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July/August 2002

Jul/Aug 02 Metrodoctors

Patient Care

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Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of HMS or RMS. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. E-mail: nbauer@mnmed.org. For advertising rates and space reservations, contact: 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.

CONTENTS VOLUME 4, NO. 4

2

July/Aug Final

SOAPBOX

Medicare and the Practice of Medicine

3

Editor’s Message Index to Advertisers

4

FEATURE

Concierge Care: A Personal Perspective

6

Rediscovering the Practice of Medicine (5 sketches) • Soteria Family Health Center

8

• Charles E. Crutchfield, III, MMB, M.D.

10

• Scott M. Jensen, M.D.

12

• Richard J. Morris, M.D.

14

• T. Michael Tedford, M.D.

15

Woodwinds Creates Healing Atmosphere for Patients and Families

17

Highlights of the AMA Code of Ethics

19

COLLEAGUE INTERVIEW

Michael D. Maves, M.D., MBA

21

Observations About Minnesota Health Care Public Policy

23

Statement of Principles for Fair Contracting

25

Minnesota’s Medical Main Street RAMSEY MEDICAL SOCIETY

28 29

President’s Message RMS Alliance HENNEPIN MEDICAL SOCIETY

30 31 32

MetroDoctors

Chair’s Report Hoban Educational Event/Nancy Bauer Leaves HMS/ In Memoriam HMS Alliance

Patient Care

with a

Customer Focus

On the cover: New clinics offer personal and satisfying relationships for both the patient and physician. Related articles begin on page 3.

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

July/August 2002

Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Richard J. Morris, M.D. Physician Co-editor David L. Swanson, 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

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PHYSICIAN'S SOAP BOX

Medicare and the Practice of Medicine

R

RECENT CUTS IN PHYSICIAN REIMBURSEMENT for Medicare

services are disturbing to many physicians. Even if the across the board reductions for 2002 are reversed, the approach that the Center for Medicare and Medicaid Services has taken toward physician reimbursement will result in an inevitable progression to an end to the practice of medicine as we know it. Our population is aging, so many physicians who care for adults will gradually see a larger proportion of Medicare patients in the future. Reimbursement for Medicare services will continue to decline. In fact, if current CMS methodology is retained, Medicare spending for physician services is projected to decrease by 28 percent from 2002 to 2005. Meanwhile, practice expenses will continue to increase due to inflation, new technology, and new regulatory requirements. Facing these projections, physicians have few options. They can continue to practice medicine as they have in the past without any change, they can leave the practice of medicine, or they can change their practices. For most employed physicians, reimbursement will gradually decline, and they will have little recourse but to accept what they are offered or leave their organization. For the independent physician, making no changes will most likely result in gradual contraction of their practice, greater difficulty taking on new physicians, and eventually, failure to survive on an economic basis. Some physicians will retire or leave medicine for other pursuits. Most will make some important changes. What can physicians do to survive in the future? Many physicians are now limiting their practice by not taking on new Medicare patients and some do not take Medicare at all. Most practices are reducing their services to Medicare patients. The utilization of physician extenders, either nurses or nurse practitioners, is increasing. These changes may be viewed as detrimental to patient care, and also to the physicianpatient relationship, but are probably unavoidable given current trends. As costs of care increase and more resources are directed toward new technologies, new drugs, and the administrative costs of delivering care, physician reimbursement for services is declining. I believe this sends a strong message to physicians that their services are less valued in our society than they have been in the past.

Who is responsible for these trends? The vast majority of Americans are unaware of what is happening to physician reimbursement and, given the increasing costs of health care, may not favor improving reimbursement to physicians even if they had the ability to do so. Business leaders also see increased costs of providing health care coverage to their employees and probably support decreasing physician reimbursement. The primary responsibility lies with our president, governors, Congress and state legislators who are responsible for decreasing Medicare and Medicaid reimbursements. I suspect these trends will not change in the future. Organized medicine, primarily the AMA, but also many specialty societies, are clearly the only advocates that physicians have for improving reimbursement. Even though its efforts have helped tremendously, organized medicine has only slowed the gradual progression toward inadequate reimbursement and increasing regulation. What are the consequences? Some physician practices will eventually close. Some physicians will leave the profession. Access to care will decrease. The practice of medicine will become less attractive, and I believe this will lead to a decrease in the number, and possibly the quality, of individuals choosing medicine for a career. This will favor the immigration of physicians from other countries seeking training opportunities and practice opportunities in the United States. Finally, in the future, I believe we will see a gradual shift to a twotiered medical landscape. The first tier will be a poorly reimbursing, highly regulated delivery system that is funded by government programs providing limited care with difficult access. The second tier will be a better reimbursing, less regulated, more expensive private delivery system which is staffed by highly trained, highly motivated providers with easy access to this system for those who can afford it. This scenario is speculation, of course, but the trends are definitely pointing in that direction. âœŚ

B Y LY L E S W E N S O N , M . D .

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Editor’s Message

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ARE WE ON THE BRINK of another signal

change in health care? Is the rustling in the wind the sound of real change or just a passing fancy? What are some of the forces that propel physicians to practice in novel ways? This issue of MetroDoctors looks at some of the ways local physicians are working to implement change. In 1998, national health care expenditures exceeded $1.1 trillion, which came to $4,270 per person, (Levit et al., 2000) and costs have continued to climb. Despite the fact that we spend more than any other country, I don’t hear a lot of satisfaction with the way our health care system works. Issues of quality and value are everyday topics. In Minnesota, the arguably unsuccessful experiment of “managed care” has about run its course, with the savings in costs used to build large organizations and the hope of new and better care systems translated instead into bigger and bigger care systems. Integration does not seem to be the answer either, as we observe the break up of Allina into its component parts. I have seen very significant changes for the better. We do not admit patients to the hospital for a check-up, nor do we keep a new mom in the hospital for a week plus one day for every child at home. The mandatory two-week stay for a patient with an acute myocardial infarction is long gone. Utilization coordinators did actually help us to use the most effective care settings for our patients. But along the way some valuable intangibles were lost, and one of them was the personal relationship between physicians and their patients.

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complicated care of the critically ill. The common thread is that the patient, not the system, is the focus, be it in the hospital or the physician’s office. This issue reflects on a number of approaches to more personal and satisfying relationships for both the patient and the physician. While it is too early to tell how these unique practices will fare in the current marketplace, they may be a preview of a movement toward something different. As you reflect on these articles presented in this issue, please let us know your thoughts. Enjoy. ✦ I think I can state that, in many ways, the changes in the systems implemented to make practices more uniform and efficient have also created strains on the physicianpatient relationship. The patients are not associated with their physician, but with their plan, and physicians, now called providers, are seen as interchangeable parts in a large organization. It is not surprising that out of discontent with the present situation new and innovative approaches to care developed. In some ways, it is back to the future, or the future is the past. Physicians and others are willing to take risks in starting to practice in new ways, even if it means starting out on their own. It is not only primary care that is involved with the innovative changes. How hospitals deal with patients is also changing. To decrease complications and improve outcomes, some hospitals, including Woodwinds in Woodbury, have added hospitalists to care for patients who have no attending physician at that hospital, and also have added intensivists to manage the

July/August Index to Advertisers Allina Education Services .......................... 13 Brainerd Medical Center ........................... 16 Central Medical Building–Wirth Co. ........ 14 Classified Ads ........................................... 13 Crutchfield Dermatology .......................... 18 Dermatology Consultants ... Inside Back Cover Hazelden .................................................. 12 HCMC CME ........................................... 26 HealthEast Care System ............................ 24 iRetrieve .......................... Inside Front Cover Methodist Hospital .................................. 11 Minnesota Healthcare Network ................ 11 Minnesota Medical Foundation ............... 21 MMIC ........................................................ 7 RCMS Inc. ............................................... 22 RiverWay Clinics ........................................ 8 U of M CME ................. Outside Back Cover Wally McCarthy Cadillac ..... Inside Back Cover Wally McCarthy Hummer ............................ 9 Weber Law Office ..................................... 22

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FEATURE STORY

Concierge Care A Personal Perspective

I

The Compass Program is a return to the traditional practice of medicine where the team of physician and nurse are able to build relationships with their patients…

IN 2000, AFTER 30 YEARS AT PARK NICOLLET, I retired from active practice and accepted a part-time position in the private sector. I was finally able to spend as much time as I wanted at our family’s cabin in Wisconsin and to think about what was important to me. It was sort of a year-long sabbatical. Why, then, have I returned to the daily practice of medicine and accepted a 24-hour, 7 day a week commitment? The answer is easy. I missed my patients, many of whom had become my friends and often provided me as much support as I did to them. I missed the daily interaction with my colleagues and the stimulus of the multiple advances and challenges in medicine. I was not eager to return to the familiar work pressures, but yearned for a more relaxed medical practice reminiscent of what existed before managed care created the time and economic constraints that are now so familiar and often troublesome to patients and physicians. Several patients wanted, and then began asking for, this slower, more deliberate personalized care. This so called “concierge care” or “boutique medicine” has come to Park Nicollet Health Services. In Park Nicollet’s “Compass Program,” patients who pay an annual fee (in addition to carrying usual health insurance) receive an added dimension of exceptional service, including same day, or conveniently scheduled, unhurried visits to their Compass Program physician – me. In addition, they receive enhanced services, such as 24-hour phone access to their doctor. When your patient load is only about one tenth of a typical primary care physician, it is possible to offer this level of service. The Compass Program is a return to the traditional practice of medicine where the team of physician and nurse are able to build relationships with their patients, spend as much time as they need to examine them, to ask and answer questions, and to offer more personal interaction than is permitted under the current restrictions of most medical practices. Since this service was introduced on the east and west coasts a few years ago, it has been the subject of some criticism. Without always fully examining the issues, many people and politicians refer to it as “elitist” medicine. I believe that at Park Nicollet we have taken the best aspects of concierge care and infused them with a commitment to the community that is typical of Minnesota in general and Park Nicollet in particular.

BY ALLAN KIND, M.D.

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Park Nicollet is a not for profit health care organization. Any proceeds from the Compass Program, like all of our proceeds, belong to the community. Following our historic tradition of investment in the communities we serve, Park Nicollet is dedicating 100 percent of Compass Program profits to support services at our free, school-based community clinics in the St. Louis Park and Plymouth/Wayzata school districts. More than 1,000 children a year receive free medical care at these clinics. Park Nicollet’s Compass Program will help ensure that these children continue to have these medical services. We believe that we should listen to our patients and do our best to provide what they want. They have asked for the services offered by the Compass Program, and are willing to pay for them. In a free marketplace, patients should have access to this service, and physicians should be able to provide it, along with traditional medical services. Additionally, programs like this may help recruit and retain physicians by creating an environment that is attractive to clinicians who may be thinking of leaving medicine or who want a reduced schedule. I can vouch for this from my own personal experience. So far, three months after launching our Compass Program, things have gone well and I am having fun. I try to be thoughtful and responsive to my patients and, in true Minnesota fashion, they go out of their way to return the favor. My patients know I am available 24 hours a day, but they are mindful of my life and privacy and do not call needlessly. They say they appreciate knowing I am available, but also say they don’t want to wear me out. I have distinguished backup in William Shimp, M.D., the former Chief Medical Officer of Park Nicollet Health Services. Bill is partially retired and he will be there when I am not. As this service grows other physicians will be added. I’ll eventually make it back to my cabin or travel, but I’m in no hurry. Right how, I am enjoying practicing medicine the way many physicians and patients want it to be. ✦ Allan Kind, M.D., is an internist with the Park Nicollet Compass Program, a program of Park Nicollet Health Services.

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Additionally, programs like this may help recruit and retain physicians by creating an environment that is attractive to clinicians who may be thinking of leaving medicine or who want a reduced schedule.

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Rediscovering the Practice of Medicine Editor’s Note: The following five sketches illustrate risk-taking in the form of the return to private practice or independent practice and offer innovative approaches to delivering patient-centered care. Each attempts to achieve a unique or higher level of service than is currently traditional in medicine. Feel free to contact the physicians directly for further information about their practice, or share your thoughts with us in a letter to the editor.

