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The Door to the Future

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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.

MetroDoctors

CONTENTS VOLUME 4, NO. 1

2

Bioterrorism Seminars Held

2

Index to Advertisers

3

Editor’s Message

4

“Leapfrog” to Trigger Giant Leap Forward in Quality, Customer Service, and Affordability

6

FEATURE

JANUARY/FEBRUARY 2002

Harnessing the Promise of Patient Safety

10

Medical Savings Accounts: Back to the Future with a Tax Twist

11

Vivius — Offering Unique Benefits to the Provider Community

12

Consumer-Driven Healthcare Gains Momentum

14

PreferredOne is Exceeding Enrollment Expectations

15

Blue Cross Launches Consumer-Driven Health Plan

16

What’s New at HealthPartners

18

“Payer Alert” Advises Members of Changes to PreferredOne Contract

20

Highlights of the AMA Code of Medical Ethics

22

Community Internship Program

RAMSEY MEDICAL SOCIETY

24 25 26 27 28

President’s Message 2002 RMS Election Results Applicants for Membership/Annual Meeting

Jan/February 2001

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

Caring Hearts for Homeless People Supply Drive RMS Alliance HENNEPIN MEDICAL SOCIETY

29 30 31 32

Chair’s Report

The Door to the Future

HMS in Action New Chair/Hoban Scholarships/In Memoriam HMS Alliance

The Journal of the Hennepin and Ramsey Medical Societies

On the cover: The future of new healthcare options is uncertain.

Related articles begin on page 3.

(Artwork by Outside Line Studio.)

January/February 2002

1

Bioterrorism Seminars Held Third in a Series is Planned

T

TWO SEMINARS ON BIOTERRORISM were

jointly sponsored by HMS, RMS, MMA, and Hennepin County Medical Center. On November 7, primary care and emergency medicine physicians attended a clinical presentation on how to diagnose and treat patients exposed to bioterroristic agents. On November 20, health care professionals in three locations, were briefed on national and local disaster preparedness.

The third seminar will be held on Tuesday, January 15, 6:15-8:15 p.m., at HCMC, Pillsbury Auditorium. The title of this presentation is, “Bioterrorism and the New Triage:

Ethical, Operational, and Policy Issues in Community Preparedness.” Kenneth Kipnis, Ph.D., Department of Philosphy, University of Hawaii at Manao, along with a panel of local healthcare leaders and policy decision makers, will be featured. Contact Nancy Bauer, 612-623-2893 or nbauer@metrodoctors.com to register. ✦

Harry Hull, M.D., state epidemiologist, Minnesota Department of Health, presented at both programs in November.

Jan./Feb. Index to Advertisers Allina Education and Research .............. 11 Brainerd Medical Center ....................... 19 Corporate Express (formerly US Office Products) ................ Inside Front Cover Financial Network .................................. 3

Michael Osterholm, Ph.D., director, Center for Infectious Disease Research & Policy and professor, School of Public Health.

John Hick, M.D., emergency medicine, HCMC, and chair, Minnesota Department of Health Clinical Care Workgroup.

HealthEast Care System .......................... 9 Methodist Hospital ................................ 5 Minnesota Medical Foundation ............. 5 MMIC .................................................. 17 Moore Healthcare Personnel ................. 13 Multicare Associates .............................. 21 RCMS Inc. ........................................... 16 U of M CME ............. Outside Back Cover Weber Law Office ................................. 15 The Q & A panel from the November 7 seminar: Dean Tsukayama, M.D., John Hick, M.D., Karen Nikolai, Stacene Maroushek, M.D., MPH, Harry Hull, M.D., and Margaret Simpson, M.D.

2

January/February 2002

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Editor’s Message

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THE FINANCING OF AMERICAN health care has had a remarkable history of experimentation over the last 60 years. In World War II, health care insurance was conceived as a “fringe benefit” to circumvent wage controls. Coincident with this, medical science soared to new capabilities. As costs rose, cost containment became the name of the game for employers. Managed care was an experiment that extracted financial concessions from providers of care, but that game has run its course, having “succeeded” mainly in dispiriting the best profession on earth, diverting care dollars to bloated, inefficient bureaucracies, and enriching executives and investors. Since health care consumes about 15 percent of the gross national product, the financing of health care will “morph” again.

Attorney General Mike Hatch is one of many who say the game is now about rationing the amount of health care, though that word is odious enough to demand a euphemism. The key uncertainty is who will do the rationing. Payers? Government (a la Oregon)? Or just maybe the consumers

themselves? It seems the next experiment in health care financing might put the consumers in the unfamiliar position of spending their own dollars out of personal funds (medical savings accounts). The bet is they will choose more carefully, and spend less overall. But how will they assess their choices?

Mr. Hatch is helping Minnesotans move toward more transparent and accountable insurance companies. It’s a start.

Let there be no mistake: we are morphing, away from MCOs, PHOs, integration, and the rest of the tired strategies,

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Dean Dedeker (612) 347-8678

Fax: (612) 623-2888 E-mail: nbauer@mnmed.org

MetroDoctors

Richard J. Morris, M.D.

Retirement plan tax law has changed…

Has your practice's retirement plan changed with it?

MetroDoctors welcomes letters to the editor and “Soapbox” opinions.

Send yours to: Nancy K. Bauer, Managing Editor MetroDoctors Hennepin & Ramsey Medical Societies Broadway Place East, Suite 325 3433 Broadway St. NE Minneapolis, MN 55413-1761

but it’s hard to predict the form (or the new acronym) of the next scheme. I, for one, have some optimism that putting the consumer in charge of purchasing health care just might help restore the magic of the patient-physician partnership.

MetroDoctors asked several of our largest insurers what they foresee; judge for yourself their responses in this issue.

It will be very disappointing if what we get next is “déjà vu all over again.” ✦

The Journal of the Hennepin and Ramsey Medical Societies

Greg Gregerson (612) 347-7816

Registered representative of and offering securities through Financial Network Investment Corporation, Member SIPC

January/February 2002

3

“Leapfrog” to Trigger Giant Leap Forward in Quality, Customer Service, and Affordability

I

IF YOU BUY CHEERIOS ALMOST any place

or anywhere, you are assured of consistent quality and taste. General Mills strives to maintain quality assurance processes to allow optimal outcomes. Of course hospital care is far more complex than making a Cheerio, but developing safer processes in the hospital is an important first step in improving patient safety. My responsibility at General Mills is the health and safety of our employees and it is still too dangerous to be admitted to a hospital in the United States.

“Leapfrog” is an initiative to educate and inform American healthcare consumers about how to make better healthcare choices, and to build safer systems into our hospitals. The Leapfrog group, sponsored by The Business Roundtable, is a consortium of public and private purchasers, of which General Mills is a member, working to identify solutions that can reduce preventable medical mistakes. It is a voluntary program aimed at mobilizing large purchasers to alert America’s health industry that big leaps in patient safety and customer value will be recognized and rewarded.

Leapfrog’s Mission The Leapfrog’s mission is to trigger a giant leap forward in quality, customer service and affordability of health care of all types by: • Making the American public aware of a small number of highly compelling and easily understood advances in patient safety; and • Specifying a simple set of purchasing principles designed to promote these safety advances, as well as overall customer value.

Leapfrog Minnesota (led by the Buyers Health Care Action Group) is one of seven “rollout” regions in a national effort to improve patient safety. Leapfrog is surveying hospitals about implementation of three patient safety practices – computer physician order entry, ICU physician staffing, and evidence-based hospital referral, which are described in more detail below. The survey responses will be used to: 1) educate and inform enrollees about patient safety and the importance of comparing provider performance on Leapfrog’s three safety standards; and 2) recognize and reward providers that meet the standards. This means that purchasers will share the survey responses with their employees. It also means that purchasers will use the survey results in their contracting discussions with plans and providers. In addition, The Leapfrog Group will eventually share all hospital responses with the public.

The seven initial roll-out regions are as follows: • Michigan • Minnesota • California • Seattle/Tacoma/Everett, WA • Atlanta, GA • East Tennessee • St. Louis, MO Computer Physician Order Entry (CPOE): Prescriptions in hospitals should be computerized – With CPOE systems, physicians enter medication orders via computer linked to prescribing error prevention software. CPOE has been shown to reduce serious prescribing errors in hospitals by more than 50 percent.

BY TIMOTHY J. CRIMMINS, M.D.

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January/February 2002

MetroDoctors

Evidence-Based Hospital Referral: For certain elective procedures and treatments, patients should be guided to the hospitals that are more likely to produce better outcomes – By referring patients needing certain complex medical procedures to hospitals offering the best survival odds based on scientifically valid criteria – such as the number of times a hospital performs these procedures each year – research indicates that a patient’s risk of dying could be reduced by more than 30 percent.

ICU Physician Staffing: Hospital ICU care should be managed by a physician certified (or eligible to be certified) in critical care medicine – Staffing ICUs with physicians who have credentials in critical care medicine has shown to reduce the risk of patients dying in the ICU by more than 10 percent.

This initial list is based on four primary criteria: (1) There is overwhelming scientific evidence that these safety leaps will significantly reduce avoidable danger; (2) Their implementation by the health industry is feasible in the near term; (3) Consumers can readily appreci-

The Journal of the Hennepin and Ramsey Medical Societies

ate their value; and (4) Health plans, purchasers or consumers can easily ascertain their presence or absence in selecting among health care providers. These safety leaps are intended as a practical first step in using purchasing power to improve patient safety.

The Leapfrog members have agreed to adhere to the following four purchasing principles: 1. Educating and informing enrollees about patient safety and the importance of comparing healthcare provider performance, with initial emphasis on the Leapfrog safety measures; 2. Recognizing and rewarding health care providers for major advances in protecting patients from preventable medical errors.

3. Holding health plans accountable for implementing the Leapfrog purchasing principles.

4. Building the support of benefits consultants and brokers to utilize and advocate for the Leapfrog purchasing principles with all their clients.

Because the health industry needs time to meet these standards, Leapfrog purchasers will work with the provider community to arrive at aggressive but feasible target dates for purchaser application and implementation of the standards.

