and Rectal Surgery Associates, Ltd. of St. Paul and Minneapolis. Dr. Buls joined RMS in 1983.

Medical Student (University of Minnesota)

Luke W. Albrecht Stephanie C. Cintora Calley A. Kennedy Julia D. Gonsoski Michael J. Gruba Matthew R. Hallman Catherine K. Hart Jennifer F. Iverson Christopher M. Lloyd Melissa A. Moore Sereen D. Sharp David J. Polga Matthew E. Prekker Scott T. Roethle Iberia R. Sosa Amanda N. Spielman Stephanie D. Stanton

GEORGE S. MITCHELL, M.D., died on September 30 at the age of 79. Dr. Mitchell was a board certified family physician practicing in Roseville for 27 years prior to retiring. He also served as a physician in the U.S. Army in France. Dr. Mitchell obtained his medical degree from Hahnemann Medical College in 1948. He joined RMS in 1960. WILLIAM H. TROW, M.D., died August 23. He was 86. Dr. Trow practiced Preventive and Occupational Medicine prior to retiring. He graduated from the University of Minnesota in 1944. Dr. Trow joined RMS in 1969. ✦ MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies


RMS ALLIANCE NEWS

D

DURING THESE TERRIBLY DIFFICULT

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Jean London Co-President

country—a time when grief is truly a collective experience. We will need to turn to a time of healing when perhaps directing our attention to the needs of others will provide mutual support and comfort. The Alliance will be available to respond to the ideas and creativity of our members as we benefit the larger community. ✦

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Ramsey Medical Society

times, when at the very least our sense of “normalcy” is changing, we are forced to evaluate the importance of our contributions. We question our judicial use of time, our attempts to relieve the burdens experienced by others. How does the Ramsey Medical Society Alliance help? There are many aspects of the Alliance that have a dramatic effect on the community. One needs merely to open our yearbook to obtain a comprehensive list. I would like to focus, however, on three programs, namely: • Our partnership with the Spare Key Foundation; • First Steps; and • Health Fair. The Spare Key Foundation was brought to my attention, (I was serving as the clinical social worker) by a parent of a critically ill infant in the Newborn Intensive Care Unit at Minneapolis Children’s Medical Center. She was a teacher, mother of three children and was grappling with the very difficult knowledge that her son was appearing to become more complex with each passing day. Rather than recovering from his birth anomaly, he appeared to be losing ground and it was clear that his life was literally hanging in the balance. The best-case scenario was that if this family was lucky and their infant survived, he might be hospitalized for up to a year. How was this family going to get through the year? Like so many families, both parents worked long hours and they were actively involved in the lives of the older children. Now they would need to spend long hours on the NICU providing the nurturing and tenderness to their son in the midst of often painful intervention. One very practical issue was clear. There were too many demands on their time and their emotional well being to continue living the way they had been. After much consideration, this mother obtained an extended leave from her job, a place of employment where everyone could understand the needs of “the family.” But the second issue, financial despite the accessibility of some financial aid provided for families ex-

periencing these hospitalizations, was problematic. And financial issues on top of the emotional trauma of the hospitalization added further stress to the family. Patsy and Robb Keech knew from personal experience the difficulty of the hospitalization and loss of a child. And they have made it their mission in memory of their son, Derian, to lighten the burden faced by other families. The Spare Key Foundation, established in 1997, has provided much needed mortgage relief and emotional support to 131 families to date. The RMS Alliance is proud to have provided nearly $20,000 to the Spare Key Foundation in their efforts to aid these families. And we plan to continue to partner with them through the coming year. Patsy Keech will provide updates to us as to the progress the Foundation is making and will introduce us to her newly released book, Mothering an Angel. The First Steps program is a highly successful program designed to provide volunteer mentors from the Ramsey Medical Alliance, Junior League of Saint Paul and the community at large. Mentors provide support to teen parents at the Birth Center at United and Children’s Hospitals. This program enrolled 117 teen parents in the year 2000. This is a population considered to be at considerable risk for which emotional support can go a very long way. Not only is a mentor effective for the particular parent-child bond at issue but success in this relationship also will provide potential for success for generations to come. The Health Fair has been a highly successful program that has affected the lives of approximately 1,200 St. Paul third graders for the past 15 years. The various booths — mental health, hospital room, nutrition, HiTECH heart, skeletal, and fitness cover most of what is required for the health curriculum needs of these students. Not only is it one of the children’s favorite field trips but it also serves to introduce the children to other positive adult influences in their community. This is a time of enormous pain in our


CHAIR’S REPORT DAVID L. SWANSON, M.D.