Soteria Family Health Center

W

WHEN DR. RUTH BOLTON finished her resi-

dency in 1983, she had two goals: to practice excellent family medicine, and to teach others to do the same. Some 17 years later, after climbing the ladder of academic medicine, she had reached her goal and was director of a family practice residency program at the University of Minnesota. She discovered, however, that the ladder she had climbed might have been against the wrong wall. She was not feeling the sense of fulfillment that she had expected and felt restricted from practicing in a way that reflected her Christian values. In a setting where she was to teach residents to be “values-neutral,” Dr. Bolton recognized this was an impossibility: “I could never be values-neutral regarding things like smoking or domestic abuse. How could I be about matters of faith and belief?” Many of Dr. Bolton’s friends picked up on her dissatisfaction and advised her that it was time for a change. At the same time, she was receiving encouragement from numerous individuals and groups, including crisis pregnancy centers, about the need for a Christian family practice clinic in the Twin Cities. 6 July/Aug Final

As Dr. Bolton gave this option consideration, she was struck by research that indicated that 75 percent of patients would like their doctor to talk with them about spiritual things.1 She also came across an American Journal of Psychiatry and Archives of General Psychiatry study that found that factors such as: participation in religious services, religion and social support, frequent use of prayer, and the personal significance of one’s relationship with God, were beneficial to mental health status 92 percent of the time.2 Dr. Bolton needed little additional convincing, and on May 10, 1996, she resigned her position, and after careful planning, on March 31, 1997, opened Soteria Family Health Center, a non-profit, family practice clinic. The Greek word, “Soteria” means: “a guaranteed place of safekeeping.” The provider staff at that time consisted of Dr. Bolton, one other family physician, Dr. Huyen Tranberg, and physician assistant, Jeanne Szarzynski. MetroDoctors

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Fast-forward to May 2002… Soteria now has five M.D.s, including Dr. Bolton, Dr. Christine Chang, Dr. Pam Kolacz, Dr. Christopher Chiu, and Dr. Connie Carleen. Physician Assistant Dan Ober, has joined Jeanne Szarzynski on the provider staff as well. A year ago, Soteria moved into facilities in Plymouth that are twice the size of its original clinic space. The site reflects Dr. Bolton’s vision, which emphasizes continuity of care and “full service” family medicine. A complete range of services is provided, including obstetrics. Laboratory, x-ray and bone density scan facilities are also available on site. Pathways Psychological Services, a Christian counseling center with whom Soteria has a close relationship, has four therapists who office at this site as well. In addition to the Plymouth location, Soteria has recently opened a part-time satellite clinic at Robbinsdale Women’s Center, where women experiencing crisis pregnancy are served. Soteria has bucked a trend in the metro area where many independent primary care clinics are closing or selling out to the larger health systems. The challenge has not been attracting patients, in fact, some travel as far as 100 miles to be seen at the clinic. Likewise, recruitment of providers and staff has not been a problem. Medical professionals contact the clinic weekly, desiring the opportunity to work in a Christian environment, even if it is for a somewhat lower salary than they might make elsewhere. Nor has securing insurance contracts been difficult. With the recent addition of BluePlus, Soteria now participates with all major health plans in the Twin Cities. The greatest challenge has been covering start-up and overhead expenses while serving both a suburban and an underinsured population. Careful management of costs and capture of charges has been key to keeping the clinic at The Journal of the Hennepin and Ramsey Medical Societies

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breakeven, or better, financially. Also, Soteria’s non-profit status has allowed it to receive donations to support its charitable and outreach activities. Soteria Family Health Center exists to: • Compassionately care for the physical, emotional and spiritual needs of anyone who seeks its care; • Communicate Christ’s love to those it serves; • Commit to respect life at all extremes; and • Cultivate healthy lifestyles in those it serves. Dr. Bolton’s vision, however, goes far beyond the clinic setting. “Our dream is to create programs and services that meet patients’ real needs. Our REACH (Responding with Empathy And Care at Home) lay home visitor program is designed to address the basic physical, emotional, social and spiritual needs of the elderly, unwed parents, and other vulnerable populations we serve. In time we would love to establish: a health resource library; a hospice, including a unit for infants with terminal birth defects; and a residency rotation or training pro-

gram that teaches health professionals how to integrate faith and health.” Would she do it again? Dr. Bolton replies, “Though the cost has been high personally, it has been very rewarding to show that medical care can be provided in a more effective way. Almost weekly, I hear from physicians around the country who want to start a practice where they can provide care in a manner consistent with their values. We’re proving that it can be done.” Dr. Bolton’s tips for physicians considering starting a clinic: •

Plan, plan, plan. Don’t ignore business basics. A solid business plan is essential to your success. Make sure it includes strategies for marketing and promotion of the practice. Commit yourself to clinical excellence. You may have the nicest associates and staff and great “bedside manner,” but your credibility and reputation along with the best interests of your patients demand good medicine.

Be willing to pay the price. Anything worth doing will demand sacrifice. You will likely have to be willing to risk your savings, reputation and personal life to make it happen. Leave yourself some margin. Avoid burnout. Plan time for personal renewal and recreation. ✦

1

Walter L. Larimore, M.D., and William C. Peel, Th.M., The Saline Solution, Copyright 2000, Paul Tournier Institute, Bristol, TN: 7. 2

D.B. Larson, K.A. Sherrill, J.S. Lyons, F. C. Craigie, S.B. Theilman, M.A. Greenwold and S.S. Larson, “Associations Between Dimensions of Religious Commitment and Mental Health, Reported in The American Journal of Psychiatry and the Archives of General Psychiatry: 1978 through 1989.” American Journal of Psychiatry 149(4) (1992): 557-559.

Soteria Family Health Center is located at 12805 Highway 55, in Plymouth, MN, (763) 577-2090. It can also be contacted via the World Wide Web at: soteriafamilyhealthcenter.org.

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Charles E. Crutchfield, III, MMB, M.D.

O

OPENING AN INDEPENDENT medical practice certainly has its challenges, but it is an ultimately worthwhile experience. Crutchfield Dermatology was opened as a solo practice in January 2002, serving St. Paul/Eagan and the greater Twin Cities area. Building my own practice meant leaving the security of a larger, well-respected clinic and jumping into the unknown. Several factors led me to hang my own shingle, not the least of which is my independent streak. Both of my parents are Twin City physicians. My father has been in private practice (Ob/Gyn) in St. Paul since 1968, delivering somewhere around 9,000 Twin City babies. Rarely a day goes by that a patient doesn’t tell me “your father delivered me/my kids”– it’s a real delight. My mother (Family Practice and current medical director of Metropolitan Health Plan, Minneapolis) was the first African-American female graduate of the University of Minnesota Medical School. They had me when they were first year medical students. My mother likes to joke that I’ve really

been through medical school twice. I’m tremendously proud of both of them. The previous practice that I worked with was an outstanding practice that’s been around for many years and I have the highest amount of respect for that practice and all my former partners. But, I seem to function better as an independent, and I’m happy with that decision. I also wanted to move in some new directions in medicine and explore several different concepts within my own practice.

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The Perfect Place to Practice An Equal Opportunity Employer

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One concept was electronic medical records. I now have a “paperless” office, which is the only dermatology clinic in the state that uses strictly electronic medical records. I also wanted to develop a system where there is one nurse per exam room, allowing for more time with patients. The way we have it set up now is we have 30 minutes allotted for every new patient and 15 to 20 minutes for every follow-up patient. I think that’s a much more quality and service-oriented approach to medical care. The patients have expressed great satisfaction in this new approach. Exploring new and innovative treatments was another factor in my decision to open my own practice. The clinic has employed several vanguard treatments, including narrow-band ultraviolet B phototherapy, a treatment for psoriasis, vitiligo, atopic dermatitis, and some forms of cutaneous T-cell lymphoma. In an attempt to smooth the transition into independent practice, I used the services of a medical consulting firm (Healthcare Management Resources, St. Paul) to guide me through the start-up process. We also assembled a team of top-flight advisors, including a business attorney, a medical accountant, information technology firms (for the electronic medical records software, office local area computer network, and website development (www.CrutchfieldDermatology.com), an architect and an interior designer for efficient office layout and smooth patient traffic flow. Aesthetics play a very important role in the new clinic for both the staff and patients. A lot of times when you’re developing a practice people say, “You have to minimize overhead – keep everything bare-bones.” And I think that’s true to a point, but I still think that you need to have your work environment be very pleasant because you spend the majority of your day there. I have received rave reviews from patients over the look of the clinic, which is not extravagant, but comfortable. We get compliments on a daily basis, both on the presentation of the office, but more importantly, on the approach that we use. Staffing was also a potential challenge that was minimized when several of the best nurses I had worked with in the past expressed an interest in participating in my new practice. The clinic has truly been a team effort with all of the nursing staff involved in design decisions from day one. Everybody has a vested interest and The Journal of the Hennepin and Ramsey Medical Societies

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works very hard because we each have a lot of pride in the practice, from the nurses to the support/reception staff. I could not have done it without the commitment of our entire office team. To ease the headache of financing the new clinic, I went to a bank (Alliance Bank, St. Paul) familiar with financing medical groups. Even with financing, staff and office design squared away, I faced the challenge of finding new patients and informing existing patients of this move. A lot of the phone books don’t come out either until the end of the summer or fall, so another challenge was letting patients know that we are actually here and up and running. To get the word out, I sent letters to many of my referring physicians and placed announcements/ads in local papers. The result of these efforts is a clinic that is unique in several ways, including the on-site “medical spa,” which offers a wide variety of cosmetic treatments, such as Botox, microdermabrasion and cosmetic peels. I also specialize in ethnic skin concerns. I am an active dermatologic laser surgeon, having performed more than 3,000 laser procedures, specializing in port-wine stain birthmarks.

Still, about 80 percent of my practice is general dermatology and the clinic is particularly “physician friendly.” If other doctors have patients that require timely attention from a dermatologist, our clinic is able to fit them in quickly. I also recently instituted a cancellation list, so clients can be seen within a week even though appointments are often booked out further. Where it’s reasonable, outsource different tasks, especially to somebody that’s more efficient and can do it in a more cost-effective manner. I decided to outsource the task of billing to a professional billing service. That was one headache we’ve gotten around. It is important that I live and work in the same area and eliminate a stressful commute. I hate commuting and I hate rush-hour traffic. As a result, I live five minutes from where I work. I can go home for lunch, I can meet my wife for lunch ... I can spend that time at home with my 2-year-old daughter, Olivia. And to me that’s a real quality of life issue. I made the decision to accept all kinds of major insurance, but will re-evaluate that

decision at the end of the year and make any necessary adjustments. My practice is currently designed as a twophysician practice, but until I’ve built up my practice more the clinic will remain a onephysician office. We have grown faster than expected, and as a result, may look at opening additional satellite offices in the future by bringing partners on board. I am thrilled with this new clinic and would do it again in a heartbeat. It’s been tremendously rewarding, both professionally and personally. The staff is very happy. They’ve worked very hard, and patients seem to enjoy the office very much. Those contemplating the move to private practice should identify what’s really important to them. The best thing I can say is, sit down and decide what type of practice would make you the happiest and design it from there. Then you need to get a strong team around you to get things going. ✦ Erin Johnson, a writer, contributed to this article. Dr. Crutchfield can be reached at: 651/209-3600.

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Scott M. Jensen, M.D.

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A CAREER IN MEDICINE had always been a goal of mine, so graduation from the University of Minnesota Medical School more than 20 years ago was a real dream come true. Following that, I worked hard in my residency program at Bethesda Hospital in St. Paul to equip myself to be a capable family doctor, ready for a long and satisfying career helping people wrestle with their very real physical, emotional, and spiritual ailments. However, nothing in my life had prepared me for the profound sense of disillusionment, sadness, and vocational bleakness that developed within me over the first two decades of my medical career. I found myself reflecting often on the pervasive sense of anger, disappointment, and overriding ill will that seemed to afflict my profession. I remember challenging some of my physician friends to count the number of happy and contented doctors that they might encounter during their workday in the hospital and clinic – it always turned out to be a very small number. Amidst this backdrop, I made the very difficult decision to strike out on my own and rekindle the values I had always held regarding the relationship-based caring for others. After considering options and receiving the advice of family, friends, and a particularly profound 42 year-old dying patient, I elected to build and create a new clinic centered on patient care. This clinic would place patients’ agendas at the top of the priority list and allow me to grow and develop in a service-based practice that might be more satisfying than “corporatized” medicine with all its fickle twists and turns. And so, in 2001, I gathered with a unique group of individuals to devote our efforts to the personalized care of patients, treating them first and foremost as friends and valued individuals. Catalyst Medical Clinic was born, and its first ad campaign centered around four axioms: 1) We know health care can feel more personalized at a smaller clinic. That’s why we started one. 2) If you think you need to see a doctor right away, who are we to tell you to wait? 3) When drugs or surgery won’t help, wouldn’t it be good to know about possible alternatives?