As a physician responsible for the health of thousands of General Mills’ employees, their safety, while hospitalized, is of utmost importance. During my career in the ER and while working in hospitals, I have seen excellent physicians make unfortunate errors simply from exhaustion because of long hours. Appropriate staffing in ICU’s and safeguards in hospitalbased medication ordering will help improve the safety in hospitals. My work with trauma systems has taught me that referring appropriate types of patients to centers of dedicated expertise does improve safety and outcome.

I am hopeful these three small steps in better patient safety will result in a giant leap in patient care. ✦

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Call for information — 952-993-6200 6490 Excelsior Blvd.

St. Louis Park, MN 55426 www.parknicollet.com

Timothy J. Crimmins, M.D., is Vice President, Director, Health, Safety, Environment for General Mills.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2002

5

FEATURE STORY

Harnessing the Promise

Patient Safety of Patient Safety

What lies at the heart of improving safety of medical care is attention to the systems used to deliver that care.

C

CONCERN ABOUT THE SAFETY OF PATIENTS is not new to medicine, but public emphasis on “patient safety,” as a subject, is. Patient safety is now a hot topic. Publication of the Institute of Medicine’s November, 1999 report, “To Err is Human,” led to press coverage highlighting risk of injury in current health care systems. The public response drove interest and action among health care purchasers, regulators, and accreditors and among health care organizations and professionals. Increasingly, the focus has shifted from injury and harm to identifying risky systems and ensuring safe care. This article discusses the current status of the patient safety “movement” and suggests ways that physicians can harness the energy in this movement in ways that improve care for their patients.

There is general consensus among health care providers that patient safety is an important and relatively large issue, but an ongoing debate and disagreement about attempts to quantify numbers of avoidable injuries continues. The use of different definitions of what constitutes “patient safety” and “errors,” is common in conversation and in published reports, and adds greatly to confusion, misunderstanding, and frustration. The Institute of Medicine’s definition of medical error: “the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim,” is widely used and is quite broad, covering omission, commission, and misuse. When reading an article or engaging in discussion about patient safety, be sure there is a shared understanding of what, precisely, is being discussed! Even when definitions are clear, it is a challenge to gather sufficient data to produce valid estimates of medical error frequency. The science of these measurements is still early in its development, so statements about precise numbers of persons harmed by medical error need to be viewed skeptically. But that, of course, does not mean the issue can be dismissed. It is hardly surprising that safety in medical care has become an increasingly urgent issue, given the increasing complexity of diagnostic and therapeutic options and the increasing number of hand-offs in care (e.g., the steps from writing a prescription in a hospital to administration of the medication).

What lies at the heart of improving safety of medical care is attention to the systems used to deliver that care. Medical training focuses on physician knowledge and skill, so thinking about “systems of care” can sometimes feel a bit foreign. Systems are the interactions of persons, processes, and things a physician works with in caring for a patient; it is the infrastructure needed to carry out medical care. Professional competence is, of course, extremely important; and necessary steps are in place to make sure that competence is B Y T O M A R N E S O N , M . D . , M . P. H .

AND JANE PEDERSON, M.D., M.S.

6

January/February 2002

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

achieved and maintained. A culture of patient safety acknowledges that individual perfection is an admirable goal but an impossible standard. Sole reliance on individuals to always perform flawlessly is insufficient to ensure freedom from harm. Systems of care that set health care practitioners up for success are needed — systems that make medical errors less likely to occur, and, when they do happen, reduce or eliminate the harm they cause patients. At its best, the current focus on patient safety can help physicians achieve their primary goal: taking good care of their patients. However, how fully and rapidly this promise is realized will depend, in part, on how several big issues play out at the local, state, and national level.

Big Issues in Patient Safety 1. Organizational Culture Fear is the enemy of improvement in patient safety, because fear inhibits learning.

Fear of lawsuits, job loss, and humiliation is very effective at preventing physicians and other health care workers from sharing observations and insights about how the systems of care they work within could be improved. These insights often come from personal experience, when the system breaks down and allows an accident to occur. A culture that reduces fear and promotes and encourages disclosure and learning is needed. This is not easy. A huge degree of commitment and action from the organization’s top leadership is needed. There are models for success, however, and some of them are here in Minnesota.

A culture of patient safety acknowledges that individual perfection is an admirable goal but an impossible standard.

2. Financial Implications The maxim, “quality pays,” might be true in a global sense, but it is not always clear that an organization’s investments in providing safer care will be repaid through subsequent cost savings or improved market share — at least not quickly. Some changes cost little, but some — especially those involving new technology — can be very expensive, both in direct costs and staff time. An urgent need exists for clear, valid documentation of the costs and benefits to health care organizations for specific process changes in particular settings. And, to the extent that the cost of process improvements cannot be recouped by an organization’s later savings, there are policy questions to be faced. Will reimbursement be increased to cover some or all of these costs? How can changes that produce net societal good be financed equitably? Are (Continued on page 8)

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2002

7

Patient Safety (Continued from page 7)

market forces sufficient to drive these changes through innovation and competition? If so, what is the collateral damage?

3. Role of public reporting In halls of government and in other quarters, there is an increasing call for information on safety of care — information to help consumers make their own health care decisions, and information for units of government exercising their regulatory responsibilities. There are two main challenges to public reporting of accidental injury.

One is the accuracy and validity of the data and the other is unintended consequences of establishing reporting requirements. States now vary greatly in what kind of reporting is required, if any. And even in states where relatively comprehensive reporting is required, underreporting is thought to be widespread. There is real danger that the fear that prevents comprehensive public reporting will also have a chilling effect on the kind of free and open discussion of system defects that allows for learning and systems improvement within health care organizations. Creative resolution to these challenges is possible. The National Quality Forum recently developed a list of 27 events that should never occur during a hospitalization (www.qualityforum.org).

Informal Minnesota feedback indicates widespread acceptance of these measures. Requiring reporting of these events and providing public access to summaries of this information might provide sufficient public accountability without harming the prospects for a culture of patient safety within health 8

January/February 2002

care organizations. As a supplement or alternative, regulators could require, validate, and publicly share descriptions of how health care organizations organize themselves to identify potential dangers in their systems of care and to act to remedy those dangers.

The Importance of the Physician’s Role Are Minnesota physicians up to the challenge of using the momentum of the “patient safety movement” to improve the health care provided to their patients? We think so. Even in the midst of resolving big policy issues and the bickering about definitions and data, physicians are taking the issue seriously, figuring out what makes sense to do now, and digging in and doing it. We encourage you to join in the effort by taking steps to learn more, by participating in professional organizations, and by being a leader and champion in facilities where you practice.

Learn More Here are some web-based resources to help you learn more about improving the safety of health care. The National Patient Safety Foundation (www.npsf.org) is a great place to start, and the American Medical Association is a founding sponsor. You also might want to check out the Institute for Safe Medical Practices (www.ismp.org) and the web site being developed by the Minnesota Alliance for Patient Safety (MAPS): www.mnpatientsafety.org.

Participate Through Professional Organizations and Associations The Minnesota Medical Association has formed a Patient Safety Task Force to provide recommendations to its governing board. The Minnesota Board of Medical Practice is taking an active interest in how its work supports safe patient care. The coMetroDoctors

chairs of MAPS are from the Minnesota Medical Association, the Minnesota Hospital and Healthcare Partnership, and the Minnesota Department of Health, and several physicians are active members. Anesthesiologists have for decades taken the lead in improving patient safety. Medical associations and specialty societies you belong to may also be taking steps to improve safety of care. If not, consider ways they could do so.

Be a Leader and Champion in Facilities Where You Practice One of the great opportunities each physician has is to become a leader at the places where he or she practices. Many physicians are now using their influence to support and lead efforts to make care safer. The following example is an illustration.

Dr. George Gordon, an Emergency Department physician at Rice Memorial Hospital in Willmar, MN, realized that patient safety is more than having good nurses and doctors working to take good care of patients. Prior to his work at Rice Memorial, he witnessed the death of a child due to a possible medication error. Everyone caring for the patient was doing his or her best, yet a tragedy still occurred.

This experience led Dr. Gordon to become a champion for improving systems and processes, which required taking a close look at everything they do on a daily basis–much of which they take for granted, such as the use of verbal orders.

An important factor in Dr. Gordon’s work was support from the administration at Rice Memorial Hospital. Although no reports of incidents where patient harm or adverse reactions occurred were found, they believed their existing systems or processes could be putting their patients at risk. Next they needed to figure out how to approach the topic of patient safety in such a way that it would not be viewed as threatening

The Journal of the Hennepin and Ramsey Medical Societies

by staff, and that they would not get bogged down in meetings trying to identify problems and solutions without ever demonstrating results.

Participating in a collaborative sponsored by the Institute for Health Care Improvement (IHI) provided the needed structure to begin their work. The Rice Memorial team identified three topics and associated measures: use of d-dimer tests in the diagnosis of pulmonary embolism, preparation and administration of high-risk medications, and noise reduction. Each of these topics provided learning opportunities for the team, not only on how to identify and measure systems and processes of care, but also on how to identify potential sources of error that could result in harm to patients.

According to Dr. Gordon, “in more than 25 years of practice and being involved in improvement efforts, the patient safety work that Rice is now doing is the most successful and sustainable because it is visible, practical, integrated, and makes our work even more patient focused.”

The IHI collaborative ended in May, but that ending also marked the beginning of a longer journey in patient safety for Dr. Gordon and the staff at Rice Memorial Hospital. They are continuing to examine the systems in their department, and are developing tools that will assist others in their facility and other locations realize the importance of not only having good, caring doctors and nurses, but also having good, safe systems and processes in place to decrease patients’ risk of harm. “Even if we wanted to cease our focus on patient safety at Rice, we couldn’t because the staff now believes and works in a new way. The culture has changed, and there is no going back.” ✦

Affairs, are employed by Stratis Health. This material was developed under Contract Number 500-99-MN02, entitled “Operation of Utilization and Quality Control Peer Review Organization (PRO) for the State of Minnesota,” sponsored by the Centers for Medicare

Tom Arneson, M.D., M.P.H., Director of Population Health Assessment, and Jane Pederson, M.D., M.S., Director of Medical MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

& Medicaid Services (CMS), formerly the Health Care Financing Administration (HCFA), Department of Health and Human Services. The contents do not necessarily reflect CMS policy.