HMS-Officers

Chair David L. Swanson, M.D. President T. Michael Tedford, M.D. President-Elect Michael B. Ainslie, M.D. Secretary Richard M. Gebhart, M.D. Treasurer Paul A. Kettler, M.D. Immediate Past Chair Virginia R. Lupo, M.D. HMS-Board Members

Michael Belzer, M.D. Carl E. Burkland, M.D. Jeffrey V. Christensen, M.D. Andrea J. Flom, M.D. Kathy Larson, Alliance President Ronald D. Osborn, D.O. James A. Rhode, M.D. David F. Ruebeck, M.D. Richard D. Schmidt, M.D. Leah Schrupp, Medical Student Marc F. Swiontkowski M.D. Michael G. Thurmes, M.D. D. Clark Tungseth, M.D. Joan M. Williams, M.D. HMS-Ex-Officio Board Members

Barbara H. Subak M.D., Senior Physicians Association Lee H. Beecher, M.D., MMA-Trustee Karen K. Dickson, M.D., MMA-Trustee John W. Larsen, M.D., MMA-Trustee Robert K. Meiches, M.D., MMA-Trustee Henry T. Smith, M.D., MMA-Trustee David W. Allen, Jr., MMGMA Rep. HMS-Executive Staff

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

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November/December 2001

T

“THE PARTY OF THE FIRST PART will be

known in the first part as the party of the first part. The party of the second part will be known in the first part as the party of the second part.” If this sort of legalese bewilders you, you probably do not spend much time reviewing your contracts with the health care plans. Maybe your overworked office manager/administrator reviews the contracts, but probably he or she is bewildered, too. Over the past couple of years, you may have noticed that the Hennepin Medical Society, the Ramsey Medical Society and the Minnesota Medical Group Management Association (MMGMA), in the spirit of advocacy, have begun reviewing payer contracts. The way this review works is that society members receive new contracts from Medica, HealthPartners, the Blues or other payers and forward copies to us (HMS/ RMS). We have an attorney and a practice management consultant express an opinion regarding parts of the contract that deserve more careful attention by physicians, and then send that information to you in the form of alerts. You probably have seen several of these alerts come across your desk in the past two years. Please understand that we cannot review your individualized, amended contracts, but we can critically analyze the general contracts offered by the plans. Our intent is to give you a heads-up on these agreements and not provide any specific legal advice. We suggest that you consult your attorney or practice consultant. Also, please be aware that others occasionally disagree with our consultants’ interpretations. For example, in our most recent letter regarding HealthPartners passive amendments contract (postmarked a mere two days before the August 1, 2001 effective date restricting the use of passive amendments), MMA staff disagreed with some of our impressions about the contracting mechanism. Our feeling is that when there are differences of interpretation, it becomes even more compelling for you to carefully review your contracts. We feel that this is a valuable service to continue on your behalf. Indeed, you have told us so in member surveys. We will continue our advocacy regarding contracts. Sometimes, advocacy means joining forces MetroDoctors

with others. Over the past year, we have participated in a “Contract Coalition” of several players in the health care contracting game. These participants include the Minnesota Medical Group Management Association, the Minnesota Podiatric Medical Association, the Minnesota Chapter of the American Physical Therapy Association, the Minnesota Chiropractic Association, the Metropolitan Anesthesia Network, and the MMA and several health care lobbyists. One important successful action of this coalition has been supporting the legislative effort of Senator Dallas Sams and Representative Jim Abeler, who authored Chapter 170, a law providing contracting relief to health care workers. This law has three sections that benefit consumers and health care providers. First, it places limits on passive amendments to contracts. These are changes that, before August 1, modified your contracts unilaterally unless you were alert enough to notice and then ferret out the contract amendments. The second section requires specific disclosure of changes to contracts. This allows you to find and review the changes without having to compare, word-by-word, 40 pages of obscure legal jargon before getting at the contract differences. The last section grants a provider the right to decline a contract without any retributive threat of a future refusal by a plan to offer a contract. The legislative protection of Chapter 170 sunsets in July 2002, so there is a compelling need to continue our participation in the coalition. It is highly likely that others will join the coalition also, pursuing fair contracting. We see the Illinois Medical Society as an organization to emulate. For an example of how broad a contracting coalition can become, see http://www.isms.org/legislative/fairness/ release.html. Thank you for your continued membership and support of these important issues. I can be reached at: Swans045@tc.umn.edu. ✦