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4) In our practice, we always get at least one second opinion — from you, the patient. With such a beginning, Catalyst Medical Clinic opened its doors on May 15, 2001 at a temporary site in Buffalo and moved to its present location in Watertown on January 28, 2002. In Webster’s New Collegiate Dictionary, “catalysis” is defined as an acceleration of a reaction produced by a substance called a catalyst. This is our goal. We are interested in serving as a catalyst for our patients so that they might take charge of their own health. At Catalyst, we are absolutely committed to providing a unique, patient-oriented, personable experience whereby the patient is motivated by the sincerity of our efforts and appreciative of our individualized approach. In an effort to provide our patients with an exceptional health care experience, we chose to provide a “menu” of exam rooms whereby patients might select the setting for their service encounter. Hopefully our clinic conveys a warm, restful mood with exam rooms displaying specific themes such as “Up North,” “The Garden Room,” “Days Gone By,” “The Golf Room,” “The Animal Kingdom,” “Pooh, Potter and Pals,” “The Map Room,” the “4077 MASH” surgical suite, and the “History of the River” room. I am immensely pleased to report that our efforts seem to have come together in a way that patients really seem to appreciate. Each patient

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is given my home phone number, my cell phone number, and our answering machine provides my 24-hour pager number. One might be surprised at how respectful and cautious patients are to utilize these numbers. We have genuinely enjoyed a mutual walk with our patients and have shared a “give and take” attitude. It is not uncommon at all for me to state very clearly that I probably will not be able to do much about “such and such” condition. I am committed to working within the scope of my abilities and being certain that my patients are aware of this as well. Last week, we had the privilege of creating our 1,000th patient chart. When I think back over the myriad challenges and tasks of the last 18 months (including a devastating fire destroying much of my stored medical equipment and the processing of fractured relationships with former colleagues), I am filled with a sense of wonder and awe that so much was able to be accomplished. I think of Saturday meetings with Dr. David Willey who served as mentor, cheerleader, and constant supporter for my efforts. I think of dear friends who helped me build an office building, shape a clinic, and prepare for patients to come through the door. I recall the arduous task of recruiting a top-notch staff, constructing a chart system from scratch, communicating with innumerable insurance companies and their representatives, finding a billing service that ultimately became so much more than that, deciding to use a hospitalist system for inpatient care, working emergency room shifts all over the state in order to pay the bills at home, reading and digesting articles that used terms such as balance sheets and debits instead of hematuria and constipation, and thanking God for the dearest wife, family, and friends that a man could ever ask for. When we opened our doors four months ago, I decided to conduct more house calls than ever. I also elected to conclude more nursing home visits with a pledge to pray for my patients. (It’s so very frustrating to have to share with my nursing home friends that I am impotent against so many of their medical ills and ailments.) Perhaps last but not least, Catalyst Medical Clinic has chosen to focus efforts in developing partnerships with new sources. We have

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a physical therapy clinic integrated into our operation. We are sharing x-ray facilities with the local chiropractor. We have an optometrist one floor below us to provide on-the-spot quality eye care, a psychology clinic, an exercise facility called “Curves for Women,” an in-house pharmacy, and a coffee shop rounding out the list of partners trying to make this building a success for a small community on the western fringes of the metropolitan area. Our patients seem to appreciate this. Alternative medicine is not something to be shunned in our clinic. We talk about it actively with our patients and it is not unusual for us to have discussions about the potential benefits of saw palmetto, Echinacea or cayenne pepper. While our financial outcome remains to be seen, I personally have experienced an uplifting rejuvenation in caring for patients. I don’t think I have ever felt such stimulation or gratification as I do now. I believe that when patients are treated more as friends and less as numbers, the care becomes immensely more pleasurable and valuable for both parties. While presently a solo physician, that is not my goal. Rather, I would like to see Catalyst attract staff and physicians committed to its mission statement and grow to a point such that physicians and mid-level providers can all take some time off and know that their patients are well cared for in a clinic devoted to personal and holistic care. In conclusion, the mission statement for all of us at Catalyst perhaps says it best: “The heart of medicine is helping others through the synergy of science and caring. At Catalyst Medical Clinic, P.A., we will strive to reach out to the communities we serve with open arms.” Our goal is to serve our patients by being a catalyst in their journey toward optimal physical health and a greater measure of contentment and spiritual wholeness. We are building on a dream that we believe in. We hope your life journey gives you the same chance. ✦

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Dr. Jensen can be reached at: 952/955-1963.

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Richard J. Morris, M.D.

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I’M OBVIOUSLY A LATE BLOOMER, or a slow learner. At age 54, I finally was ready for the second biggest medical adventure of my life. (The first was my medical internship.) After 23 years of practice, the last nine in a huge multispecialty group, I decided to start an independent practice. And it has, indeed, been an adventure, one that I would not recommend for anyone with dyspepsia, insomnia, or tuition bills. Having survived the first year, I can definitely subscribe to the aphorism “no pain, no gain.” The “pain” has been in several forms: leaving wonderful old friends with whom I had been practicing; a steady regimen of nights and weekends for about eight months as I got things organized; considerable financial risk and foregone income for a while; and stress on my family. The “gain” has already more than compensated. It can be summarized in one concept: satisfaction. I had no idea how much my relationship with my patients would be enhanced – in both directions. It feels indescribably good

to provide for them in a much more personal way and to feel their appreciation. I’ve practiced for 23 years, but this has taken my satisfaction to a new level. I’ve re-learned the truth of “give and you will receive.” Our office provides exceptional courtesy, office amenities, and accessibility to our patients. Service is the name of the game. Perhaps it was my fault not to have found this satisfaction in other settings, but I don’t think so. There is something quite different

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about the personal responsibility in a small independent practice where there are no layers between my patient and me, and where I don’t feel like a replaceable commodity. There are no bureaucratic barriers to communication or implementation. A friend of mine, upon hearing I was leaving the large clinic, said, “You don’t need committees, you can make your own mistakes.” And that’s fine with me. It’s not only the patients I intend to spoil. The office is decorated comfortably, our computer systems are first-class and efficient, the staff is dedicated to making my work easier, and I can set my own hours and pay. I truly enjoy the closer collegiality with my staff. And soon Tom Helm, M.D. will be my full partner in this experience. He, too, comes from a background of corporate medicine. Our idea never was to be solo, but to be small and personal. We’ve all heard that “size matters”…I couldn’t agree more. I’m glad I established my independent practice at this point in my career. Without my prior experiences, I wouldn’t have had the perspective to appreciate what I’ve got. This adventure will extend my professional enthusiasm

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many years. I’m one of the few, apparently, who wants to intensify their practice, not escape it. Which is not to say I don’t have many outside interests, but now I have the best of both worlds. I had lots of help from my family, an accountant, a computer expert, a bank, an attorney, a graduate student, and supportive friends in the business world who know about risk-taking. I also had support from our medical societies, specifically Jack Davis at Hennepin Medical Society, Diane Murray, Doug Hanson, and Dave Allen at Minnesota Specialty Physicians, and from several like-minded doctors who gave from their experience. In our profession, some are queasy about calling small independent practices “entrepreneurial,” but to me that’s not a pejorative term. It’s about innovation, ownership, self-determination, taking a risk, pride, and in this case, providing a social good as well. I know there are many fine physicians thriving in large clinics who relish the freedom from daily administrative tasks, but having lived in both worlds, I will register my vote for self-determination. After a couple of decades of mergers and acquisitions of physicians’ practices, I’m told there is an accelerating reversal of the pendulum as doctors take more control of their professional destiny and patients assert their preferences. Three cheers for that! ✦ Dr. Morris can be reached at: 763/420-1010.

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T. Michael Tedford, M.D.

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WHEN A FRIEND ASKED ME why I was

starting a solo practice and I told her it was so I could have everything the way I wanted, she responded with another question. “So this is a matter of control?” And my reply was “of course.” Being in independent practice gives me control of practice style, management decisions, and finances. Although I have enjoyed and valued my relationships with every former partner and associate, both professionally and personally, working in a group has necessarily meant compromise. Even though I think of myself as reasonably flexible, I suppose my decision to start a new practice is an example of a commitment to personal values and of stubbornness. I believed I could create a practice environment that would better serve my patients’ needs and my own. There is no doubt that the greatest challenge to building a new practice from scratch is overcoming the publicity hurdle. How will referring doctors and new patients know about

the new clinic and overcome every obstacle to change in order to make a referral or visit a doctor without a track record of success? Fortunately, I was in practice as an otolaryngologist in the community for ten years before starting an independent solo practice. A wide community of referring physician’s and established patients knew me, so my schedule was nearly full from the beginning. Extensive marketing of a

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Dr. Tedford can be reached at: 952/832-5252.

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new practice was not critical to the clinic’s success. Although I built an independent practice, in the strictest terms I did not do it from “scratch.” Luckily, I had a book of business from the beginning. To preserve that book of business, I made a point of establishing the new office in the same geographic community that I had served previously. Most of the challenges of building an independent practice can be met with the assistance of competent consultants. Although some key employees were recruited through previous acquaintances and established networks, I worked with a top-notch practice manager who helped me find excellent people to staff the office. She also helped choose a practice management software system and a billing service. Through referrals provided by hospital contacts, I had excellent assistance in locating available office space, finding a general contractor for the office build out, identifying an interior design firm, a telephone specialist, and an information technology company that provides a “computer guy” who always has the solution to our problem and is always available by cell phone or pager. The practice manager helped me choose an employee benefits consultant. My own banker helped with the financing and choosing an accountant and lawyer were simple matters. The greatest difficulty starting the practice was dealing with health plans. Even though I had established contracts with every plan and in real terms, all I did was change my address, writing new contracts was a complicated headache. None of my credentials had changed, but this is where the process really involved starting from scratch. It took months for the plans to verify that I really was who I said I was and who they knew I was. It took months for the assignment of new provider numbers and many more months for the claims to be processed and paid. Shortly after I started the new practice, a colleague asked if it took a lot of work. Creating a new clinic did take a lot of work, and the process overall was very enjoyable. Having a practice culture that reflects my values without compromises is very rewarding both professionally and financially. I would do it all again. ✦

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Woodwinds Creates Healing Atmosphere for Patients and Families

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NEARLY TWO YEARS OLD, yet still the newest hospital in the state of Minnesota, Woodwinds Health Campus in Woodbury, a collaboration between HealthEast Care System and Children’s Hospitals and Clinics, has intrigued patients, physicians and health care professionals from throughout the metro and around the world. Considered a full-service community hospital with its 70-inpatient beds, five operating suites and a 24-hour emergency department, the hospital at Woodwinds Health Campus has been referred to as a model for hospitals of the future because of its unique physical design and innovative model of patient care – both of which are centered around creating a healing atmosphere for patients and families. Each patient has a private room with an outdoor view and there’s also room for a family member or loved one to stay overnight. There are fireplaces in many of the waiting areas, and family can access a spacious Resource Center to learn more about a patient’s condition or diagnosis. “We tried to look at the patient experience from a new perspective–the patient perspective,” says Craig Svendsen, M.D., the hospital’s medical director and a family physician with the HealthEast Woodbury Clinic. “As physicians and health care providers, we know we are going to give our patients the best that medicine has to offer; at Woodwinds we also want to make sure the emotional and spiritual needs of our patients and families are met.” Dr. Svendsen was part of the Woodwinds Physician Leadership team that helped develop the scope of care for the hospital during the early design phase. That spectrum of care includes an eight-bed ICU, telemetry, med/

BY DINA FASSINO

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surg, maternity and pediatrics, as well as a Surgery Center, Radiology Care, Lab, Infusion Therapy, and Cardio-Pulmonary Diagnostics and Rehabilitation. Inpatient physical and occupational therapy are also available. Embarking on the design phase, Woodwinds had the unique opportunity to “start from scratch” and to actually create a new health care experience. Setting the stage for all the work to be done in creating this campus was an unprecedented vision: To be the innovative, unique and preferred resource for health by fundamentally creating the health care experience in a way that has not been done before. Given the latitude of a “blank sheet of paper” a core team was established in 1997 to gain an external perspective of how to recreate the health care experience. Numerous site visits were conducted across the country to gain best practice information on architecture design, patient flow, models of care, etc. The work of the core team and the planning teams was driven by 10 Guiding Principles that were developed to further articulate the vision for the campus. Each departmental or functional planning team had interdisciplinary membership and followed a common template based on the guiding

principles. These teams were charged with defining the scope of services, the physical design, and developing the care or service model. One of the key Guiding Principles was to be patient and family centered so attention was focused to design “through the patient’s eyes.” To fully build upon this perspective, many community focus groups were engaged to assist in defining patient centered services. Patients were very passionate about their desire to create a less institutional setting in which to seek medical care. They were also outspoken about the importance of including family members in the cycle of care. Based on the important input received by consumer and physician groups, Woodwinds created, then implemented a well-planned facility and service design. The hospital opened in August 2000. The same core team that helped usher in this healing environment concept moved quickly to find out whether or not the goals were being met. • Using the Picker Institute Customer Satisfaction Survey, Woodwinds has been able to measure patient satisfaction on a variety of dimensions. The facility has received very positive results and has performed above external benchmarks, as well as outperformed the other hospitals in our system. • JCAHO surveyed the hospital four months after opening, assigning an overall score of 97, which helped reinforce the facilities clinical competence given its “new kid on the block” status. • Using a variety of methods, direct patient feedback is sought during and after a patient stay. Woodwinds has established a patient service hotline, comment cards, and “rounds” made by a Service Quality consultant. Patients express satisfaction with staff as well as the hospital environment.