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January/February 2002

9

Medical Savings Accounts: Back to the Future with a Tax Twist

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TAX DEDUCTIBLE MEDICAL Savings Account plans (MSAs) became part of the federal tax code on January 11, 1997 as a four-year pilot project. That legislation has been extended for another two years, with pending legislation that would make MSAs permanent. MSA legislation extends this tax-preferred means of paying for health care to the self-employed and small employers from two to 50 employees. Self-employed persons are defined as sole proprietors, S-Corporation owners, and partnerships. Simply put, an MSA plan is a federally approved high deductible major medical plan with a “medical IRA” attached to cover routine medical care needs. Unused dollars accumulate from one year to the next within the MSA, earn interest and tax deductibility, and may be used tax-free for eligible health care needs. The major medical plan protects the owner from large claims above the deductible, and must meet both state insurance requirements and federal MSA regulations. MSAs are a financial planning approach combining insurance with investments and tax advantages to meet the problems of high premiums, limited coverage, and reduced access to medical care from the typical HMO plan.

MSAs are intended to make both health care and health insurance more affordable and accessible to more individuals. They are also intended to help people save for their future medical care needs, and to lessen major medical premium rate increases for both employers and individuals. The Internal Revenue Service has been tracking the number of applications nationally, and 25 percent+ of applicants indicate they had no prior health insurance prior to obtaining the Medical Savings Account plan. In this regard

B Y K E N H E I T H O F F, M . D .

AND JOHN TYLER

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January/February 2002

alone, MSAs have proven effective in reducing the number of uninsured nationally.

The savings account provides a greatly enhanced definition of health care “coverage,” which includes medical, dental, prescription drugs, routine preventive care, dental coverage including orthodontics, vision coverage including eye glasses and contact lenses and lasik eye surgery, chiropractic, acupuncture, long term care and long term care insurance, and more.

In this regard the health care consumer has greater choices than they have ever had.

The major medical plan is typically very affordable because the deductibles range from $1,600 to $2,400 for single coverage, and $3,200 to $4,800 for family coverage. Major medical plans like this remind one of the basic medical plans purchased by most peoples’ parents in the 1940s and 1950s and before—basic medical coverage supplemented by the family piggy bank. Rather than buy very expensive medical policies that were rarely used, our parents and grandparents chose to purchase less costly plans and pocket the difference. This is basically what the MSA does, only with significant tax advantages to the owner.

Another intended result for the MSA is to encourage investing for future medical and/or retirement needs. MSA administrators now know that more than two-thirds of all MSA deposits remain in the account for future medical consumption needs. Accumulations are substantial in very short periods of time for most people.

Interest applies to deposits in most MSA plans, and deposits may be invested into anything you might use in your retirement savings plan, including money-market accounts, mutual funds, bank CDs or interest earning debit card accounts. Withdrawals for eligible medical care are tax free, and withdrawal may be made at age 65 for non-medical care without penalty other MetroDoctors

than regular taxation. Rather than paying everlarger premiums for limited medical coverage, the health care consumer may convert premiums to cash, then use the cash to provide for their own health care needs. They keep what they do not use.

The implications to the medical care provider community are both positive and immense.

The physician will once again be providing care to the person paying for the care (from their MSA). Care management may be accomplished by the patient’s physician, rather than by the managed care providers. As MSAs become more common, physician participation in managed care systems may become optional, rather than mandated by market demands. Care quality, access, and choice will again become the primary driver of health care decisions, rather than just cost containment. Patient incentives to conserve on unnecessary care will naturally curb over-consumption of unnecessary care, the main driver behind expensive health insurance premium increases. Experience thus far shows all these aspects of MSAs to be working very well. ✦ Ken Heithoff, M.D. is the Chairman and founder of Center for Diagnostic Imaging, a national radiology clinic organization based in St. Louis Park.

John Tyler is a principal owner in the insurance and investment agency, Medical $avings Accounts, Inc., and Boys and Tyler Financial Group, Inc. located in Eden Prairie.

Dr. Heithoff and Mr. Tyler were among the originators of the Medical Savings Account concept, and worked as Chairman and Vice Chair of the Republican Health Care Task Force respectively to help see MSA legislation passed into law. Dr. Heithoff is currently president of AMOM (Advocates for Marketplace Options for Mainstreet) and Mr. Tyler currently serves on the board of directors of CCHC (Citizens Council on Health Care).

The Journal of the Hennepin and Ramsey Medical Societies

Continuing Medical Education

Vivius Offering Unique Benefits to the Provider Community

sponsored by Allina Hospitals & Clinics

January 2002

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THE VIVIUS PERSONALIZED Healthcare

System is alive and well and being implemented in three metropolitan areas. The Vivius model, unlike some of the other consumer driven healthcare models, is designed as a “wholesale” model — meaning that we implement our program in partnership with a local insurance company, managed care organization, or Blue Cross plan. We have great partners in these areas and will have the program up and running in early 2002. In addition, in each market we have found the physicians and other healthcare providers to be very supportive of our efforts, and recognize the benefits of the Vivius model.

The Vivius model provides unique benefits to the provider community, allowing physicians and other healthcare providers the opportunity to establish their own price, or reimbursement schedule and interact with their patients without onerous referral systems.

Vivius is still interested in bringing our model to Minnesota and is actively working on finding the right insurance partner. We are very pleased that the Minnesota Department of Commerce approved our product filing this past October, which will allow us to offer the Vivius program on a fully insured basis.

Vivius appreciates the opportunity to keep the Minnesota medical community updated on our progress and we look forward to the time when we will have the program available to Minnesota physicians and consumers. ✦

25

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March 2002 2

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April 2002 5

Minneapolis Heart Institute Cardiology Conference PRESENTED BY: Minneapolis Heart Institute LOCATION: Hotel Sofitel Bloomington, MN

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MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2002

11

Consumer-Driven Healthcare Gains Momentum

A

A YEAR AGO, THE EARLIEST adopters of

Definity Health’s consumer-driven healthcare program prepared themselves for the unexpected. For their employees, the new benefit program would grant greater freedom of choice in providers and services – a feature that would no doubt be welcomed. But the new benefit design would also require greater responsibility and involvement on the part of employees, charging them for the first time to manage the use of an employer-funded healthcare “spending account” – and giving them financial incentives to support the more judicious use of these funds. And for the employers, there were the obvious uncertainties of employee acceptance and satisfaction, as well as the potential impact of consumer-driven healthcare on their benefit costs.

As Chicago-based Aon Corporation, Minneapolis-based Medtronic, Inc., and Ridgeview Medical Center, a Twin Cities area healthcare organization, took the first steps with Definity Health’s consumer-driven health benefit in early 2001, others took a wait-and-see stance, looking perhaps to learn: • Would employees select a benefit program that encourages and requires greater involvement on their part?

• How would employees react to greater freedom to choose healthcare services combined with financial incentives to use health benefit dollars prudently? Would they be willing to play a bigger role in managing their health benefits? Would they act as they do when they make other purchases – gathering and evaluating inBY TONY MILLER AND TOM VALDIVIA, M.D., M.S.

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January/February 2002

•

formation on cost, quality, convenience and service – before making a decision?

What might be the impact of consumerdriven healthcare in bringing costs under control?

A New Benefit Design Consumer-driven health plans vary. But the design that Definity Health offered the early adopters includes a Personal Care Account (PCA) that employers fund at a set amount each year for each participating employee. Members then use PCA benefit dollars to pay for routine healthcare services of their choice. Any funds left in the account at year-end roll over and may be used by employees for future medical expenses.

If an employee’s annual healthcare costs exceed PCA funds, health coverage is provided once a deductible is met. Extensive information — on health conditions as well as local health providers, services and costs — is available via telephone and the Internet to support employees as they exercise greater choice and take on increased responsibility.

Early Insights Data collected in 2001 from those first companies to try consumer-driven healthcare provides preliminary insight to those continuing to wait and watch.

health benefit. The adoption rate was even higher — ranging from 40 to 85 percent — among those who participated in more “active” benefits enrollment, specifically new hires and employees who were required to re-enroll in a health plan. Bob Stevens, CEO of Ridgeview Medical Center, says of the nearly 85 percent of his organization’s employees who chose Definity Health, “Cost was clearly important. But the broad choice and greater personal control over their health decisions also attracted strong enrollment.”

“The Personal Care Account is sparking great interest,” says Don Broecker, director of corporate benefits at Charter Communications, a company that is offering Definity Health to employees for enrollment effective January 2002. “It gives them a starting point from which to become much more involved in their healthcare decisions.”

How will employees behave, given greater freedom to make healthcare choices and financial incentives to use their health benefit dollars wisely? Will they spend prudently or with abandon?

Among the three employers who made the Definity Health program available in 2001, nearly 16 percent of employees to whom it was offered opted for it, a rate greater than expected and impressive for the first offering of any new

Employees are using their PCA benefit dollars with discretion. These funds cover traditional medical services, but also can be applied to an expanded set of services including alternative care, doctor prescribed programs for smoking cessation and weight loss, vision and dental care, hearing aids, and even a number of over-thecounter healthcare products.

• All first year employers offered varying degrees of access to services not covered under traditional health plans, such as vision care and massage therapy. Employees, however, remained protective of their PCA

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Will employees opt for the consumer-driven benefit option?

•

funds. Less than 10 percent of members applied PCA funds to these non-traditional services.

As year-end approaches, over 50 percent of Definity Health members are expected to roll over PCA dollars to next year.

Choice, information, and incentives are having an impact on the use of more traditional healthcare services as well. Early indications are seen in member pharmacy decisions.

• Definity Health does not apply a drug formulary that restricts members’ pharmacy choices. Yet, year-to-date results show generic drug utilization at approximately 90 percent — nearly 10 points higher than industry norms. Overall prescription use is also below industry averages.

Will employees actually use the health information tools and resources that consumer-driven healthcare provides to help them make better informed choices?

The tools and information provided are being used by members.