The Journal of the Hennepin and Ramsey Medical Societies


HMS Physicians: Leaders at Every Level

Minnesota Medical Association • Gary Hanovich, M.D., President-Elect, MMA and chairs the Committee on Bylaws, Committees and Membership. • Robert Meiches, M.D., elected to a second term as Chair, MMA Board of Trustees. • David Estrin, M.D., past HMS chair, reelected MMA Secretary. • Michael Ainslie, M.D., HMS PresidentElect, re-elected MMA Treasurer and chairs Committee on Administration and Finance. • Lee Beecher, M.D., President of MPPA, West Metro Trustee, and chairs the MMA Legislative Committee. • Henry Smith, M.D., West Metro Trustee. • Karen Dickson, M.D., West Metro Trustee. • John Larsen, M.D., West Metro Trustee. • Benjamin Whitten, M.D., Chair, MMA Committee on Ethics & Medical-Legal Affairs.

Gary Hanovich, M.D., President-Elect, MMA, Chair, Committee on Bylaws, Committees and Membership

Robert Meiches, M.D., Chair, MMA Board of Trustees

David Estrin, M.D., past HMS Chair, MMA Secretary

Michael Ainslie, M.D., HMS President-Elect, MMA Treasurer, Chair, Committee on Administration and Finance

Lee Beecher, M.D., President of MPPA, West Metro Trustee, Chair, MMA Legislative Committee

Henry Smith, M.D., West Metro Trustee

Karen Dickson, M.D., West Metro Trustee

John Larsen, M.D., West Metro Trustee

Benjamin Whitten, M.D., Chair, Committee on Ethics & Medical-Legal Affairs

Carolyn McKay, M.D., AMA Delegate since 1996; served as Alternate Delegate for four years

Andrew J. K. Smith, M.D., AMA Delegate since 1995

Anne Towey, M.D., President, Minnesota Women Physicians

Hennepin Medical Society

HMS physicians are involved in many aspects of organized medicine. Please take time to thank your colleagues for the efforts they put forth on your behalf.

American Medical Association • Carolyn McKay, M.D., Minnesota Delegate since 1996 and served as an Alternate Delegate for four years. • Andrew J. K. Smith, M.D., Minnesota Delegate since 1995. Minnesota Women Physicians • Anne Towey, M.D., serves as president, Minnesota Women Physicians. ✦

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

November/December 2001

29


HMS NEWS Cristina R. Santiago, M.D. College of Medicine University of the East, Quezon City Internal Medicine North Hospitalists—CDU

New Members HMS welcomes these new members to the Society. Schools listed indicate the institution where the medical degree was received.

Active Ellen E. Bellairs, M.D. Baylor College of Medicine Radiation Oncology Minneapolis Radiation Oncology, P.A. Rachel Boeyer, M.D. Albany Medical College Family Practice North Clinic, P.A. John F. Bowar, M.D. University of Minnesota Medical School Physical Medicine & Rehabilitation Hennepin County Medical Center Pamela Susan Jaworski, M.D. University of Nebraska Family Practice North Clinic, P.A. James M. Kelleher, M.D. Brown University of Biological Medical Sciences Family Practice Multicare Associates of Twin Cities—Rosedale Laura D. Koch, M.D. George Washington University School of Medicine Orthopedic Surgery Minnesota Orthopaedic Specialists, P.A. Thomas B. Koenig, M.D. Creighton University School of Medicine Internal Medicine North Clinic, P.A. Jennifer M. Lee, M.D. University of Minnesota Medical School Dermatology North Clinic, P.A.

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November/December 2001

Marie Angelique Struyk, M.D. University of Minnesota Medical School Family Practice Silver Lake Clinic, P.A.

Iqbal Ahmed Memon, M.D. Liaquat Medical College, Hyderabad West Pakistan Pediatrics Monticello Clinic

Patricia L. Westerberg, M.D. University of Minnesota Medical School Obstetrics & Gynecology North Clinic, P.A.