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Woodwinds (Continued from page 15)

“Everyone in this hospital goes the ‘extra mile’ – you understand customer service here”; “You have good people here, you must have tried very hard to hire only the best in all departments”; “We have nothing but nice things to say about the care and treatment I have received here – patient and family alike are treated very compassionately”.

The physical environment and innovative hospital design enhance a solid clinical foundation found in Woodwinds medical staff and patient care programs, including its hospital service. Yet another commitment to patient care was made with the implementation of an Intensivist model of care, which was rolled out in November 2001 at both Woodwinds and St. John’s Hospital after HealthEast penned a partnership with Pulmonary and Critical Care

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Dina Fassino is Executive Lead of Marketing for Woodwinds Health Campus. MetroDoctors

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Associates. PCCA includes 10 board-certified intensivists. In addition, the physicians have completed two-year fellowships in pulmonary care. Intensivist models of care have traditionally been limited to large tertiary care centers and teaching hospitals. Most community hospital ICUs don’t have intensivists managing care, yet there is a growing body of evidence that points to their value in reducing patient complications, reducing a patient’s length of stay in the ICU, and reducing mortality rates. An important role of the intensivist includes managing the multi-disciplinary team that is required to provide this complex care. Numerous medical and surgical specialists may also be part of this team and the critical care physician is often best suited to facilitate communication among these various consultants. Keeping families constantly informed can be difficult in this setting; therefore, coordinating family conferences becomes another role for the managing intensivist. HealthEast decided to bring intensivists into the ICUs at Woodwinds and St. John’s based on nursing feedback and national studies demonstrating shorter lengths of stay, better cost per case, and improved patient outcomes. The results of this approach are so positive that a national patient safety initiative, led by Fortune 500 companies, recommends the intensivist model as the new standard for ICU patient care. Dr. Svendsen says, “We took this step because we believe it will have a positive effect on patient care and satisfaction, physician relations, staff retention and recruitment.” St. John’s Medical Director Tom Lundsten, M.D., also recognizes the benefits of the intensivists in the ICU. “This is an innovative model for critical care that will further improve our high quality ICUs and greatly benefit our critically ill patients and their families,” he says. As Woodwinds plans for the future, it does so with confidence and encouragement from leaders within its parent organizations, as well as others throughout the medical field, who’ve been inspired by the opportunity this new campus presents and show great interest in adopting many of the concepts being piloted here. ✦

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Highlights of the Code of Medical Ethics of the American Medical Association Section E-6.00: Opinions on Fees and Charges In recent months, the popular press has reported on a new practice trend (often labeled as premium care or boutique medicine), whereby physicians offer personalized services to patients for an additional fee, distinct from the cost of treatment. The attention this trend has received recalls past debates regarding matters of physician compensation. In particular, commentators have pointed to the pervasiveness of conflicts of interest irrespective of the mechanisms used to pay physicians. Whereas fee-for-service raised concerns of over-utilization of resources, managed care raises concerns of under-utilization and inaccessibility. Indeed, no general system of physician compensation has been found to ensure that patients receive no more and no less than the care they require. It is not surprising then to find that many Opinions in this section of the AMA’s Code of Medical Ethics have deep historical roots. In 1957, when 10 Principles of Medical Ethics were extracted from the various provisions that then constituted the Code, Principle 7 directly addressed compensation in the following terms: In the practice of medicine a physician should limit the source of his professional income to medical services actually rendered by him, or under his supervision, to his patients. His fee should be commensurate with the services rendered and the patient’s ability to pay. He should neither pay nor receive a commission for referral of patients. Drugs, remedies or appliances

may be dispensed or supplied by the physician provided it is in the best interests of the patient. This statement clearly distinguishes the services rendered by a physician as those of a professional rather than being ordinary commercial transactions. By the 1970s, when managed care began to expand, reimbursement schemes had become a matter of contractual terms between physicians and insurers or managed care organizations. Therefore, the 1980 version of the Principles of Medical Ethics made no reference to fees – nor does the 2001 revised version. This omission also coincides with the lawsuit brought against the AMA by the Federal Trade Commission (already referred to in this series’ previous installment in relation to advertising), which ordered the AMA to cease and desist from: “…interfering with the consideration offered or provided to any physician in any contract with any entity…in return for the sale, purchase, or distribution of his or her professional services.” Nevertheless, the Code includes general guidance that advises against receiving payments for certain activities, as is illustrated by a closer analysis of individual Opinions. Opinions included in Section 6.00 Some may be inclined to think that Opinion 6.01, “Contingent Physician Fees” originated from the rise in professional liability lawsuits over the past two decades. In fact, the prohibition against a fee contingent on the successful outcome of a malpractice (or worker’s compen-

sation) claim dates back to the mid-1950s. Interestingly, the Opinion explains that by accepting such fees, a physician would become less of a healer and more of an advocate. Yet, in the era of managed care, the concept of being a patient’s advocate has taken on a more positive connotation, as physicians are expected to assist patients in obtaining needed services despite barriers set by managed care. This, however, does not diminish the claim that physicians should not be paid on the basis of an uncertain outcome unrelated to the value of their services. Several Opinions included in Section 6.00 refer to fee-splitting, a practice that one commentator traces back to the 1890s,1 when physicians began to accept payments for prescribing products from specific apothecaries and medical supply companies. The scope of fee-splitting was expanded during the early 1900s when it took the form of a payment by a physician (often a surgeon) to another for the referral of a patient. This payment usually was a portion of the patient’s fee for services rendered. Because this practice was not made transparent to the patient, some regarded it as deceptive and condemned it. There also were concerns that referring physicians would seek fee-splitting arrangements with physicians who charged higher fees, irrespective of their skill or qualification, to the potential detriment of the patient, or even worse, that these arrangements could lead to unnecessary surgery. In 1912, these concerns led what was then the American Medical Association’s Judicial Council to recommend that “Any member of the American Medical Association found guilty of secret fee splitting or of giving or receiving commissions shall cease to be a member of the American Medical Association.”

BY FRANK A. RIDDICK, JR., M.D. AND KARINE MORIN, L.L.M.

(Continued on page 18)

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AMA Code of Ethics (Continued from page 17)

Opinion 6.02, “Fee Splitting,” reflects these concerns, stating that such payments made by or to a physician violate the requirement to deal honestly with patients. In an effort to safeguard against potential abuses, the Opinion also requires that referrals be based on the skill and quality of the physician to whom the patient is referred, or that a prescription be based on the efficacy of the product prescribed. Inappropriate practices in connection with prescribing are also addressed in Opinion 6.04, “Fee Splitting: Drug or Device Prescription Rebates.” Opinion 6.03, “Fee Splitting: Referrals to Health Care Facilities,” simply extends the prohibition against fee splitting to payments made by health care institutions to referring physicians. In 1994, an amendment was added, which prohibits payments made to physicians referring patients to research studies. This particular practice received more attention in a recent CEJA Report on “Managing Conflicts of Interest in the Conduct of Clinical Trials,” published earlier this year in the Journal of the American Medical Association.

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Opinion 6.05, “Fees for Medical Services,” is the only attempt in the Code to determine the appropriateness of fees. Its origin can probably be dated to the late 1950s, a time when fee-for-service prevailed. The original guidelines emphasized first and foremost that fees should be commensurate with the services rendered but also should take into account a patient’s ability to pay. In the early 1980s, these two balancing considerations were abandoned; instead emphasis was placed on illegal or excessive fees. Several criteria were offered in determining the reasonableness of fees, such as the difficulty and/ or uniqueness of the service rendered, the time, skill and experience required, the fee customarily charged in the locality, and the experience and reputation of the physician. Opinions 6.07, “Insurance Form Completion Charges,” and 6.08, “Interest Charges and Finance Charges,” both address practical matters, as they provide guidance in regard to the administrative aspects of a medical practice. Opinion 6.10, “Services Provided by Multiple Physicians,” echoes concerns raised in relation to fee splitting, reminding physicians that they are entitled only to compensation for services rendered. Moreover, they cannot bill nor be paid for a service that they do not perform and they cannot charge a markup on the services provided by others. A type of practice that these guidelines tried to prevent received great attention in the mid-1990s when the Office of the Inspector General of the Department of Health and Human Services began auditing teaching hospitals to review whether Medicare had been billed inappropriately for work performed by residents, as part of the “physicians at teaching hospitals,” or PATH, audits. Similarly, though in the context of laboratory services, Opinion 6.09, “Laboratory Bill,” states that “the referring physician’s bill to the patient should indicate the actual charges for laboratory services…as well as any separate charges for the physician’s own professional services.” Surprisingly, Opinion 6.11, “Competition,” represents a policy statement that mentions fees only briefly and provides little, if any, ethical guidance to physicians. It encourages competition on the basis of factors such as quality of services, skills, experience, conveniences offered to patients, credit terms, and fees. In addition, it claims that medical practice thrives MetroDoctors

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best under free market conditions when patients have adequate information and opportunity to choose freely. Issued in 1983, this Opinion in part appears to be a concession to the Federal Trade Commission that physicians, despite their claim of professionalism, should not engage in antitrust activities but rather provide services in a competitive environment. However, the Opinion also may serve to criticize limitations imposed by managed care. Finally, Opinion 6.12, “Forgiveness or Waiver of Insurance Co-Payments,” warns against another possibly illegal or fraudulent practice whereby physicians waive the patient’s co-payment but charge the insurer. While such a waiver may seem justifiable in that it takes into account a patient’s ability to pay, it violates most public and private insurers’ requirement. Special attention to professional courtesy, a form of fee waiver, is provided in Opinion 6.13, “Professional Courtesy,” which recognizes the practice as a long-standing tradition but warns of its legal implications. Conclusion As briefly mentioned above, there exists a fundamental distinction between the provision of professional and commercial services. A commercial transaction is initiated by a buyer’s want, which a seller attempts to gratify. In contrast, a professional should address clients’ true needs. On this basis, a physician should recommend only necessary treatments and must not abuse the trust of patients by seeking additional financial gain through either the provision of superfluous services or by withholding necessary ones. Making such determinations often places the physician in a situation of potential conflict between the interests of the patient, those of insurers or managed care organizations, and his or her own. With regard to financial gain derived from fees, section 6.00 of the Code offers time-tested guidance. The full content of the AMA’s Code of Medical Ethics is accessible online at www.amaassn.org/go/ceja. ✦ 1

M. Rodwin, Medicine, Money and Morals, Oxford University Press, New York, 1993.

Frank A. Riddick, Jr., M.D., is Chair, Council on Ethical and Judicial Affairs. Karine Morin, L.L.M., is Secretary, Council on Ethical and Judicial Affairs. The Journal of the Hennepin and Ramsey Medical Societies

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COLLEAGUE INTERVIEW

Michael D. Maves, M.D., MBA Editor’s Note: Michael D. Maves, M.D., MBA, serves as executive vice president and chief executive officer for the American Medical Association. Dr. Maves received his medical degree from Ohio State University, and his MBA from the University of Iowa College of Business Administration. A clinically trained and board-certified otolaryngologist, Dr. Maves is adjunct professor at the Saint Louis Universtiy School of Medicine. Most recently, Dr. Maves headed the Consumer Healthcare Products Association in Washington D.C. Interview questions were provided by Drs. Lee Beecher, Gary Ivins, Jim Hart and William Jacott.