• More than half of Definity Health members are using their personalized web sites at least once per month. And their use of NurseLine, a phone link to healthcare professionals available 24 hours a day, is being used by 15 percent of Definity Health members — two times the national average.

Will only the young and healthy opt for consumerdriven healthcare?

Membership data from 2001 shows Definity Health to have strong appeal across age segments and stages of healthcare needs.

• The average Definity Health member age is 42, in line with the average for the three employers in their first year of offering.

• The average family size is 2.6, well above the industry norm which approaches 2.2.

• Definity Health also has an appropriate percentage of members who would be considered “high use” consumers – people who are undergoing surgery or treatment for cancer, or who are managing such chronic diseases as multiple sclerosis and diabetes.

MetroDoctors

Employer Costs How will consumer-driven healthcare affect employer costs for employee health benefits?

A more engaged member population is having a positive effect upon healthcare costs for employers. As the year comes to a close, preliminary indications are encouraging. Financial performance for year one employers who offered Definity Health is exceeding objectives. This is being driven by a number of factors, including the more judicious use and selection of drugs, strong use of telephone-based and online services, the more effective and efficient use of hospital stays and efforts by members to judiciously use Personal Care Account benefit dollars.

As We Begin 2002 As employers continue to grapple with rising healthcare costs and seek to provide benefits that their employees will view as more valuable, in-

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quiry into consumer-driven healthcare is increasing. What began with three companies in January 2001 has grown to nearly 20 companies for 2002. This list includes Ridgeview Medical Center, as well as Aon and Medtronic who have expanded the offering of Definity Health across the United States. In addition, Raytheon, Textron, Charter Communications, the University of Minnesota, Dade Behring, Countrywide, Scientific Atlanta and others will make the Definity Health program available to their employees in 2002. Consumer-driven healthcare has arrived, apparently meeting the needs of a diverse range of companies for an effective solution that raises employee satisfaction and improves employer control over healthcare costs.✦ Tony Miller is CEO and Tom Valdivia, M.D., M.S., is CMO of Definity Health.

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The Journal of the Hennepin and Ramsey Medical Societies

January/February 2002

13

PreferredOne is Exceeding Enrollment Expectations

P

PREFERREDONE IS experiencing another success-

ful year. The PreferredOne Community Health Plan is exceeding enrollment expectations and will have reached the state mandated reserve requirements by the end of the year. This should allow a return of a greater provider withhold than the last two years. The self-insured product continues to grow very well also.

PreferredOne administers this product but the employer keeps the insurance risk. Our traditional PPO product is not as strong in the Twin Cities market or the national market as it has been in past years. This is a more complicated product for the providers to work with, so while the reimbursement is usually better, the hasslefactor is worse. The overall assessment is that PreferredOne is holding its own in the market, despite tough competition from the “Big Three.”

In the year 2002 the competition in the market will get even tougher. PreferredOne, along with the other plans, will offer a defined contribution/medical savings account product.

This is more of a consumer model plan where the patient has more financial involvement in their healthcare. The patient is expected to make wise healthcare decisions with the understanding that these decisions will have a financial effect directly back on them. The difficult part of this product is getting the patients the information they need to make wise decisions.

PreferredOne looks forward to working with providers to get the best information possible to the patients as they make their choices of healthcare and providers.

In 2001 PreferredOne became an associate sponsor of ICSI along with UCare and the “Big Three” Plans. The expectation is that that forum will allow the plans and providers to work

BY JOHN FREDERICK, M.D.

14

January/February 2002

together to improve the quality and efficiency of healthcare. The major initiative for ICSI in 2002 will be Diabetes management. The hope is that the plans can combine their efforts in the measurement of Diabetes outcomes so the providers will have fewer hassles and more provider specific information available to them. There is great potential from having the plans and providers at the same table focusing on quality issues.

PreferredOne continues to enhance our secure website for our provider partners who have access to the internet. The website now consists of information regarding member eligibility, claims inquiry, referral submissions (PAS and PCHP), PPO Group/Payer lookup and PPO Payer listing. We are hopeful that you will find this a useful tool.

PreferredOne has joined the credentialing coalition for recredentialing services only. This coalition was developed in conjunction with the Minnesota Council of Health Plans, Minnesota Hospital and HealthCare Partnership, and the Minnesota Medical Association. This coalition represents an effort to achieve a system for statewide credentials verification. After a transition period of about two years, the anticipation is a dramatic reduction in the number of applications a provider needs to complete, with the ultimate goal being practitioners filling out only one application that can be used by everyone in Minnesota who needs it.

In an effort to continue to provide enhanced network coverage to our employers and payers, PreferredOne continues to expand its geographic presence. Recently we have expanded into parts of South Dakota and Iowa. We continue to look for opportunities to work with providers to expand our access for employers and payers.

PreferredOne has made the decision to disMetroDoctors

continue Preferred WorkCare (PWC), the workers’ compensation certified managed care plan, as of December 31, 2001. We appreciate the relationships we have established over the years.

To all our PWC providers, thanks for your service and support throughout the years.

Over the last year, PreferredOne has also made an enhanced effort to strengthen our medical management programs and work collaboratively with our providers. The medical management program has increased provider compliance regarding notification of acute inpatient admissions and is following with a focus on anticipating and managing short and long-term discharge needs and costs. This has enabled us to more quickly identify cases that may be in need of case management, and disease management programs and an ability to report to our payer customers what their utilization and potential costs will be. It also allows us to work closer with the providers to help assure members are receiving cost-effective quality care and help assure member’s benefits are being best utilized.

In the upcoming year, PreferredOne will be enhancing the disease management programs, and provide the medical policies criteria, and drug formulary on the web site. Work is continuing on further development of the case management programs to assure our payers and members that the benefit plan is being maximized appropriately and that the necessary outside resources are being accessed.

This has been an exciting year at PreferredOne and we look forward to our continued relationships and the opportunity to work with our provider network to provide strong programs that will meet our client’s needs. ✦ John Frederick, M.D., is vice president and chief medical officer for PreferredOne. The Journal of the Hennepin and Ramsey Medical Societies

Blue Cross Launches Consumer-Driven Health Plan for Small Businesses and Individuals MSA product delivers low cost, consumer control and choice

Primarily due to increasing utilization and the rising cost of care itself, health care costs have skyrocketed 10-20 percent each of the past three years and are expected to rise at least 15 to 18 percent in 2002 with no end in sight. Because of state mandates and their smaller risk pools, Minnesota’s small businesses and individual purchasers shoulder a disproportionate amount of those increases – sometimes reaching 33 percent or higher in a given year for a purchaser. Yet these small businesses are the backbone of Minnesota’s economic growth, making up more than three-quarters of all startup companies in the state. — BCBSM

I

IN RESPONSE TO SKYROCKETING health

care costs and growing consumer demand for more choices, Blue Cross and Blue Shield of Minnesota (Blue Cross) will soon be offering a health plan option for small businesses and self-employed individuals that combines a high-deductible health benefit plan with an interest-bearing, federally qualified medical savings account.

Called MSA Blue, the new plan allows employers or self-employed individuals to contribute up to 75 percent of their plan’s deductible (for family coverage) to a tax-free personal account. The individual withdraws the money as needed to pay for health care expenses, even ones not covered by traditional health plans, such as laser eye surgery or complementary care. If needed, the balance of the deductible is covered by the individual member. For 2002, employees can choose between three deductibles: $1,650, $2,500 and $3,300 (for single-only

coverage). For family coverage, the deductible is roughly twice as much.

Meanwhile, 4.5 percent interest accrues on the individual’s entire account, encouraging wise health care decisions. (In the future, Blue Cross plans to add further investment options for the medical savings account, using a third party financial institution.) Any year-end balance rolls over to the next year and continues to accumulate – unlike other flexible spending accounts.

Because it is owned by the individual, the account is portable and moves with him/her.

Once the deductible is met, members are covered by a standard health plan, with the insurance plan paying either 80 or 100 percent after the deductible is met.

“Consumers like the plan because their premiums are lower and they’re in the driver’s seat as to how to use the money,” said Kathy Kelly, head of product management at Blue Cross. “Small businesses and self-employed individuals like the plan because it significantly reduces their health care costs and in some cases makes the difference to allow them to offer health care coverage.”

At the same time, Blue Cross networks include access to nearly every health care provider in the state — allowing most employees to keep their current physician. And with MSA Blue, they’re free to see the physicians and specialists they choose, without referrals. And if they choose, claims can be paid automatically out of the account by Blue Cross.

MSA Blue will be available to small groups

beginning Jan. 1 and self-employed individuals beginning April 1. It is available through Blue Cross agents. Blue Cross, the first and largest health plan in Minnesota, is the only one of Minnesota’s three largest health plans to offer a medical savings account product for small businesses. ✦ James D. Woodburn, Jr., M.D., is the national account medical director, and Joel Swanson, APR, is the senior communications consultant for Blue Cross and Blue Shield of Minnesota.

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MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2002

15

What’s New at HealthPartners

O

OVER THE PAST YEAR, there have been several changes at HealthPartners and there are several changes that are coming in the near future.

In 2001 HealthPartners was honored to be one of 12 health organizations within the United States to be part of the Robert Wood Johnson Foundation/Institute of Healthcare Improvement Pursuing Perfection Initiative. In addition, HealthPartners was also given the highest accreditation mark from the National Committee for Quality Assurance. There have been other smaller accomplishments as well, with the west

BY CHRIS REESE

metro clinics moving their care for labor and delivery and with more choices being allowed to consumers of the health plan.

Pursuing Perfection The Pursuing Perfection program was launched in May with the release of survey findings showing that more than half of health care providers and administrators believe the overall quality of health care in the United States is not good. The survey also indicated that 80 percent of medical providers believe fundamental changes are necessary in the health care system.

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January/February 2002

MetroDoctors

ganizations from across the country applied for Pursuing Perfection grants. A national advisory committee, comprising business and policy leaders, selected the 12 first phase grantees based on a series of criteria, including their ability to develop: • a strategy for training their organization’s administrative and clinical staff to redesign their processes based on what they learn from pilot tests; • a strategy for building partnerships outside the organization, necessary to pursue perfect care for patients; • an internal financial analysis of how net revenue will change as a result of the improvements; and • plans for directly involving organizational leaders, responsible for assuring continued dramatic quality improvement.