Charles F. Moldow, M.D. State University of New York Downstate College of Medicine Internal Medicine University of Minnesota Mark S. Paller, M.D. M.S. Northwestern University Medical School Nephrology University of Minnesota Kurt S. Partoll, M.D. University of Illinois College of Medicine Internal Medicine North Clinic, P.A. Mary J.Y. Ong Phuong, M.D. University of California College of Medicine Anesthesiology Northwest Anesthesia, P.A. Howard David Pomeranz, M.D. Columbia University College of Physicians & Surgeons Ophthalmology UM Physicians—Ophthalmology Michael K. Popkin, M.D. Pritzker School of Medicine University of Chicago Psychiatry Hennepin County Medical Center Daniel Keling Ries, M.D. University of Minnesota Medical School Nephrology Kidney Specialists of MN, P.A. Steven R. Sabers, M.D. University of Minnesota Medical School Physical Medicine & Rehabilitation Institute for Low Back & Neck Care

MetroDoctors

Residents Stefan D. Kramarczuk, M.D. University of Minnesota Medical School Pediatrics Park Nicollet Clinic—Bloomington Lora J. Princ, M.D. University of North Dakota School of Medicine Obstetrics & Gynecology University of Minnesota Medical School Mark R. Sannes, M.D. University of Minnesota Medical School Internal Medicine Hennepin County Medical Center Michael C. Fang-Yen, M.D. University of Minnesota Medical School Ophthalmology Fairview-University Medical Center

Students Marina Sara Abramovich Paul Joseph Anderson Gregory Gerald Ausmus Holly Jean Barron Michael Jon Bauman Kathy Helene Brandli Amy S. Brendel Anders Lawrence Carlson Jori S. Carter Amy Beth Christopherson Angela Hsu-Yin Chua John Paul Colianni Sujata Rao Costello Endea Janelle Curry LeeAnn I. Decker Jason Matthew DeVries Mohit A. Dewan Daniel P. Dewey Andrew C. Dietz The Journal of the Hennepin and Ramsey Medical Societies


Brent Eric Nykamp Ryan Michael O’Donnell Marc Christopher Osborne Matthew James Ostrander Ausra Pond Thomas J. Pulling Kevin Patrick Riess Aaron D. Rutzick Arash Alen Sabati Amy E. Schmitz-Lelwica Daniel Scott Schreider Don Ryan Schroeder Megan Kosel Shaughnessy Terra Jo Shockman Troy Allan Sikkink Aaron Douglas Smith Stephanie Stanton David Hugh Staplin Abby Christine Stritesky Jared D. Sturgeon Michael C. Talberg David Mauricio Tasso Kari Joanne Thompson Dustin Michael Timmons Katie Jean Toft Quy That Ton Phil Tsai Noah Silver Ure Andrew J. Vasil Amanda B. Vossen Nancy Weaver Webster Derek Richard Weiland Marcus August Westerman

Susanne L. Wheeless Galen C. Whipple Andrew Palmer Wilson Troy D. Wolter Suzanne Linnea Woodward Clara Olivia Zamorano Dylan Michael Zylla ✦

In Memoriam SHELLEY N. CHOU, M.D., died July 21 at the age of 77. He graduated from the University of Utah College of Medicine in Salt Lake City. Dr. Chou, a retired neurosurgeon, was the acting dean of the University of Minnesota Medical School as well as the deputy vice president of medical affairs from 1993-1995. He was awarded the American Association of Neurological Surgeons’ highest honor, the Cushing Medal, in 1996. He joined HMS in 1962. LEWIS J. ROBERTS, M.D., died July 2. He was 90. He graduated from the University of Minnesota Medical School. Dr. Roberts founded Columbia Park Medical Group and was the first chief of staff at Unity Hospital. He joined HMS in 1941. ✦

Ollila Named Volunteer of the Year

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EUGENE OLLILA, M.D., past HMS chair, was

named Volunteer of the Year by the University of Minnesota Alumni Association (UMAA) at its national awards event held Friday, September 14. Dr. Ollila is credited with bringing a positive outlook and a considerable professional reputation to the leadership of the Medical Alumni Society. He has helped that board reemerge as a vital supporter of the school and its students. He has sought out fellow positive thinkers from many medical disciplines to serve with him and added student representatives from each class. He has put truth to the Medical Alumni Society’s tagline of “alumni helping students,” and in the words of Medical School Dean Al Michael, has “helped make believers out of skeptics who previously felt the Medical MetroDoctors

Dr. Ollila (left) receives the University of Minnesota Alumni Association’s Volunteer of the Year Award from UMAA national president, Bruce Nelson.