Q

Membership attrition is due in part to a greater number of MDs now employed, more competition for dues from specialty societies, and lack of a vision for the future of American health care. What are your top three strategies to increase AMA membership?

A

Membership is and will remain a challenge for most professional organizations, not just for us in organized medicine. People simply do not join organizations to the extent they once did. I am convinced, however, that physicians will support organizations that demonstrate value to them. Unless physicians feel they are receiving something of value for their dues dollars, no amount of discounting or deal making will prompt them to join or remain active. Therefore, job one toward attracting and retaining members has to be addressing the issues that matter most to physicians. Right now the AMA is on the front lines addressing many issues that are critically important to physicians and their patients – issues such as fixing the Medicare payment problem, tackling professional liability, and fighting for antitrust relief. As battles on these issues are won – even when they are only partial victories – we need to communicate these accomplishments to members and non-members, letting them know that these improvements are a direct result of AMA advocacy. Most important, we need to engage physicians in these efforts. I believe physicians have to feel connected to the organizations they join and believe they have an opportunity to contribute.

Describe a public relations campaign to enhance the value of physicians in a patient’s health care. Not even the best PR shop on Madison Avenue can develop a PR campaign that will magically command the public’s respect for physicians and the work we do. While some may view health care as a commodity, it’s not like selling hamburgers or soft drinks. If we are going to capture the respect of the public and enhance the value of what we do as physicians, MetroDoctors

July/Aug Final

then we have to earn it each and every day through our actions. I believe the best public relations campaign we can mount as physicians is to be visible on the front lines addressing the issues that are important to patients and physicians. PR campaigns like the AMA’s National House Call can help focus media and public attention on these efforts, so that even more are made aware of them. But ultimately, I think our work in the exam room, our communities, our statehouses, public arena, and up on Capitol Hill will be what determines our value to the American public.

Will the AMA oppose further Medicare managed care increases to get better (Medicare) fee-for-service payments? No. It is critical that Congress provides adequate funding for both parts of the Medicare program. The Medicare proposal developed by House Republicans will help Medicare Plus Choice as well as fee-for-service Medicare.

As a Midwestern (Minnesota) internist who spent seven years in Florida, why is Medicare reimbursement significantly less here when the cost of practice, rent, staff, etc. is significantly less in Florida! Furthermore, there is no financial respite in the Twin Cities with managed care being the only alternative. The Medicare payment issue is very complex. The AMA is sympathetic to the problems of geographic disparity. However, the projected acrossthe-board cuts in Medicare payment are a much larger problem for physicians than geographic disparity, so the AMA has made that issue its top priority. We’re confident that a proposal in the House of Representatives will avert Medicare payment cuts of almost 20 percent over four years. Where physicians faced across-the-board Medicare cuts of 15 percent over the next three years – the House proposal will give them a 6 percent increase instead, a much greater difference than any geographic disparity. (Continued on page 20)

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Colleague Interview (Continued from page 19)

Over the last 25 years or so, patients and physicians have lost control of the medical marketplace to insurance companies, health plans, pharmaceutical companies, and device manufacturers. Do you see any hope of regaining some control and if so, how might this occur? While the medical marketplace has changed dramatically over the past two decades or so, I still believe there is tremendous opportunity for physicians to take control of the medical marketplace. Our call for patients’ rights, Medicare reform, professional liability and regulatory relief are being heard, although definitive action on these issues is slower than we would like. I think discontent and push back from patients in response to concerns in the current delivery system will help bring change, as will some of the recent high-profile court cases favoring patients and physicians. I view our move toward creating a better practice environment for physicians as a journey. Right now we find ourselves smack dab in the middle of the woods. We’re going to get out. It may not be the same place as we entered, but the landscape will be improved. We need to continue working together and keep plugging away. The alternative is to roll over and let these other entities control our profession and that is simply not an option as far as I’m concerned.

Wouldn’t the AMA be able to function more effectively for physicians and patients if the House of Delegates were eliminated? The House of Delegates is one of the great strengths of our AMA. This body has guided the AMA and our medical profession through many complex and challenging issues for 155 years. I think we need to celebrate the democratic process of the HOD and the diversity it embodies. The democratic process is not always as efficient or direct as we would like, but I do believe the end result of making an informed decision after rigorous debate from voices across medicine’s broad spectrum is immensely valuable and certainly worth preserving.

Has the AMA considered concentrating its resources on representing physicians’ interests in Washington, D.C., moving to Washington D.C., and eliminating all functions that are not related to national health care public policy? I contend that almost everything the AMA does is directed toward shaping national health care public policy. The important work we do on Capitol Hill is only the tip of the iceberg, but like an iceberg, often the most visible. I think it would be a grave mistake to abandon our other important work – ethics, standard setting, medical education, publications, public health, and private sector advocacy. In fact, I truly believe that this important work not only serves physicians well, but also enhances our credibility, so when the AMA goes up on Capitol Hill our views and opinions are sought out and our viewpoints heard. Without this work, the AMA would be viewed as just another trade association.

20 July/Aug Final

The AMA is pursuing relief from anti-trust legislation with a no-strike clause. There are legal contracts in the commercial HMO marketplace between patient and HMO corporation and between physician and HMO, but there is none between patient and physician. Physicians on strike have not abandoned patients when their contact is with the corporation and not with the patient. One can hardly say they have abandoned a corporation if on strike. Just because patients are locked in a network, why does this somehow make it wrong for physicians to walk like any other American contract worker? Is there some moral or legal obligation to work under intolerable work rules or financial conditions, both of which are bad for the quality of care? Is it not the moral and legal obligation of the HMO corporation, which has the patient’s money in hand, to arrange for proper care? First and foremost, I believe the oath we took as physicians to always act in the best interest of our patients supercedes any legal contracts we enter into. AMA policy supports that view. As physicians, I believe we have an ethical – if not legal – responsibility to pursue anti-trust relief in a manner that does not compromise or jeopardize patient care. As difficult as securing anti-trust relief is proving to be, I think it will be even more difficult if we lose the trust and confidence of our patients and the American public in the process. I believe we need to educate patients about how securing anti-trust relief for physicians will improve their care and then enlist their support in our fight. Patients are as frustrated and concerned as physicians with the unfair advantage insurers hold in today’s marketplace, we need to leverage that and use it to our advantage. Insurance carriers do have a responsibility to ensure access to proper care, but not all do, that’s why winning anti-trust relief for physicians is so important. Is the AMA planning to become less reliant on membership recruitment and dues billing by state medical associations in the future? If yes, how is the AMA planning to implement the strategy? Membership is the life’s blood of any professional organization and the AMA is certainly no exception. To be effective, we need the support and involvement of the physician community – whether it’s achieved through the traditional individual membership model or new alternatives. But whatever membership model we pursue, it is essential that the AMA and its Federation groups improve how we work together to deliver value to physicians. How dues are collected are an important consideration, but the priority must remain on delivering value and communicating the value of membership to our paying customers, otherwise how dues are collected will be a moot point. Even with improvements, however, I think it’s essential that the AMA and its Federation members be aggressive in pursuing appropriate sources of non-dues revenue to support needed programs and initiatives. The AMA is committed to growing business operations to minimize the cost of membership to physicians. ✦

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Observations About Minnesota Health Care Public Policy

L

LATE LAST YEAR, GOVERNOR Ventura cre-

ated a task force comprised of commissioners, senators and representatives to study health care costs and quality. His stated intentions were to develop a bipartisan and comprehensive approach to addressing Minnesota’s health care public policy issues. The legislature acted to address several issues this year, even before a consensus had been reached on overall issues. The most disturbing action they took was to permit HMOs to substantially increase cost-shifting to patients. Physicians and other providers now find themselves needing to collect a far larger portion of their fees directly from patients. Meanwhile, the governor’s Joint Task Force on Healthcare Cost and Quality has continued working — investing substantial amounts of time discussing how the state should “fix” health care problems. The stated goal of the task force is to publish recommendations by the end of this year for the legislature and governor to address in the 2003 session. Having attended every task force and subcommittee meeting, I believe physician advocates should be energetic in delivering two key messages to the joint task force:

just 81.9 percent of the national average of $4,309. The portion of Minnesota’s economy devoted to health care, according to the same source, is 9.7 percent as compared to 12.7 percent nationally. Minnesota’s overall health care costs are exemplary! The explanation for the discrepancy between low overall costs and high costs for private insurance is simple and straightforward: too much of the cost of public health programs is being shifted to private insurance. The most egregious example of cost-shifting is from inadequate Medicare and Medicaid reimbursement. But provider and premium taxes are also shift-

ing costs from the public sector to the private sector. We need to send the message loud and clear that the public policy of shifting costs from the public to the private sector must stop. Message #2: The lack of competition in health care is causing inefficient allocation of health care resources. Requiring health plans to disclose costs (reimbursement) of health care to consumers, physicians, and employers will fix this problem. It’s not hard for any of us who work in health care to identify shortages or waste. For (Continued on page 22)

Message #1: Minnesota doesn’t have a problem with health care costs; we have a problem with health care public policy. All of us are concerned about the high cost of health insurance in Minnesota. Evidence suggests that commercial insurance and HMO premiums are as high or higher than national averages and are increasing at a faster rate than national averages. Yet, at the same time, Minnesota’s per capita health care expenditures, according to the Department of Health, were $3,528 in 1999, BY DAVID W. ALLEN, JR.

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MN Health Care Public Policy (Continued from page 21)

example, low reimbursement, increasing overhead and aggravating administrative issues are leading to shortages of physicians and declining physician accessibility. At the same time, redundant tertiary facilities are under construction and high technology equipment proliferates well past any public need. Seniors are bussed to Canada in search of affordable medications, while high cost medications are over-prescribed. The problem isn’t that there aren’t less costly alternatives. For example, in the Twin Cities, the cost of technical and professional fees associated with an MRI chest scan ranges from as low as $400 to well above $1,200. Hospital costs associated with a routine maternity case are as much as twice as expensive at some Twin Cities hospitals as others. A treatment course of antibiotics can cost anywhere from $6 to well over $100. Many procedures performed in expensive hospital-based settings would be appropriately done in a doctor’s office. This list could go on and on. Why isn’t supply and demand working to move care to less costly alternatives? One rea-

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son is that patients, physicians and employers generally don’t know what alternatives cost and have little financial incentive to use less expensive options. Another is that the three health plans which provide more than 90 percent of commercial coverage in Minnesota do know what alternatives cost, but don’t want to share this information. The consequences of health care market dysfunction are several. Costs are higher than they need to be, as unnecessarily expensive services are over-utilized. Expensive treatment facilities multiply while shortages of physicians worsen. Hospital and physician organizations consolidate in order to better negotiate reimbursement with the large health plans. As time goes on, these problems are becoming more entrenched and will be more difficult to correct. Requiring health plans to disclose the costs of care is an easy and effective way to enhance competition in the marketplace. When patients, physicians, and employers have access to information about the differences in cost, the laws of supply and demand will start working again. Patients who have to pay for care out of their own pockets will be amenable to using less costly alternatives. Physicians will have the information to better serve their patients, will find relief as the managed care philosophy of centrally directed care is made obsolete by functioning capitalistic economics, and will be empowered to set their own prices as the market will bear. And new health plans will find that they can finally be competitive in the Minnesota market even though they don’t have enough enrollment to demand the steepest price discounts from providers. I heartily urge Minnesota physicians to become energetically involved in the debate about the future of health care in this state. Since the issue of cost-shifting from the public to the private sector is often not well understood by public officials, contact your representatives and let them know that inadequate Medicare and Medicaid reimbursement, combined with state taxes on health care, are making healthcare unaffordable to your privately insured patients. One of the biggest obstacles facing the open disclosure initiative is opposition from the health plans and large, expensive provider organizations; you should make sure that your clinic, your hospital, and the MMA know that you want them supporting open disclosure. ✦

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Statement of Principles for Fair Contracting

T

THE HENNEPIN AND RAMSEY Medical

Societies have been working for the last couple of years with the Minnesota Fair Health Plan Contracting Coalition. This Coalition has been working to correct the inequalities that physicians experience when reviewing a contract from the large managed care entities that function in our marketplace. In 2001 we got: (1) The prohibition of shadow contracts; (2) Mandatory disclosure of contract changes; and (3) Physician option to decline and later participate in insurance products. These were important changes, but our work is not done. In the 2002 session we gained a lot of recognition on the issue of unfair managed care contracting and the coalition is moving forward to carry the issue in 2003. In the process, we have developed “Principles of Fair Health Plan Contracting.” The principles are as follows:

Disclosure Contract terms that will affect the quality and cost of care should be fully disclosed to providers and consumers. a. Consumers should have access to information that will assist them in making informed decisions regarding the quality of care and the costs of providing care. b. Providers must have adequate prior notification to any proposed contract changes that have an impact on care delivery and/ or payment methods and costs of care, to assist them in deciding whether to participate in the contract. Accountability Decisions by health plans that result in denied care, are “medical decisions.” Decision makers must be Minnesota licensed practitioners and

be accountable under Minnesota regulations and liability standards. a. Consumers must be able to hold health plans, which deny recommended care, responsible for any adverse events resulting from the decision. b. Providers should be held harmless if they make appropriate medical recommendations that are subsequently denied by a health plan. c. Employers who do not directly participate in medical care decisions should also be held harmless for medical decisions. Shadow Contracting Shadow contracting within and between health care categories should be prohibited. a. Consumers can be negatively impacted by a disruption in their continuity of care, if their provider drops out of a plan because of contract stacking. b. Providers should not be required to participate in an extension of their contract with a health plan for additional products without their express consent. Such extension could adversely affect the quality of care and require providers to deliver services for a financial loss. Unilateral terms Health plan contracts should not contain unilateral terms regarding termination, indemnification, or arbitration. a. Consumers are best served when their provider is allowed to serve as their advocate. b. Providers should have the ability to provide input for contract terms in advance of contract submission and have the same rights on key contract issues as payers.