At the end of a seven-month planning phase, which started in September, up to six of the 12 organizations will be selected to receive grants between $1.5 million and $3.5 million to help implement their plans. During the sevenmonth phase, the HealthPartners Medical Group and Clinics will initially pilot two interdependent initiatives for care improvement as part of its pursuing perfection initiative. Those two initiatives are: • A care system redesign, using a new model of planned care, improving methods, approaches, systems and workflows used to care for patients with depression, heart disease and diabetes; and • Health information availability, giving patient care teams easy access to information, at the time they need it, to make good decisions through an automated care summary of the current status of chronic conditions and preventive care needs of its patients.

The Journal of the Hennepin and Ramsey Medical Societies

Reasons for these changes are to bring out better care for the patient. Other industries have embraced a systems approach as the best way to bring about improvements in quality and performance that, in turn, significantly boost customer satisfaction and produce better results.

The Pursuing Perfection initiative will apply the same approach to health care.

NCQA The quality standard from the National Committee for Quality Assurance awarded HealthPartners an “Excellent” accreditation status for its Commercial HMO/POS combined product. HealthPartners has achieved the “Excellent” status in only its second year of availability.

The status is based on an analysis of the HealthPartners 2001 HEDIS report, which showed significant increases in several areas when compared to the 2000 results. The report shows that HealthPartners scored high in preventive care and in treating patients with chronic illnesses. The report also showed that HealthPartners scored well in patient satisfaction in both physician and administrative areas. It is because of this thorough process, that

MetroDoctors

the NCQA accreditation is especially important to employers, who are choosing health plans for their employees.

Some of the comparison results included in the scoring needed to achieve the “Excellent” status included breast cancer screening, with HealthPartners at a rate of 83 percent, compared to the national average of 74, comprehensive diabetes care/eye exam (HealthPartners 66, national 48), prenatal and postnatal care/timeliness of care (92 percent to 83 percent), childhood immunization status/combo 1 (78 percent to 67 percent), along with several other categories.

Consumer Choice Employers have always wanted more choice in the health plan they offer and this year HealthPartners responded with a plan that has now enrolled over 150,000 members.

HealthPartners has offered a primary clinic plan in which members choose a primary care clinic.

The network has more than 600 clinics and over 11,000 physicians available. Also presented to the employees is an open access plan, which will allow members to see any provider without a

The Journal of the Hennepin and Ramsey Medical Societies

referral in the HealthPartners Open Access network. With these options, along with several others, there has been a 63 percent increase in the number of members who are more satisfied with their option.

Labor and Delivery HealthPartners Medical Group and Clinics has decided to change the location as to where its west metro patients will be delivering their babies in 2002. Expectant mothers who use one of the west metro HealthPartners clinic locations will be delivering at Abbott Northwestern Hospital, starting January 2002.

Abbott Northwestern consistently ranks number one in the west metro area for patient satisfaction in maternity care. With ready access to specialists at the adjacent Children’s Hospitals Clinics, members are ensured that their babies will receive the highest quality care.

HealthPartners members who visit the HealthPartners West, Uptown, Ridgedale, Brooklyn Center, Maple Grove, Bloomington and Riverside clinics will be delivering at Abbott. ✦ Chris Reese is communications specialist for HealthPartners.

January/February 2002

17

“Payer Alert” Advises Members of Changes PreferredOne Contract Amendments to Provider Agreements Editor’s Note: In November, the following Payer Alert was sent to members of the Hennepin and Ramsey Medical Societies and the Minnesota Medical Group Managers Association. These “alerts” are designed as a starting point to consider the contractual decisions that could make a significant impact on your practice, but should not be considered legal advice.

P

PHYSICIANS WHO CONTRACT with PreferredOne through their Preferred Provider Organization (PPO), their TPA (PreferredOne Administrative Services, Inc.), and their Community Health Plan (HMO) products should take note of contract amendments recently distributed by the company. The new amendments became effective November 1, 2001.

The contract amendments relate to the following substantive areas:

1. Article 1: New Medical Savings Account (MSA) product – PreferredOne has announced a new MSA option, applicable to their HMO product. The addition of this new product option results in a change in the contract terms relating to “covered services.” The provider reimbursement is based on the HMO fee schedule, which is 10 percent less than the PPO. The definition of “covered service” is amended to include the medical expenses that are paid either through the MSA or the enrollee for qualified medical expenses. The provider reimbursement is based on the HMO fee schedule, and generally requires physicians to accept the contract payment rates for non-covered services that are basic health services. The amendment defines “basic health services” as the health care services an enrollee may reasonably require to be maintained in good health. (Section 3.1)

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January/February 2002

2. Article 3, Section 3.1: Clean claims – The contract section relating to payments of covered services is amended to incorporate Minnesota’s prompt pay law. The amendment now requires submission of clean claims which, consistent with state law, defines a clean claim as a claim that is without defect or impropriety and lacks no required substantiating documentation and involves no particular circumstances requiring special treatment that prevents payment from being made within 30 days of receipt.

This section also states that PreferredOne will require payers to pay clean claims within 30 days; should a payer exceed the 30 day limit, however, the amendment requires providers to bill payers for any interest payments owed under the prompt pay law. The Minnesota prompt pay law gives payers and third party administrators (TPAs) discretion in terms of requiring providers to bill for interest. Due to PreferredOne’s position on this issue, physicians may find the attached document regarding implementation of the prompt pay law useful in managing interest billings (http:// www.mhdi.org/auc/Promptpay_desc.htm) The amendment now also extends contract payment terms to Non-Covered Services that are considered basic health services.

3. Article 5, Section 5.6.1: Billing procedures and deadlines – There are a number of significant amendments to the billing requirements for providers that should be noted: Claims adjustments: Providers must request an adjustment of a claim within 180 days of the date that the claim was initially paid. (Previously the adjustment period was 12 months from the date of initial payment). It should be noted that the contract does not include a time limit for payers making adjustments to previous payments.

MetroDoctors

Recoding Procedures: Although not new language in the amendment – the “Company or Payer” may change, combine or recode the procedures codes or other billing codes in accordance with industry standards (our underlining). In other words, they can pay whatever and however they want.

Appeals: Any appeal from a claim denial for untimely filing must be submitted within 60 days of the initial denial or the denial will be considered final.

Claims submission: The amendment explicitly notes that payers will not be obligated to pay any claims that are submitted more than 365 days from the date the charges were incurred (the date of the treatment or procedure). The amendment retains the current requirement that claims must be submitted within 120 days from the date services were provided or within 60 days of the date of the primary payer’s explanation of benefits when the payer is not the primary payer.

If after submission of a claim, the payer requests additional information, such information must be submitted within 45 days of the date of the request. If there are extenuating circumstances preventing the provider from meeting the 45-day timeline, the provider may notify the payer within the 45-day period and then provide the requested information within 90 days of the payer’s initial request.

4. Article 4, Section 4.2: Enrollee Identification Cards – The amendment changes PreferredOne’s obligation to identify the payer on enrollment/ID cards. Instead, PreferredOne will require the payer to be identified on the enrollee identification card OR on the remittance advice.

Company Obligations: The Company is not the Payer, it only provides the fee schedule.

The Journal of the Hennepin and Ramsey Medical Societies

It has been the Company’s obligation to identify the payer, by requiring the payer to include PreferredOne on enrollment/ID cards. The amendment loosens this obligation by alternatively allowing identification “on the remittance advice” – which obviously occurs weeks or months after the actual service has been delivered.

5. Article 6, Section 6.2: Information Retention and Release – This section makes significant changes to the previous non-disclosure and data release terms of the contract and should be examined carefully by the physician.

Under this section, the provider contract is modified to state that the provider authorizes PreferredOne to market provider’s services both to payers and directly to customers and potential customers. Under the contract terms, marketing information that is released could include, without limitation, the provider’s fees, comparative quality indicators, and demographic data.

If a provider wishes to deny or revoke authorization of release of this data, they may do so by giving PreferredOne 30-days advance written notice. Physicians may wish to note that the contract does not define any of the terms in this provision, such as customers or comparative quality indicators. Prior to this amendment, some of these items, including fees for services, were considered “confidential business information” and were not to be disclosed to third parties. Because of the vagueness of this provision and the potential for misinterpretation and misuse of the data, we strongly recommend that you consider revoking this data authorization.

6. Article 6, Section 6.5: HIPAA compliance – The contract references the new federal Health Insurance Portability and Accountability Act (HIPAA) privacy rule, which is scheduled to take effect in April 2003. The contract acknowledges that there may be additional modifications to the privacy rule prior to implementation and requires that, six months prior to the compliance deadline, provider and PreferredOne will negotiate in good faith regarding any contract amendments required by the new law.

7. Article 5, Section 5.8.7: Notification – Lastly, physicians should be aware of a new notification requirement, under Section 5.8.7, that MetroDoctors

requires contracting providers to notify PreferredOne within 10 days of any additions or deletions of practitioners available to provide services to PreferredOne enrollees under the contract (i.e., departure of a physician or other practitioner from the group’s practice). ✦

The information provided in this Notice is not a substitute for legal and accounting advice. Providers interested in determining the specific application of the Contract Amendments to their practices should discuss the matter with their own attorneys, accountants and consultants.

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The Journal of the Hennepin and Ramsey Medical Societies

January/February 2002

19

Highlights of the Code of Medical Ethics of the American Medical Association SECTIONS 3.00: OPINIONS ON INTERPROFESSIONAL RELATIONS AND 4.00: OPINIONS ON HOSPITAL RELATIONS This article considers two sections of the Code that include a handful of Opinions, respectively based on interprofessional and hospital relations.

Several Opinions in the first section have deep historical roots traceable to the 1847 edition of the AMA’s Code. In contrast, Opinions in the second section only go back to the twentieth century.