School favored its research mission over its mission of educating future doctors.”

The Journal of the Hennepin and Ramsey Medical Societies

Dr. Ollila used his own professional network to help create “Connections,” a physicianstudent mentoring program that involved 350 community physicians in its first year. Alumni host prospective medical students when they visit campus and they participate in the “White Coat Ceremony” that welcomes new students to the school. He acts as alumni spokesperson at many Medical School events and wrote to all alumni supporting the University’s legislative initiative and urging advocacy. The 52,000-member University of Minnesota Alumni Association creates lifelong connections for alumni and friends, advocates for educational excellence, and promotes pride and spirit. A volunteer-driven organization, the UMAA honors outstanding people, events, and groups each fall. ✦ November/December 2001

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Hennepin Medical Society

Cristian Mircea Dobre David K. Durnick Kari M. Forde-Anderson Sheila Marie Froemming Melissa Anne Hersey Justin David Hill Allison Anne Hoffman Medina Horrigan Anne Aronson Johnson Derek Richard Johnson Sara K. Johnson Rhodessa Fidela Kabatay Meredith E. Kasbohm Allison Suzanne Kienke Tracey Ann Kieser Paul Dale Kleinschmidt Dawn M. Krabbenhoft Brian Glenn LaBine Anthony Karl Larson Louis B. Lin Matthew J. Logan Sara Marie Lokstad Jennifer K. Mahling Vui Van Mai Daniel Joseph Marek Benjamin John May Michael Anthony May Brian R. Miller Julie E. Milne Naomi R. Mraz Elizabeth Mary Nesset Jeanne Margaret Nugent Arlene E. Nunez


HMS ALLIANCE NEWS K AT H Y I V E R S O N

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WHAT IS ONE EASY THING you can do to improve the health of all the citizens in your community? Make a few phone calls to your city council members. What for? There are some metro communities that currently have secondhand smoke initiatives underway. The goal will be city ordinances that create smoke-free workplaces, including bars and restaurants. As you probably know, Moose Lake, Duluth, and Cloquet all have smoke-free restaurant ordinances in place. Now, the challenge is for metro communities to step up to the plate and join in this movement. Three million Minnesotans – 89 percent of the adult population – believe that secondhand smoke harms adults. Even 78 percent of current smokers agree. Even more Minnesotans – 95 percent of the state’s adult population (3.2 million people) – believe that secondhand smoke harms children. Almost all Minnesotans believe this, regardless of whether or not they smoke. We are in a

position, as health professionals, to deliver that public attitude in a formal way, to the public officials who will make the decision on local smoke-free ordinances. Health professionals have the opportunity to effectively educate city councils and advocate for the importance of smoke-free ordinances. What can you say to the most common arguments against regulations for smoke-free workplaces? There are two common themes used by the tobacco industry to challenge these laws. One argument states that smoke-free ordinances cause economic damage to business. Smoke-free ordinances do not hurt restaurants. Economic studies using objective sales tax data from nearly 100 different communities across the country have shown that smoke-free regulations do not have an adverse economic impact on restaurants. Smoke-free ordinances do not hurt tourism. Despite arguments from the tobacco industry that smoke-free ordinances will destroy a community’s tourism

ABBOTT NORTHWESTERN HOSPITAL

St. Cloud, MN Abbott Northwestern Hospital, a premier 612-bed facility located in Minneapolis, has just started a brand new and exciting venture — a clinic and surgery center — in the booming town of St. Cloud, MN, which rests on the banks of the beautiful Mississippi River, 50 miles northwest of Minneapolis. As such, we now seek experienced healthcare professionals to join us as:

• • • • •

Gastroenterology Vascular Surgery Hospitalist Neurology Pulmonology

• Fellowship trained Orthopedic Surgery Subspecialities – Hand Surgery – Foot and Ankle – Sports Medicine

In return for your expertise, we offer a very attractive salary, generous benefits, and a refreshingly diverse environment, which boasts a myriad of cultural, sporting, and recreational choices. For immediate, confidential consideration, please forward resume and salary history to: Allina Physician Recruitment Attn: Susan A. Kordosky 8450 City Centre Drive, Woodbury, MN 55125 Phone: 800-248-4921; Fax: 651-714-3311 E-Mail: recruit@allina.com www.allina.com

Kathy Iverson is the Health Promotion Chair for the Minnesota Medical Association Alliance. She is the Chemical Health Coordinator for the City of Edina and the Chair of the Hennepin County Prevention Coalition. She can be reached at: menze002@tc.umn.edu.