Coding Changes Health care providers should be notified in advance of any coding changes made by a health plan and the entities that originated the coding system used (CPT4, CDT3, HCPC) should be the final arbiters in any dispute. a. Consumers can be inconvenienced, have care delayed, and have personal financial exposure when plans interpret codes in ways that limit care or reimbursement inappropriately. b. Providers must be kept apprised of coding changes and have an expedited process for appeal to assure that their administrative costs are not excessive and that their patients are well served in a timely manner. Codes that are submitted as a basis for payment are essentially a medical record and change may not be authorized by anyone other than the submitting provider. Efficient Notification Plans requiring services to be pre-authorized must do so in an efficient and timely manner, including accommodating notifications and requests 24 hours per day, seven days per week. a. Consumers must not have care delayed because of cumbersome pre-authorization requirements. b. Providers should not be required to absorb unnecessary administrative costs related to slow and complex pre-authorization processes, which may also affect the quality of care they can deliver to their patients. Recoupment Health care providers should receive an explanation for recoupments of overpayments, with advance notice of any disputed amounts of (Continued on page 24)

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Fair Contracting (Continued from page 23)

b.

$100.00 or more prior to the recoupment, and with an adequate time period allowed to challenge the decision. a. Consumers may be financially at risk for recoupments in that they may be held financially responsible for denied charges.

Providers should have the right to challenge “automatic” reversals of charges and have the right to hold the disputed funds while the issue is being resolved. A reasonable “statute of limitations” must be contractually provided to assure unreasonable recovery efforts are limited.

®

Interest Calculation Claims for services rendered must be submitted by providers in a timely manner and paid by health plans within 30 days, or interest must be calculated and paid by the health plan. a. Consumers benefit when claims are submitted and paid in a timely manner and administrative costs are reduced. b. Providers may be required to carry unreasonably large receivables because of delayed reimbursement. Late payments compound already low levels of reimbursement.

SHARING A SINGLE FOCUS

For further information about the Minnesota Fair Health Plan Contracting Coalition or its “Principles for Fair Health Plan Contracting,” contact: Jack Davis, 612/623-2893; jdavis @metrodoctors.com; or Roger Johnson, 612/ 362-3799; rjohnson@metrodoctors.com. ✦

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24 July/Aug Final

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Profiling If a health plan creates a profile of providers based on cost and/or quality, the plan must allow the providers to correct any errors and make comments prior to release of the data. The plan must release the methodology used to create the profile. a. Consumers must be given accurate and understandable information in order to confidently make health care decisions. b. Providers can sustain damage to their reputation and financial viability if inaccurate or misleading information regarding care, quality, or cost is circulated.

The Journal of the Hennepin and Ramsey Medical Societies

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Minnesota’s Medical Main Street

M

MINNESOTA’S MEDICAL MAIN street is ®

growing and it’s called Medical Alley. Medical Alley was founded in 1984 as a non-profit trade association to support Minnesota’s health care industry. The association’s goals were to focus on legislative issues, provide members with educational opportunities, and promote interest and investment in Minnesota as a major center of health care achievement, research and innovation. The term “Medical Alley” is known around the world as a 350-mile health care rich corridor in Minnesota that is home to thousands of medical-related organizations. Medical Alley is comprised of over 250 member organizations. Members include medical device and equipment manufacturers, health plans, pharmaceutical and biotechnology companies, hospitals and clinics, education and research organizations, and a broad range of health care service and consulting companies of all sizes. While the majority of members are located in Minnesota, membership is growing beyond the Minnesota and United States borders. Just over a year ago, the organization hired Don Gerhardt as its new president and CEO. His charge from the Medical Alley Board of Directors was to re-invigorate the organization, to raise its profile, to grow it, to positively impact member organizations, and to positively impact the area. In just over a year, a broad range of changes, implementations and activities have taken place in Medical Alley, the health care industry, and the economy which have made the mission of Medical Alley even more urgent and important. Gerhardt’s reflections of the past year and what lies ahead were captured in a recent interview.

BY JACK G. DAVIS, CEO, HMS

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Don Gerhardt, President, CEO

Question: Welcome back! You have been in your position for just over a year — how would you rate the last year for Medical Alley? Thanks for the welcome back home! It was a pleasure living in beautiful Vermont for the past five years, but it is so good to be back home, and once again involved in an active business climate. The last year has been both rewarding and just plain fun as we implemented a number of new programs and services in Medical Alley to benefit our members. We’ve also worked very hard to reconnect with member companies as well as connect with new companies and the area’s business and academic community. We have been successful in growing the membership (178 member organizations in June of 2001 vs. 250 in May, 2002); we have stabilized the organization financially; and have implemented a number of new initiatives that add value for our members. We are receiving positive response from our members, so I would rate the first year a good start. Question: What makes Medical Alley unique? Medical Alley is quite unique – there isn’t another organization like it anywhere. Our membership is comprised of industry leaders that

encompass the entire spectrum of the health care world. Because our membership includes providers, manufacturers, insurers, education, pharmas, other associations, hospitals and other health care organizations, we are uniquely positioned to act as a “convener” of these diverse elements of the health care industry. We are able to get the best people in the industry to meet and focus on key challenges and opportunities facing the industry. Our most recent convener initiative, “Town Hall Forum for Healthcare Decision Making” is just going into its second stage of development and implementation. The potential outcome from this major initiative is enormous as it can provide the industry with a new, effective approach of including the consumer/patient in managing and containing health care costs and allowing the physician and patient to concentrate on their interaction rather than the physician being caught in the middle. We are confident that Medical Alley’s powerful cross section of health care organizations can contribute substantially toward assuring the long-term health and vitality of Minnesota’s economic climate. Question: How do you view the present situation in medical technology development and manufacturing in Minnesota? There is no doubt that the med tech sector is on the move right now. The momentum of development and production of high tech medical devices and bio-related products is growing, and may not slow for a number of years. However, as I came back from the east coast, I was very surprised to find that our small start-up and small emerging med tech companies have a very different experience here from say, Boston

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Medical Main Street (Continued from page 25)

MARK

YOUR

or the Carolinas. Our business climate is much more random and difficult for entrepreneurs and developers to navigate. It is extremely important that there are places for an individual with a great idea, a CEO of a start-up, or a physician with a neat innovation, to access clinical or engineering expertise, or marketing help, or capital. We need to more quickly “muscle up” our small companies. That’s how we grow the next Medtronic or St. Jude. Companies with that kind of impact are vital to the state’s economy. Not too long ago this area was considered the Mecca for computer hardware and software development. Control Data, Unisys, and Cray Research were flying high. Where are those companies now? That Mecca is now called Silicon Valley. We need to be very aggressive about making sure that the rich sources of ideas, research and development, and new companies is promoted, assisted, and made to flourish. While we may think our position in health care is strong, there are many areas both in this country and abroad that are doing their best to chip away at our Medical Alley – we need to make sure they don’t succeed.

CALENDAR

SEPTEMBER 2002 26-27 Advanced Life Support in Obstetrics Kimberly Petersen, MD Pillsbury Auditorium, HCMC 17.0 Credit Hours OCTOBER 3-4 18th Annual Forensic Science Seminar Kathryn Berg, MD Pillsbury Auditorium, HCMC Approx. 12.0 Credit Hours 17-19

32nd Annual Orthopaedic and Trauma Seminar Richard Kyle, MD Minneapolis Convention Center Approx. 18.0 Credit Hours

Question: How and where are physician interests represented in Medical Alley structure and activity?

NOVEMBER 1 HIV Care Conference Co-chairs: Ronald L. Schut, MD Hanan J. Rosenstein, MD Abbott Northwestern Hospital Approx. 7.0 Credit Hours

Physicians are consistently involved in Medical Alley governance and in our activities and projects – and, it is vital that it remain that way. At the present time our Board has three physician participants: Drs. Frank Cerra of the University of Minnesota; Jim Woodburn, a Medical Director for BlueCross & BlueShield of Minnesota; and Bob Meiches, representing the Minnesota Medical Association. All three are active participants in Medical Alley. Dr. Cerra will become the Chairman of the Board in 2004. Our educational programs often feature physician speakers – just last week we had physicians from the Fairview system and from HealthPartners make presentations. Our Town Hall project’s Executive Committee has two physician members, Drs. Becky Hafner, and Mark Paller. We feel very strongly that strong physician participation and contribution is key to the success of what we do. We have member organizations that are physician driven organizations such as Mayo, Park Nicollet, and the Minneapolis Heart In-

DECEMBER 13 11th Annual Family Practice Update Charles Anderson, MD Radisson, Roseville Approx. 7.0 Credit Hours 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 HCMC Continuing Medical Education at (612) 347-2075. Fax (612) 904-4210. Toll Free 888-263-4262. www.hcmc.org

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stitute. Add to that our member organizations of HealthPartners, Allina, Memorial Blood Centers, the Fairview system, HealthEast and others, and you have pretty strong physician representation. I know that the direct participation of physicians and their representative organizations would be welcomed into Medical Alley. Question: How does all this activity in Medical Alley impact the practicing physician? All of this comes together in a linked system and, perhaps, no better anywhere than here in Minnesota. If we focus on the fact that the health of the entire range of participants and stakeholders comes down to making the interaction between the physician and an informed patient be the most efficient and impactful. Providing our physicians and patients with the best technology, the best care systems, the best educational possibilities, and a continuing strong economic base in our state is key to healthy and fulfilling practices. To help achieve this goal, Medical Alley has created a new not-for-profit spin off called Alley Institute. We intend to participate in a number of grants that will be directed toward research and development opportunities with our broad range of participating organizations including hospitals, clinics and educational organizations. Having physicians actively participating in these projects will be critical in maximizing the potential health care-related outcomes.