In part, this is a direct result of the fact that in the mid-nineteenth century, only the most destitute patients received hospital care, while a majority of patients received care in their own home. By the turn of the last century, however, more hospitals had been founded and more patients were being treated in them, particularly those undergoing surgery. Still, it was not until the late 1920s – early 1930s that references to hospitals began to appear in the Opinions and Reports of the Judicial Council (now, the Council on Ethical and Judicial Affairs).

Apart from the historical factors that influenced the development of guidelines on interprofessional relations and on the practice of medicine in the context of hospitals, changes in the structure of the Code also have transformed these two sections to considerable extent. This historical and structural evolution is traced below.

Evolution of the two sections Physicians and other healers As explained in the first article of this series, the Code underwent a profound change in 1957, such that all of its provisions were distilled into ten Core Principles of Medical Ethics. Each other statement – now considered as an Opinion – fell under the Principle it most directly referred to or interpreted.

The newly-established Principle 3 reflected lasting concerns to eradicate quackery and other non-allopathic forms of medicine, stating that “A physician should practice a method of healing founded on a scientific basis; and he should not voluntarily associate professionally with anyone who violates this principle.” These sentiments were not completely removed until the 1980 revision of the Principles.

From the late 1950s through the 1970s, Opinions under the new Principle 3 defined “sectarians” as those who followed dogma or tenet to the exclusion of demonstration or experience,” and also used the term “cultist” to identify other suspect practitioners. Specifically identified were osteopaths, podiatrists, and optometrists. In the late 1960s, chiropractors were added to the list, while prohibitions to associate with osteopaths were removed. This in part reflected that there was acknowledgement that the medical care osteopaths provided had become more similar to the care provided by “regular” physicians.

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

20

January/February 2002

MetroDoctors

The 1977 edition of the Code brought about a new structure, such that Opinions were now organized in terms of broad subject matters rather than listed in reference to a single Principle. Section 3.00, the content of which has not changed much since, was titled “Interprofessional Relations.”

Provision of care by hospitals and other corporate entities As mentioned above, there was no reference to hospitals in the AMA’s Code until the 1920s.

After 1957, they were placed under Principle 6, which stated that “A physician should not dispose of his services under terms of conditions which tend to interfere with or impair the free and complete exercise of his medical judgment and skill or tend to cause a deterioration of the quality of medical care.”

An early formulation of this sentiment had claimed that it was “unprofessional” to dispense services under conditions that made the rendering of adequate care impossible. In effect, it rendered unethical all contracts between lay institutions and physicians to provide care to a predetermined group of patients, such as employees of a company or members of a fraternal order (an arrangement known as “the corporate practice of medicine”). Specifically, it was argued that such circumstances presented an untenable conflict of interest between the economic restraints or profit-making demands of the lay institutions and the patients’ best interests.

Specifically, in 1929, the Judicial Council had found that “Organizations controlled by groups of laymen… offering medical and hospital service to any who will buy ‘membership’ and pay a nominal sum … as ‘dues’” were engaged in schemes that were “economically unsound, unethical and inimical to the public interest.” Courts also supported the claims that The Journal of the Hennepin and Ramsey Medical Societies

only a natural person could be licensed to practice medicine, and consequently that corporations could not.

Also in 1929, the Judicial Council had determined that hospital rules regarding “hospital privilege tax,” whereby attending staff physicians were prohibited from accepting fees for professional services that instead were collected by the hospitals themselves, were unethical.

In the late 1950s, as an increasing number of salaried physicians provided care in hospitals or through pre-paid group insurance clinics, and as residents provided a greater portion of care within teaching hospitals, these types of ethical limitations became contentious. For some, regardless of whether payments were made by a corporation or a hospital, the physician’s allegiance to the patient was undermined. Yet, courts had begun to view that not-for-profit hospitals, at least, were not in violation of the corporate practice of medicine since they employed physicians as independent contractors, without restrictions on physicians’ provision of medical care. This new reality was incorporated into the less restrictive formulation of the 1957 Principles, cited above.

All that is left of those concerns today is the statement found in the current Principle VI, which refers to a physician’s ability to choose freely “with whom to associate, and the environment in which to provide medical services.”

In 1977, hospital relations became one of the Code’s broad subject categories, and contained many of the Opinions that are found in section 4.00 today.

Current Opinions Section 3.00: Interprofessional Relations Today, this section offers a composite of old and new professional concerns. Opinion 3.01, “Nonscientific Practitioners,” echoes old prohibitions against quackery as it states that it is unethical to aid and abet in the provision of a treatment that has no scientific basis and is dangerous. Today, however, this language lends itself to setting ethical parameters on the practice of complementary and alternative medicine.

Opinions 3.03, “Allied Health Professionals,” and 3.04, “Referral of Patients,” raise more contemporary concerns related to physicians’ scope of practice. They recognize that various professionals can offer valuable services at the MetroDoctors

same time as they warn against inappropriately abdicating care to such non-medical practitioners.

Opinion 3.041, “Chiropractic,” which permits the collaboration with chiropractors, also serves as a reminder of the historical prohibition that was lifted less than 25 years ago.

Opinions 3.08, “Sexual Harassment and Exploitation Between Medical Supervisors and Trainees,” and 3.09, “Medical Students Performing Procedures on Fellow Medical Students” highlight ethical concerns that can arise in educational settings.

Section 4.00: Hospital Relations Opinions in this section continue to address primarily the contractual arrangements between physicians and hospitals. For instance, Opinion 4.01, “Admission Fee,” states that it is unethical to charge a separate fee for merely securing the admission of a patient to a hospital.

Opinion 4.02, “Assessments, Compulsory,” tersely prohibits that fees be levied against a physician, which if not paid would be cause for the revocation of the physician’s staff privileges.

Opinion 4.03, “Billing for Housestaff and Student Services,” presents a good example of long standing ethical guidance that recently became a matter of law with severe consequences. Specifically, the Code has cautioned physicians since 1965 that when they assume the responsibility for the services rendered by a resident (or student), they may bill the patient only for services that were performed under the physician’s personal observation, direction, and supervision.

Opinion 4.04, “Economic Incentives and Levels of Care,” warns against over-hospitalization that is motivated by greater reimbursement.

It was issued in 1986, at a time when the high inflation rate of medical costs was under scrutiny.

Opinions 4.05, “Organized Medical Staff,” and 4.07, “Staff Privileges,” present the structure under which relationships can be established between hospitals and physicians, without undermining the integrity of physicians’ professional services. Specifically, Opinion 4.05 notes that the organized medical staff may be the vehicle for collectively communicating with the governing board and others about issues of concern to the organized medical staff. Opinion 4.07 emphasizes the necessity for physicians to

The Journal of the Hennepin and Ramsey Medical Societies

act fairly and equitably in recommending the granting of clinical privileges to the governing board.

Conclusion In sum, this brief discussion of a selection of Opinions included in sections 3.00 and 4.00 of the Code offers a unique perspective on some of the perennial professional concerns that physicians have faced through time, from the appropriate clinical role of non-medical providers to the establishment of financial structures that avoid undue conflicts of interest. Although this analysis is far from exhaustive, it nevertheless should serve as a reminder that despite what have been perceived as profound changes in the health care systems over the past two decades, history has important lessons to share, many of which are contained in the Code.

The full content of the AMA’s Code of Medical Ethics is accessible online at www.amaassn.org/go/ceja. ✦ Frank A. Riddick, Jr., M.D. is Chair, Council on Ethical and Judicial Affairs. Karine Morin, L.L.M. serves as Secretary, Council on Ethical and Judicial Affairs.

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

Shareholder status potential after one year.

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

January/February 2002

21

Community Internship Program Offers a New Perspecive of Medicine

N

eficial in showing them a new perspective of medicine and a more positive look at physicians.

28 physicians the opportunity to participate in the Hennepin and Ramsey The Community Internship Program is always looking for names of Medical Societies Joint Community Internship Program. The program possible interns and for HMS/RMS members to participate in future prowas developed to help expose community leaders and professionals to the grams. Please complete the form below and fax to the HMS/RMS office daily routine of a physician’s life. Each intern spends one-half day with at (612) 623-2888. physicians in primary care, emergency medicine, surgery, and one additional specialty experience.

The program closes with the interns gathering for an evening of sharing their experiences.

The consensus of the group was the observation of the overall quality and caring by the physicians and the pleasure they get out of doing their job, despite their concerns about managed care, liability, etc. The technology used in the settings they observed was amazing and the teamwork involved in treating a patient (i.e., surgery, emergency room) was very surprising to see. Teamwork is usually not considered when you think of going to the doctor. One intern was quoted as saying “physicians do very well in asking questions and trying to put together the puzzle to help diagnose.” Another intern observed, “whether you spend five minutes or four hours, you will learn something you can’t pick up in a Senator Mady Reiter, David Giel, Natosha Thompson, Marilyn Becker, Deanne St. George and book.” They all felt this program was very ben- Roger Storms.

NOVEMBER 12-15, 2001 OFFERED seven business professionals and

____ Yes, I would like to participate in the 2002 Community Internship Programs.

(Dates to be determined. You will be contacted to confirm the date and your availability.)

NAME: ____________________________________________ (please print) Best way for us to contact you:___________________________________ The following community/business leaders may be interested in participating as an intern: (Please list name, business name, and phone number.)

(Please return this form to: Hennepin and Ramsey Medical Societies, 3433 Broadway St. NE, Broadway Place East, Suite 325, Minneapolis, MN 55413-1761; or fax: 612/623-2888.)

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January/February 2002

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Community Interns and Physicians MARILYN J. BECKER – Director of Admissions, University of Minnesota Medical School Paul Benn, M.D., Surgical Consultants, P.A. Robert Couser, M.D., Neonatology, P.A. Eugene Ollila, M.D., Allina Medical Group Randall Steinman, M.D., Fairview Southdale Emergency Medicine

Dr. Trent Haywood, Chief Medical Officer, Region V, CMS (far right) is hosted at Family Medical Center by Dr. Jerome Potts, and clinic manager, Marie Maes-Voreis.