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November/December 2001

business, studies have found no change in tourist business and even some instances where business has increased after ordinance passage. Restaurants can even save money by going smoke-free. Employers who implement smoke-free policies often experience cost-savings related to fire risk, damage to property and furnishings, cleaning costs, workers’ compensation, disability absenteeism and productivity losses. Another argument is that an effective alternative to smoking restrictions would be the use of proper ventilation. Ventilation simply recirculates smoky air. The only way to properly ventilate a space from secondhand smoke would require a thousand-fold rate of exchange that would create a virtual windstorm indoors. Ventilation technology can help reduce the irritability of smoke, but does not eliminate its poisonous components. Separately ventilated areas are costly and don’t protect workers. Unfortunately, installation, maintenance and remodeling costs associated with a proper ventilation system that includes an enclosed smoking area and outside exhaust will be costprohibitive for many businesses. In addition, separately ventilated rooms do not take into consideration the health of employees who must enter these rooms. Restaurant and bar employees have been found to be at a higher risk of disease due to their disproportionate exposure to secondhand smoke. Watch for information in your community newspaper, or in your clinic about smoke-free workplace ordinances. Your influence can make a tremendous difference by supporting our elected officials to make a vote for smoke-free communities! Contact Isis Stark at the American Cancer Society, 651/999-1210, or the Smoke-free Coalition: www.smokefree.org for more information. ✦

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies


C O N T I N U I N G

M E D I C A L

E D U C A T I O N

Continuing Education and Extension, University of Minnesota Partial 2001-2002 CME Calendar Radiology 2001: On-Call Radiology November 1-2 • Radisson Hotel Metrodome • Minneapolis 26th E.T. Bell Fall Symposium: Advances in Surgical Pathology November 2 • Radisson Hotel Metrodome • Minneapolis New Strategies in the Treatment of Venous Thromboembolism (ACCP Satellite Meeting) November 5 • Philadelphia Marriott • Philadelphia PA 10th Annual Mechanical Ventilation: Principles & Applications November 9-11 • Hyatt Regency • Mpls.

Lymphatic Mapping and Sentinel Lymph Node Biopsy November 12 • U of MN Campus • Mpls.

7th Annual: Emerging Infections in Clinical Practice with a special lecture on Bioterrorism Update by Dr. Michael Osterholm November 16 • Hyatt Regency • Mpls.

Emerging Cellular Therapies: Enhancing the Human Hematopoietic and Immune Systems (American Society of Hematology, Corporate Friday Symposium) December 7 • Orlando FL

2002 Lymphatic Mapping and Sentinel Node Biopsy January 14 • U of MN Campus • Mpls. Geriatric Medicine and Drug Therapy Symposium February 27-28 • Radisson Hotel Metrodome • Mpls.

Prevention, Screening & Management of Lung Cancer March 12 • Hilton Airport • Blmgt. Tobacco Cessation Conference: Breaking the Nicotine Chain in 2002 March 22 • The Depot/Marriott • Mpls. National Assoc. of Medical Minority Educators (NAMME) April 4-7 • Radisson Hotel Metrodome • Mpls.

Prevention and Management of Atherosclerotic Diseases March 1 • Radisson Hotel Metrodome • Mpls.

Allergy & Clinical Immunology April 19 • Radisson Hotel Metrodome • Mpls.

Health and Women’s Rights March 8 • Radisson Hotel Metrodome • Mpls.

Annual Allergy Nurses Program April 20 • Radisson Hotel Metrodome • Mpls.

Continuing Medical Education, Medical School, Academic Health Center Radisson Hotel Metrodome, Suite 107, 615 Washington Avenue S.E., Minneapolis, MN 55414 (612) 626-7600 • 1-800-776-8636 • www.med.umn.edu/cme The University of Minnesota is an equal opportunity educator and employer


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