Question: What are the key components in preserving and growing Minnesota’s Medical Alley? We really do have a jewel that is the key to continuing our strong economic base and maintaining our state as a great place to live. We feel that it is time for action, and definitely not the time to sit on the sidelines and study the situation. Action is needed now to begin to positively impact major components vital to our strong and advanced medical industry. Some key components and the actions Medical Alley is taking are: • Workforce – we are experiencing the front edge of a major workforce shortage in all of the health care workforce areas – including nurses, design engineers, lab specialists, biologists, physicians, etc. While we MetroDoctors

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have a highly skilled workforce, we must build and maintain it. We need to make sure skilled workers educated here want to stay here, and that skilled people want to move here to work. Very importantly, kids need to be made aware of the vast array of health care career opportunities. A recent study showed that less than 13 percent of the kids in Minnesota’s junior high schools know that health care careers even exist. It may be surprising to learn that most kids only know about “doctor and nurse” and have no idea about what else is possible in health care. Getting kids to consider health care career options early in their education will impact the workforce issue long-term. Medical Alley will soon be announcing several important efforts impacting the workforce issue, both short-term and longer-term. The efforts will range from joint venturing new educational offerings, to moving our annual golf tournament to the Tournament Players Club and making it a fund-raiser for scholarships for students going into health care occupations. Education and Research – the University of Minnesota and Mayo Clinic stand out as major contributors. Because of the state’s budget cuts, we are in danger of doing major injury to the University and its ability to produce both skilled graduates and ample research. Without direct participation by U of M physicians and researchers, Medtronic, St. Jude, and hundreds of small med tech companies would not exist in Minnesota. Medical Alley has been very active in supporting bonding requests by the U of M and MnSCU for new laboratories and the Translational Research Facility. Mayo’s recent announcement of its partnering with IBM on genomic development is another great sign of the importance of strong moves by key organizations. Capital – our small and emerging health care businesses need quick and clear lines of access to high-end expertise and capital of varying types. Small and emerging companies have an extremely difficult time getting the attention and funding needed for their success – we need to make sure that our entrepreneurs have the best chance possible of succeeding. Medical Alley

Question: You have a very ambitious agenda. How do you make sure Medical Alley’s voice is heard? It starts with a strong, active board whose members are willing to pitch in and make things happen – we have that attitude and participation from our board. We also need to participate with our member organizations to leverage the strength and influence they bring to the table. Our member organizations employ about 225,000 people in Minnesota – that’s an important statistic! We need to have strong relationships with education and research institutions; we already have some of those relationships, but are working on adding more. During the last few months we have begun to increase our visibility with both state and national legislators and regulators. We will increase that effort during the next six months. And, we will continue development of new programs for our member organizations that help extend our reach into the region. All of our initiatives will be thoughtful and actionoriented with the goal of continuing to be a vibrant resource for our health care community. In the end, we think that it is important that our organization shows a real passion and produces real action for keeping this wonderful Minnesota medical main street, Medical Alley, as strong and productive as possible. ✦

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(along with member companies Mayo Medical Ventures, Oppenheimer Wolff & Donnelly, and Rider Bennett) sponsored a major venture capital and private investor conference in Minneapolis on May 22 and 23. We will be following this conference with some new initiatives focused on assisting small and emerging companies. Business Environment – we need to build the business climate in a positive way to both defend and preserve what we have. And, it needs to be positioned to grow. The spotlight is on the health care sector and we have to play in the game to be the “best in the class.” Our physicians have had an immense impact on Minnesota’s ranking as the healthiest state in the nation. We need to make sure that we include physicians along with the broad range of participants in our health care economy to assure that our business environment is #1, too.

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PRESIDENT’S MESSAGE P E T E R H . K E L L Y, M . D .

A Letter to Grace RMS-Officers

President Peter H. Kelly, M.D. President-Elect Michael Gonzalez-Campoy, M.D. Past President Robert C. Moravec, M.D. Secretary Jamie D. Santilli, M.D. Treasurer Peter J. Daly, M.D. RMS-Board Members

Kimberly A. Anderson, M.D., Specialty Director John R. Balfanz, M.D., Specialty Director Victor S. Cox, M.D., Specialty Director Gretchen S. Crary, M.D., At-Large Director Charles E. Crutchfield, III, M.D., At-Large Director Laura A. Dean, M.D., At-Large Director Thomas B. Dunkel, M.D., MMA Trustee James J. Jordan, M.D., Specialty Director Robert V. Knowlan, M.D., At-Large Director Charlene E. McEvoy, M.D., At-Large Director Ragnvald Mjanger, M.D., Specialty Director Kenneth E. Nollet, M.D., Ph.D., At-Large Director Stephanie D. Stanton, Medical Student Lyle J. Swenson, M.D., MMA Trustee Charles G. Terzian, M.D., Specialty Director David C. Thorson, M.D., Specialty Director Russell C. Welch, M.D., At-Large Director RMS-Ex-Officio Board Members & Council Chairs

Brenda Andrewson, Alliance 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 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 Melanie Sullivan, Clinic Administrator Donald B. Swenson, M.D., Sr. Physicians Association President *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

28 July/Aug Final

I

I AM WRITING THIS editorial as I sit in the airport on my way to Boston and New York to help make a final decision on my second child’s future college. She is convinced that she wants to be a doctor. I am often asked if this is a good career path to encourage a young person to pursue, particularly given the changes that have occurred in the medical landscape over the past two decades. My thoughts on this subject are contained in the following letter to my daughter.

Dear Grace, You are about to embark on a great journey as you start your college career. You are full of hope and promise and have the world before you. I know that you have expressed a strong interest in becoming a physician and I believe that you possess the skills to accomplish this. A more crucial question is whether this is a wise choice in this day and age. There are several reasons that this question arises and I will try to make sure your eyes are open as you ultimately work your way through this decision. Some people claim that the golden age of medicine is behind us, yet some argue that the golden age lies before us. I think that both may be right to a degree. It depends upon which aspect of medicine you are discussing. I think that medicine as a profession is suffering, yet our capability to diagnose and treat illness continues to make incredible advances. Let me separate these out for further discussion. The practice of medicine is becoming less of a profession and more of a job. I define a profession here as a calling, when what you do is truly a way of life, where it becomes difficult to step outside of your role. Medicine continues to become more and more of a business. Much of medicine is now practiced in a corporate setting where administrators dictate what your wages, work hours and vacation time will be. For those physicians who still own their own practice tough issues of decreasing reimbursement in the face of increasing overhead equate into longer hours to maintain the status quo. In many parts of the country, these conditions have MetroDoctors

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become so bad that it is difficult to recruit new doctors into the community and shortages have developed. Physicians no longer have either the time or the interest in participating in professional organizations, which is an important way of exchanging ideas. Add to this that the cost of a medical education continues to rise and that the average medical student is graduating from medical school with over one hundred thousand dollars of debt. The education and training to become a physician is long and arduous, but this used to be offset by the promise of high compensation and a more reasonable work schedule upon entering private practice. Student loans could be quickly wiped out and years of deferred gratitude could be erased in short order. Unfortunately, this promise has vanished. While the golden age of medicine as a profession may be waning, the ability to better treat and serve our patients continues to accelerate at dizzying rates. The field of medicine is fascinating and will never leave you bored. The mental challenge and stimulation of the medical field only grows with each new advance. We are now diagnosing patients’ diseases at an earlier stage with such tools as new generation CT scans and PET scans. Treatments advance every day with new pharmaceuticals and less invasive surgery. The fields of immunology and genetics will continue to revolutionize the way we practice medicine. People are living longer and are relatively healthy in their old age because of these developments. Your generation will probably see an average life expectancy of one hundred years. It will be 11 to 15 years before you are out of residency and what we are doing today to treat patients will seem archaic. In this sense, I envy the doctors of the future. You will look upon my generation of physicians with historic (Continued on page 29)

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RMS ALLIANCE NEWS REBECCA GONZALEZ-CAMPOY

W

President’s Message (Continued from Page 28)

interest and wonder how we managed to have patients survive at all, much as I look back at previous generations of doctors with wonder and respect for their pioneering spirit. So you see Grace, the answer to the question of whether I should encourage you to pursue a medical education is not straightforward. If you want to become a physician for social rank and money, it is not a wise choice. However, if you have a keen interest in helping people as well as in the science of medicine, you will have a long and fruitful career as a doctor. I wish you good fortune on your journey. ✦ With All My Love, Dad MetroDoctors

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ing. As one Alliance member so insightfully observed, we could have accomplished a whole lot more if we’d pooled all of our resources and made one beautifully done final product. The team leader hadn’t even thought of that possibility! Collaboration. It’s a simple idea on the surface, but its complexities are deep and wide. Even so, collaborate is what we must do to effectively advocate for America’s health. It’s what we must do to preserve and restore the strength of the medical profession. RMS Alliance members collaborate with other organizations in many ways on many levels to advocate for the health of our communities. And thanks to the AMAA, we have access to a wealth of valuable resources that we can bring to the table such as the many SAVE (Stop America’s Violence Everywhere) and healthy lifestyle learning tools. Alliance members work as individuals who represent the Alliance. And they work as a whole to take on projects, or at the very least, provide financial support. As our membership grows and diversifies, so does our impact on our communities. We work with our local private and public schools to enhance the health of students. Bullying is a problem everywhere. So is childhood obesity. Kids are drinking and using drugs at younger and younger ages. We volunteer to serve on school district chemical health and curriculum advisory boards. We work with teachers and administrators to address everything from violence prevention to child nutrition. We work on SAVE projects with our faith communities. We help teenage mothers get off to a healthy start raising their babies through a program called First Steps. We run an annual Health Fair for elementary students. We gather necessities for Caring Hearts for the Homeless. We are poised to do more. Collaboration often requires thinking creatively, identifying a need and then looking for others who can help you fully address that need. Sometimes this can mean collaboration between Alliances. Starting this summer, Hennepin and

Ramsey Alliances will work together to invite resident and medical student spouses to join our organizations. We can accomplish so much more, pooling our collective resources and talents, than either organization can do alone. There’s another type of collaboration in which Alliance members have not yet established themselves. And that’s the collaboration that can preserve and strengthen the medical profession – in other words, political action. We have to work together to elect officials who support the medical profession (And, by the way, they sit on both sides of the aisle, so this isn’t a bipartisan effort.). If we don’t speak up for health care, we can expect others will determine its fate. A few of us are politically active as individuals. However, we can accomplish much more by working collectively to educate candidates and those already in office about issues facing health care. This is an important election year. Between redistricting and numerous retirements, there will be many new people hoping to represent us at the Minnesota Legislature and in Congress. Medicare reimbursement, skyrocketing malpractice insurance costs and patient access to quality health care are all issues on the table. Two RMS Alliance members sit on the Minnesota Medical Association (MMA) Legislative and MEDPAC committees. During the coming months, we’ll be working with the MMA and MMA Alliance to help Alliance members statewide become more involved in the political process. We’ll cover everything from how to figure out where to vote to how to get the attention of your senators and representatives. As the collaboration exercise clearly shows, the need to work with others on a common goal isn’t always obvious — nor is it inherently comfortable. However, it is the best way to get things done well.✦

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Ramsey Medical Society

WE COUNTED OFF BY EIGHTS and moved into our assigned groups. The team leader then gave each cluster an unmarked paper bag. Our assignment was simple: follow the directions in the bag. The leader offered one piece of advice before letting us loose: We could use only our hands and feet to help complete our task. At first, we muddled through what seemed to be impossible instructions to make things out of construction paper without the necessary tools. Several minutes passed before we realized each group had the same task, but different supplies in their bag. We hesitantly bargained with each other to use whatever tools we needed, trying to ask for as little help as possible and jealously guarding our “product” — the object we’d been assigned to make. You could feel the competitiveness and the distrust in the room. This exercise in collaboration took place at a recent leadership conference sponsored by the American Medical Association Alliance (AMAA). Here we were — all incoming leaders of county and state Alliances — and we had demonstrated perfectly how human nature gets in the way of progress and community build-


CHAIR’S REPORT DAVID L. SWANSON, M.D.