DAVID GIEL – Legislative Analyst, Senate Counsel and Research Peggy Hickey, M.D., SouthLake Pediatrics David Joesting, M.D., Surgical Consultants, P.A. Jeff Lukens, M.D., Fairview Southdale Radiology Charles Pexa, M.D., North Memorial Emergency Medicine TRENT T. HAYWOOD, M.D., J.D. – Region V Medical Officer, Centers for Medicare and Medicaid Services (formerly HCFA) Daniel Dunn, M.D., Dunn, Graber, Alden, Johnson & Bretsky Robert McKlveen, M.D., Northwest Anesthesia, P.A. Jerome Potts, M.D., Family Medical Clinic Steven Sterner, M.D., HCMC Emergency Medicine SENATOR MADY REITER – Minnesota State Senator and Insurance Agent/Partner Brent Asplin, M.D., Regions Hospital Emergency Room Les Forgosh, M.D., St. Paul Cardiology Peter Kelly, M.D., St. Paul Surgeons, P.A. Jamie Lyn Reinschmidt, M.D., North Suburban Family Physicians - Roseville

Senator Mady Reiter is exposed to medical decision making by Dr. Jamie Lyn Reinschmidt.

DEANNE ST. GEORGE – Quality/Risk Management Coordinator, Lakeview Hospital Kenneth Crabb, M.D., Advanced Specialty Care for Women Stephen England, M.D., Gillette Children’s Specialty Healthcare Rich Lamon, M.D., Regions Hospital Emergency Room Inell Rosario, M.D., Otolaryngology, Head & Neck Physicians, P.A. ROGER STORMS – Member, Park Nicollet Foundation Board and Electrical Industry RennerAnderson, M.D., Park Nicollet Clinic, Pediatrics Paul Damrow, M.D., Park Nicollet Clinic, Orthopedic & Hand Therapy Leonard Nordstrom, M.D., Park Nicollet Heart Clinic Erick Zeitz, M.D., Methodist Hospital Emergency Medicine NATOSHA F. THOMPSON – Health Insurance Specialist, Centers for Medicare and Medicaid Services, Region V Won Chung, M.D., Regions Hospital Emergency Room Peter Daly, M.D., Summit Orthopedics, Ltd. Laura Dean, M.D., Stillwater Medical Group, P.A. David McAlpine, M.D., MinnHealth Family Physicians, P.A. Woodbury ✦

David Giel and Dr. Peggy Hickey discuss electronic prescribing.

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The Journal of the Hennepin and Ramsey Medical Societies

January/February 2002

23

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

Reflections on a Most Auspicious Year End of the Year Report RMS-Officers

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

Kimberly A. Anderson, M.D., Specialty Director John R. Balfanz, M.D., Specialty Director Victor S. Cox, M.D., Specialty Director Charles E. Crutchfield, III, M.D., At-Large Director Thomas B. Dunkel, M.D., MMA Trustee Michael Gonzalez-Campoy, M.D., At-Large Director James J. Jordan, M.D., Specialty Director Kathryn M. Klingberg, M.D., Resident Physician Charlene E. McEvoy, M.D., At-Large Director Ragnvald Mjanger, M.D., Specialty Director Kenneth E. Nollet, M.D., Ph.D., At-Large Director Paul M. Spilseth, M.D., At-Large Director Stephanie D. Stanton, Medical Student Lyle J. Swenson, M.D., MMA Trustee Charles G. Terzian, M.D., Specialty Director Jon V. Thomas, M.D., At-Large Director David C. Thorson, M.D., Specialty Director Russell C. Welch, M.D., At-Large Director 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 Paul J. Dyrdal, M.D., Sr. Physicians Assoc. President Stephen P. England, M.D., Community Health Council Chair Robert W. Geist, M.D., Ethics & Professionalism Council Chair *Michael Gonzalez-Campoy, M.D., Education Resource Council Chair Frank J. Indihar, M.D., AMA Delegate William E. Jacott, M.D., U of MN Representative Matthew D. Layman, M.D., AMA Delegate for American Society of Anesthesiologists Melanie Sullivan, Clinic Administrator *Lyle J. Swenson, M.D., Public Policy Council Chair *Russell C. Welch, M.D., Communications Council Chair *Also elected RMS Board Member RMS-Executive Staff

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

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January/February 2002

WHEN I ASSUMED the RMS Presidency, I

identified four priorities for the year that I would focus on. I think it is important to report to the RMS membership and Board of Directors the progress and current status for each of these.

1.

Continue the role of RMS as an advocate for the patient/doctor relationship and assist where possible other groups that advocate for the same thing.

Much activity has occurred focusing on advocacy as RMS and the Board of Directors have participated in the review and potential development of an Accountable Provider Network.

This model for health care coverage has at its base the doctor-patient relationship and a philosophy of patient and physician autonomy in the determination of appropriate medical care.

An APN model has been under development for the past year. Several Board members have participated in monitoring, discussions, and planning for this model.

RMS, in partnership with Hennepin Medical Society, Minnesota Group Managers Association and the MMA has continued to review provider contracts and issue “Payer Alerts” for practicing physicians. This service is very important to the overall enhancement of the relationship between the physician and patient.

Many of the resolutions presented and supported by the RMS delegation to the MMA House of Delegates Annual Meeting this year focused on the doctor-patient relationship and improvements in patient care. RMS was very successful in getting most of its resolutions accepted by the MMA as policy.

2.

Continuing medical education is a key element of good medical care.

RMS continues to work towards becoming an accredited provider for CME. Currently, RMS sponsors CME through joint sponsorship with the MMA. The RMS Education Council continues to develop processes and policies necessary to support our application for accreditaMetroDoctors

tion. Because of national and intrastate conversions to a new system of accreditation, our efforts are on hold until 2002 when the MMA will accept new applications.

3.

Credentialing of physicians and other health care providers.

RMS and HMS have exited the physician credentialing business and participated in the conversion to the joint purchasing coalition. The three partners of the coalition are the MMA, Minnesota Hospital and Healthcare Partnership, and the Minnesota Council of Health Plans.

CredentialOne was chosen as the credentials verification organization on behalf of the coalition. RMS and HMS continued to provide a bridge credentialing service through April so as to preserve continuity and successful transition of the services to the new organization.

4.

Finally that brings me to the fourth issue, that of patient safety.

What a year it has been! As you may recall, I made patient safety the centerpiece of my focus for the year. At last year’s annual meeting the Don Berwick, M.D. lecture, “Escape Fire” was presented as a thought provoking call to action.

I am happy to report much progress in this arena. Numerous groups have borrowed the tape from RMS throughout the year. The overall impact of the lecture to one’s psyche is profound and long lasting. Everyone has had some experience related to medical errors and patient harm – whether as a practicing physician in a system that failed a patient or as a family member or patient who has experienced some level of medical error.

The Mayo Clinic, St. Cloud Hospital and Twin Cities hospital CEO’s have formed a consortium to work together to make this state the “Safest in America.” By combining efforts and The Journal of the Hennepin and Ramsey Medical Societies

MetroDoctors

2002 Ramsey Medical Society Election Results Congratulations to the newly elected RMS leaders.

President-Elect J. Michael Gonzalez-Campoy, M.D.

Secretary Jamie D. Santilli, M.D.

Director-at-Large Gretchen S. Crary, M.D.

Director-at-Large Laura A. Dean, M.D.

Director-at-Large Robert V. Knowlan, M.D.

Hospital Based Specialty Trustee Charles G. Terzian, M.D.

Ramsey Medical Society

sharing best practices around the initial two projects, they hope to create the nation’s safest environment of care with intentional improvements in patient safety. RMS and HMS meet regularly with the hospital physician leaders, VPMA’s and medical directors. We have agreed to support and enhance the “Safest in America” projects of: 1) Correct site/side surgery; and 2) Medication safety. The medication safety initiatives will aim to eliminate all harm to patients related to: • One or two high risk drugs (focusing on ordering, preparation and administration); • Dangerous medication ordering from a list of unacceptable abbreviations; and • High risk medications for pediatric dosing errors.

I have been asked to chair the MMA Task Force on Patient Safety. This task force will focus on the physician’s role in improving patient safety. We have just started our work and will focus on at least three key issues during the initial year: • Disclosure issues when medical errors occur; • Communication issues/Confusing orders and illegible orders and notes; and • Education of physicians at the medical school and residency level.

Also important for us is the support of a culture and regulatory environment that enhances identification, investigation and review of medical errors instead of a punitive and sanction-focused one.

Finally, I also now attend the Minnesota Alliance for Patient Safety (MAPS) coalition meetings. MAPS is a coalition of the MMA, Minnesota Hospital and Healthcare Partnership, and the Minnesota Department of Health. With over 40 participants representing health care systems, employers, insurers, physicians, hospitals, pharmacy and education, this group is working on multiple fronts to address patient safety in all health care boundaries.

I plan to continue to focus on patient safety issues as the Past President for RMS and support the efforts of the incoming President, Dr. Peter Kelly. I thank all of the RMS membership for the support and encouragement this past year. I look forward to the future of health care with hope and optimism that we can meet whatever challenges present themselves. ✦

MMA Delegates Richard L. Baron, M.D. Kenneth W. Crabb, M.D. Frank J. Indihar, M.D. Jane C. Pederson, M.D., M.S. Steven W. Siegel, M.D.

Internal Medicine Specialty Trustee Kimberly A. Anderson, M.D.

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2002

25

R M S U P DAT E Kimberly Pekarek Turinske, M.D. University of Minnesota Family Practice East Metro Family Physicians - Maryland Clinic

Applicants for Membership

Medical Student (University of Minnesota)

Norwood D. Paige Michelle L. Sorensen ✦

Resident Kimberly A. Mark, M.D. University of South Dakota Obstetrics/Gynecology Regions Hospital

Active Patricia M. Chang, M.D. University of Peruana Obstetrics/Gynecology Parkview Ob/Gyn - Allina Medical Clinic John P. Hamerly, M.D. University of Minnesota Family Practice MinnHealth Family Physicians – Woodbury Robert V. Knowlan, M.D. Creighton University Orthopaedic Surgery St. Croix Orthopaedics, P.A. John D. Mageli, M.D. SUNY at Buffalo Internal Medicine Aspen Medical Group – Bandana

1st Year in Practice Melvin Ashford, M.D. Boston University Obstetrics/Gynecology/Urogynecology Aspen Medical Group – Bandana

Fourth District Congresswoman Betty McCollum hosted an East Metro Summit on Homeland Security on Monday, November 12, 2001, at the RiverCentre in St. Paul.