Acknowledging Some Good Guys

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. Diane Gayes, Alliance Co-President Peggy Johnson, Alliance Co-President Ronald D. Osborn, D.O. James Peters, M.D. 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. Michael J. Walker, M.D. Joan M. Williams, M.D. HMS-Ex-Officio Board Members

Paul F. Bowlin 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

30 July/Aug Final

O

ONE OF THE MANY WAYS Hennepin and

HMS-Officers

Ramsey Medical Societies have been working on behalf of their members is through the health plan “contracting alerts” that have been regularly sent to our membership. A great deal of positive feedback about our contract alerts program has been received, and this benefit to our members is considered a very successful endeavor. It has not been easy getting these alerts out in a timely fashion, however. In the past, the Plans have not been forthcoming in providing information about the changes in provider contracts. After we get our hands on a contract, usually sent to us by one of our members, we scramble to get the contracts reviewed by legal counsel. We then send the legal opinions to others for comment, including the Medical Group Management Association and our colleagues at the MMA. Finally, we forward the contract alerts to our members by mail, fax, and electronic communications. Our goal is to be able to garner the information in those contracts at a reasonable period of time before their release to physicians. Ferreting out all that contract information too often has been like pulling teeth, or, perhaps with better simile, like snaring cecal polyps. So, it is a joy to acknowledge the cooperation of BlueCross and BlueShield for their response to our call for contract information. Not only were we given a copy of the new AWARE contract in a timely fashion, but also changes were red-lined and an honest attempt was made to accommodate our desire to study the details. Earlier, the Blues actually invited a participant from organized medicine to participate in and provide input for the new proposed contract. In fact, David Estrin, M.D., former chairman of the Hennepin Medical Society, had an opportunity to meet with the insurer’s leadership during the AWARE contract development. Hopefully, there is now a spirit of cooperation that will grow between the Plans and the metro physicians who care for their patients. Now is the necessary time for that spirit to take hold. Physicians are becoming far more sophisticated in their financial relationships and neMetroDoctors

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gotiations with payers. They are organizing into larger groups with greater negotiating clout. They are finding out that they can survive the walk away from contracts and plans that over-mandate and underpay. At the same time, the physician base is shrinking relative to the growth of the metro population. Some specialties, like neurosurgery, are critically understaffed. It seems probable that the Plans will soon find themselves unable to find providers for their needy enrollees in some specialty areas. HMS/RMS, working with Frank Cerra, M.D. and the University of Minnesota Academic Health Center, is undertaking a “brain-drain” study to try and understand the dynamics of this crisis in physician demographics. Whatever the outcome of that study, it seems certain that a large part of the relative loss of manpower that is apparent now relates to the poor relationship physicians have had with Minnesota payers in recent years. There is little relief in sight. From 1998 to 2001, the number of Minnesota residents entering medical school at the University of Minnesota Twin Cities campus fell from 156 to 119, while the number of non-residents rose from nine to 46. Are these non-residents more or less likely to stay in Minnesota after completing their training? That will depend on how graduating medical students perceive the vitality of the Minnesota health care marketplace. We will need that marketplace to be one that supports its caregivers. So, it is refreshing to witness any glimmer of cooperation between a major player such as BlueCross and BlueShield and the Metro doctors of Hennepin and Ramsey Medical Societies. Let’s look for the same to occur with all the participants in our delivery system. ✦ David L. Swanson M.D., HMS Board Chairman, can be reached at: Swans045@umn.edu.

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HMS NEWS

Hoban Educational Event

T

THOMAS W. and Mary

Nancy Bauer has decided to leave the Hennepin Medical Society to become a stayat-home mom. Our loss is Madelyn and Molly’s gain. Nancy joined HMS in November 1990 as Associate Director and has contributed greatly to the shape and success of the medical society—both within the organization itself and in the community. MetroDoctors

July/Aug Final

In Memoriam JAMES P. GINSBERG, M.D., 76, died on April 10. He graduated from the University of Minnesota Medical School, and completed postgraduate training at the University of Illinois, the Minneapolis General Hospital, and the Mayo Foundation. He practiced and taught psychiatry in Chicago from 19571973. In 1973, he began practicing at the Nicollet Clinic where he headed the Department of Psychiatry from 1974-1980. Dr. Ginsberg joined HMS in 1974. EMERSON E. HOPPES, M.D., died in May at the age of 83. He graduated from George Washington University School of Medicine, and completed a fellowship in surgery at Mayo Clinic and the University of Minnesota. Dr. Hoppes joined HMS in 1957.

Nancy Bauer Leaves HMS AFTER 11 YEARS,

wrote for a public health intervention to prevent Type II Diabetes in Latino Children. Christine Taddy – “Healthcare Consumerism” – told of the effective marketing tools used by pharmaceutical companies to entice patients to inquire about their products to their health care providers. Last year’s scholar, Jessica Levine, described the trials and tribulations of coordinating a small, non-profit health center including the process of seeking on-going funding, staffing, and meeting the needs of the community. ✦

Her endeavors in recent years have included the appearance, design, and content of MetroDoctors; membership recruitment; community internship program; medical students “Shadow a Physician” program; and serving on several public health and public service committees throughout the west metro area. Nancy has been a great supporter of the profession and a friend to medicine. All is not lost. Nancy will continue as Managing Editor of MetroDoctors. Please join me in wishing Nancy and her family all the best. ✦

KENNETH B. ROMNESS, M.D., died on April 19. He was 76. He graduated from the University of Minnesota Medical School. He began practicing at the Mounds Clinic in 1951. He joined HMS in 1952. GORDON W. STROM, M.D., died on April 26 at the age of 91. He graduated from the University of Minnesota Medical School, and completed his residency at the University of Tennessee. Dr. Strom practiced urology for 39 years. He retired in 1983. Dr. Strom joined HMS in 1940. ✦

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Hennepin Medical Society

Kay Hoban returned to Minneapolis in May to celebrate and participate in the annual Hoban Scholar Educational Event, held at the Edina Country Club. Each of the scholarship award winners is asked to participate in this educational foleft: Thomas W. Hoban, Mary Kay Hoban, Gebra Cuyun rum, describing a class From Grim, Jessica Levine, Christine Taddy, and Eric Nielsen. project or work assignment in which an experience or knowledge was gained that other “Hoban Scholsicians Health Plan (now Medica), Midwest ars” could learn from. Current and past scholars Medical Insurance Company, and centralized participate in this event in addition to members credentialing. He noted the greatest satisfaction of the Selection Committee and Hennepin he gained from his job was the relationships he Medical Foundation Board of Directors. built with physicians. Tom Spiczka, President of the Minnesota Four Hoban Scholars gave presentations Medical Group Management Association, and on their work: CEO of the Institute for Low Back Care, proEric Nielsen – “Cost Saving Strategy” devided an eloquent synopsis of his health care scribed the process used to evaluate the addimanagement style of building a complementary tion of a new service to his clinic versus relationship between medicine and administracontinuing to purchase the service from an outtion. side vendor. Thomas Hoban also made a few comments Gebra Cuyun Grimm – “Preventing Type at the event, highlighting some of the accomII Diabetes in Latino Children” – illustrated a plishments of his tenure, e.g. formation of Phygrant application that she and team members


HMS ALLIANCE NEWS

M

MAY 3, 2002, a beautiful sunny day at the

Golden Valley Country Club, provided a delightful setting for the HMSA annual meeting and installation of the 2002-2003 HMSA Board of Directors. Peggy Johnson, and Diane Gayes have joined forces this year to be the co-presidents. Peggy: “As I talk with friends about HMSA, I realize there are many more potential members, many who are not familiar with our organization and the variety of projects locally and statewide which we are involved in.” Diane: “As I reflect on my experience as Past President for the HMSA (1996-1997) and Minnesota Medical Association Alliance (MMAA) (20002001), I know that as an individual medical alliance member, I can make a difference; that as a group of 150 HMSA (county) members, we make a bigger difference; that as a group of 800 MMAA (state) members, the difference we make, is not only bigger, but covers a larger geographic area; that as a group of 45,000 American Medical Association Alliance (AMAA) members, our unified mission, voice and actual work done as volunteers, is unparalleled.” At the annual meeting, HMSA members recognized Nancy Bauer for her many years as an advisor, motivator, supporter and friend of the Alliance. Nancy, HMS Associate Director, is retiring in June. She was presented with a gift certificate and a lifetime HMSA Honorary Membership. HMSA members look forward to continuing an on-going connection with Nancy.

Nancy Bauer was honored with a lifetime HMSA Honorary Membership.

32 July/Aug Final

Diane Gayes

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Peggy Johnson

Our guest speakers, Charles and Lara Foley Co-President Co-President (Lara is Peggy Johnson’s daughter), captivated us with a slide presentation and informative talk regarding their study of the elephant population in Tarangire National Park, Tanzania, East Peggy and I look forward to volunteering Africa. They know over 800 elephants by name with other HMSA members and partnering and spend most of the year living amongst the with the HMS throughout the coming year. We herds. They are truly living a life filled with love are honored to have the privilege of being in for each other, a life of love for the African wildthis leadership position as HMSA co-presidents, life, and a life of adventure, and love for Africa. th an organization of volunteers who are energizDuring April of 2002, the 19 annual ing, inspiring, committed, caring, giving and HMSA Body Works educated more than 2,400 continuing to make a difference in the health Minneapolis Public School third-graders about of their local, state, national, and international their bodies and how to keep them healthy. Since communities. the first Body Works in 1983, more than 34,000 For additional information about the elementary school children have participated in HMSA, membership, projects and activities, the program and greater than $200,000 has been please check out our website: www.hmsa.net. ✦ donated to cover the costs. HMSA members feel a deep sense of gratitude to their own HMSA volunteer members, volunteer friends, hospitals, individual physicians, the HMS and HMS Foundation, Lutheran Brotherhood, and other organizations that have supported the Body Works program throughout the 19 years. The 2Oth Anniversary Body Works will be held at the Lutheran Linda Smith, HMS Alliance volunteer, leads the VIK (Very Brotherhood Auditorium, Important Kid) section of the HMSA 19th Annual Body April 21 -25, 2003. Works where 2,400 Minneapolis Public School 3rd graders As co-presidents, Peggy participated. and I are enthusiastic about the HMSA activities and projects planned for the coming year. We are especially excited to announce an HMSA benefit to raise funds for HMSA philanthropic endeavors. Gerald Charles Dickens presents “A Christmas Carol,” to be held December 20, 2002 at the Interlachen Country Club in Edsina. Details of this event and a ticket order form will be in the next issue of MetroDoctors and the upcoming issue of Pulsations (HMSA newsletter). To order tickets now, Charles and Lara Foley in their “tent office” please contact Diane Gayes at ladydi.mn.rr.net Tarangire National Park, Tanzania, East or Peggy Johnson at Johns719@gold.tc.mn.edu. Africa. The Journal of the Hennepin and Ramsey Medical Societies

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DR. JOE SHAFFER was born in London, England. He moved to New York City with his family at the age of eight, then returned to England for high school and medical school. His medical degree was obtained from St. Thomas’ Hospital in London, where he also received a degree in Clinical Pharmacology. He practiced internal medicine and dermatology for four years in London before returning to America in 1997 to undertake his internship at the Cleveland Clinic in Ohio. Dr. Shaffer completed his Dermatology Residency at St. Luke’s/Roosevelt Hospital Center in New York City where he was Chief Resident from 20002001. He finished his Fellowship in Mohs Surgery and Laser Surgery at the University of Minnesota in 2002. His interests include skin cancer screening, prevention, diagnosis, and treatment using excisional surgery or the Mohs technique. Laser surgery for wrinkles, blood vessels, tattoos, warts and pigmented lesions. Sclerotherapy for leg veins. Botox injections for wrinkles, and excessive sweating. He lives in Saint Paul with his wife Tina, a dermatologist in training and a Minnesota native.

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Sept/Oct FC IFC IBC BC

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M E D I CA L

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Continuing Education and Extension, University of Minnesota Partial 2002 CME Calendar Endorectal Ultrasonography September 10 • Radisson Riverfront Hotel • St. Paul Pelvic Floor Workshop September 11 • Radisson Riverfront Hotel/Riverside Pelvic Floor Center • St. Paul 65th Annual Principles of Colon and Rectal Surgery September 12-14 • Radisson Riverfront • St. Paul 65th Annual Radiology 2002 September 19-20 • Radisson Hotel Metrodome • Mpls. Heart Failure Society of America: 6th Annual Mtg. September 22-25 • Boca Raton Resort • Boca Raton, FL

5th Annual Twin Cities Marathon Sports Medicine Conference September 27-28 • Four Points Sheraton Metrodome • Mpls.

8th Annual: Vascular Diseases: A Primary Care Perspective October 4-5 • Radisson Hotel Metrodome • Mpls.

3rd Annual Psychiatry Review: Impulse Related Disorders October 7-8 • Radisson Hotel Metrodome • Mpls.

Internal Medicine Review October 9-11 • Radisson Hotel Metrodome • Mpls. 3rd Annual FairviewUniversity Brain Tumor Symposium October 25-26 • Mpls. 33rd Annual Seminar Obstetrics and Gynecology October 28-29 • Radisson Hotel Metrodome • Mpls. 27th Annual E.T. Bell Fall Pathology Symposium November 1 • Radisson Hotel Metrodome • Mpls.

11th Annual Course Mechanical Ventilation: Principles and Applications November 8-10 • Hyatt Regency • Mpls.

Mature Women’s Health: Memopause November 9 • Four Points Sheraton-Capital • St. Paul

8th Annual Conference: Emerging Infections in Clinical Practice November 15 • Hyatt Regency Mpls.

Continuing Medical Education, Medical School, Academic Health Center 200 Oak Street SE, Suite #190, Minneapolis, MN 55455 (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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