Representatives of the police, firefighters, FBI, and the Minnesota Department of Public Safety presented an overview of plans for response to terrorism in the East Metro area. Dr. Kenneth Nollet, RMS Board Member who is with the American Red Cross and the VA Medical Center, and Roger Johnson, RMS CEO, represented the RMS at the meeting and they are pictured here with Congresswoman McCollum following the Summit meeting.

Mark Your Calendar

RMS Annual Meeting Friday, January 25, 2002

Robert J. Dado, M.D. University of Minnesota Anesthesiology Midwest Anesthesiologists, P.A. Michael Forseth, M.D. University of South Dakota Hand Surgery/Orthopaedic Surgery Metropolitan Hand Surgery Associates, P.A. Maria Luz Lao, M.D. University of Wisconsin - Madison Internal Medicine Woodwinds HealthEast Clinic

Town & Country Club 300 Mississippi River Blvd. N., St. Paul

6:00 p.m. — Social Hour (cash bar) 6:45 p.m. — Dinner •

Inauguration of Peter H. Kelly, M.D. as the 131st President of the Ramsey Medical Society

•

Presentation of Community Service Award

Entertainment: Westonka Pop Singers — A musical review of songs from the 50s to the 90s.

Watch your mail for further details!

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January/February 2002

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

It Takes a Village…

Supply Drive February 8-25

centage of homeless adults who are working (41 percent) has more than doubled since 1991.

HealthEast Care System, Ramsey Medical Society, and the Ramsey Medical Society Alliance have taken a leadership role in educating the community on the needs of homeless people from a medical perspective. These groups have coordinated efforts to secure needed medical and hygiene supplies for the homeless in Ramsey County.

The Tenth Annual “Caring Hearts for the Homeless People” supply drive will kick-off on Friday, February 8, 2002 and conclude on Monday, February 25, 2002. The goal of the campaign is to collect more than $40,000 worth of supplies to support three St. Paul programs’ efforts to help our community’s homeless: • Health Care for the Homeless - A team of medical, mental and social health providers brings care, medicine, referrals and sup-

Shopping List (non-alcoholic) (trial/travel sizes) any of these items would be helpful

W

AS

HI

N G T ON l EA

ST ND AKOTA

MetroDoctors

Sponsored By: l

ER

Hygiene • Sanitary pads/tampons • Toothbrushes & travel size toothpaste • Soap for sensitive skin, travel size shampoo and lotion • Deodorant & Razors • Vaseline, lip balm

Other • Foot care (corn pads, anti-fungal powder and cream, white socks) • Diapers (M to XL), travel size baby wipes • Band-aids for kids and new Ace wraps • Baby powder, baby bottles, teething rings, sippy cups, pacifiers • Winter gloves, hats, white socks, underwear • Washcloths

R AM S E Y

Medications (not expired) • Children’s pain medicine, cold products, and vitamins • Adult Tylenol, Ibuprofen, and Aspirin • Cold products (non-alcoholic), cough syrup, cold and flu tablets, decongestants • Ointments (antibiotic, hydrocortisone, diaper rash, antifungal) • Antacids (Maalox, Tums, Rolaids) • Pedialyte, Enfamil or Similac (with iron)

RAMSEY MEDICAL SOCIETY

The Journal of the Hennepin and Ramsey Medical Societies

plies into nine shelter and drop-in locations each week.

• Listening House - “The living room of the streets” provides nurturing space, personal supplies, and a daytime sleeping place for night workers whose shelters are closed during the day.

• SafeZone - A non-threatening haven for youth between the ages of 11 and 21, SafeZone provides hospitality, “family,” medical care, supplies and referrals.

Here’s how you can be a part of the village and help combat homelessness. If every family in your clinic donates items, what a difference a village can make!

1. Commit your clinic to participate. All we ask is that you designate a “Caring Hearts for the Homeless People” coordinator for your clinic. Have this person call Doreen at 612-362-3705. We will then send you posters and a shopping list to post within your clinic. During the campaign, collect as many supplies on the shopping list as possible. On Monday, February 25 or Tuesday, February 26, volunteers from the Ramsey Medical Society Alliance will pick up the supplies from your clinic and deliver them to the collection site where they will be sorted and prepared for distribution. All participating clinics will be listed in the Ramsey Medical Society journal, MetroDoctors.

2. Another opportunity to help is by making a cash contribution. Just send a check payable to: Ramsey Medical Society Foundation, P.O. Box 131690, St. Paul, MN 55113-0015. Note in the memo that it is for the Homeless Collection.

Thank you for considering this opportunity to contribute to improving the health of our most vulnerable population, the homeless.

Please call the RMS office at 612-362-3705 if you have any questions. ✦ January/February 2002

27

Ramsey Medical Society

T

THE PHRASE “IT TAKES A VILLAGE...” certainly applies when looking at the wide-ranging needs of homeless people. Homelessness is not going away, and indications show the problem is getting worse.

The Wilder Research Study on Homelessness in Minnesota (2000) reports that women and children comprise the fastest growing segment of the homeless population. Since the first Wilder Survey in 1991, the number of homeless families has increased 325 percent, representing almost 4,000 children and unaccompanied youth. Another disturbing trend is the growing number of homeless people who are working but unable to find housing that they can afford. The combination of a severe housing shortage and skyrocketing rents means that people remain homeless for longer periods while searching for a place to live that fits their income. The Wilder Survey reports that the per-

RMS ALLIANCE NEWS BRENDA ANDREWSON

W

WINTER MONTHS IN MINNESOTA can be a time for reflection, a time to gather together with friends and family, a time to establish goals and resolutions, and a time to plan for the future. Now that the holiday season is over, I invite you to sit down for a moment, make yourself a cup of tea, relax and think about the pace of your life. The holiday season can sometimes seem like a blur of constant activities. Do you feel rushed and harried rather than nourished by your activities?

Recently I had coffee with a good friend whom I had not seen for a while. When the conversation turned away from the myriad of activities that our children are involved in, we began telling one another what we were busy doing “to keep ourselves out of trouble.” After several minutes of conversation, regaling each other with complaints about how busy we were, we both looked at one another and laughed. It sounded as though we were competing with one another. It really didn’t matter which of us was the busiest, but that moment of realization turned the conversation to what we get out of the activities and responsibilities that we choose to take on.

We all need to take the time to think about why we choose to participate in some activities and organizations. Sometimes we do take on too much. It is important for each of us to learn that it is o.k. to say no to an activity or organization when our lives are too busy with other equally important activities. Each of us is at different stages in our lives; what is important to me right now may not be as important to you.

We need to appreciate these differences and be more tolerant of the needs of one another.

You may be wondering why I am asking you to contemplate whether your life is too busy.

Don’t I want you to volunteer to help with the Alliance’s many worthwhile projects and causes?

Of course I do, but the Ramsey Medical Soci-

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January/February 2002

ety Alliance is probably one of many organizations that you are active in. Balance in our lives is important in order to sustain our energy and enthusiasm. What I want from you is quality time, not quantity time that exhausts you and leaves you feeling worn out and resentful. Guilt is never a very effective motivator.

I want you to think about what you get out of your volunteer activities. What nurtures you? Only when you know what you enjoy doing can you choose wisely how to spend those precious extra hours and minutes. If someone asks you to do something that you don’t think you would enjoy or be good at, don’t be afraid

What I want from you is quality time, not quantity time that exhausts you… to say no. Another friend of mine loves to tell the story about being asked to serve on the local board of Habitat for Humanity. After thinking about it, she said she was very flattered to be asked, but what she really enjoyed doing was slinging a hammer, not attending meetings.

What do you enjoy doing?

Most of us are RMSA leaders because we believe strongly in the mission of the Alliance, but we don’t have to try to do everything ourselves. Our membership is strong and has a depth and wealth of experience that needs to be tapped. We need to find ways of involving more of our members in our Alliance projects.

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President Bush recently urged Americans to “become a September the 11th volunteer” by committing to community service. He said, “You can serve your country by tutoring or mentoring a child, comforting the afflicted, housing those in need of shelter and a home.

Through this tragedy, we are renewing and reclaiming our strong American values.” This is not news to members of the Alliance, but perhaps we can use this renewed feeling of caring, of wanting to do something to make a difference in our society to involve more of our members in our activities.

When you meet or talk with members of our Alliance, ask them how they would like to become involved. We have many ways that they can help including: • Mentoring a teen mother through the First Steps program; • Assisting at our annual “Body Language” Health Fair, April 15-18; • Helping with the “Caring Hearts for the Homeless” project; • Learning more about the legislative process and how we can impact legislation at the Minnesota Medical Association/ Alliance’s annual Day at the Capitol; and • Working with our Alliance board as we explore ways we can help our community deal with the problem of bullying, its effect on children and ways to overcome bullying in school or on the playground.

I hope that each and every one of us can be involved in at least one of these programs, but remember to maintain balance in your life.

Without balance, how can you hope to sustain your energy and enthusiasm? And with enthusiasm, others will want to join in to help. ✦

The Journal of the Hennepin and Ramsey Medical Societies

CHAIR’S REPORT DAVID L. SWANSON, M.D.

Leapfrogging Over Quality?

HMS-Officers

HMS-Board Members

Michael Belzer, M.D. Carl E. Burkland, M.D. Jeffrey V. Christensen, M.D. Andrea J. Flom, M.D. Kathy Larson, Alliance President Ronald D. Osborn, D.O. James A. Rhode, M.D. David F. Ruebeck, M.D. Richard D. Schmidt, M.D. Leah Schrupp, Medical Student Marc F. Swiontkowski M.D. Michael G. Thurmes, M.D. D. Clark Tungseth, M.D. 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 Nancy K. Bauer, Associate Director

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I

IN 1990, THE 80-YEAR-OLD GURU of qual-

ity, W. Edwards Deming Ph.D., was visiting the Twin Cities as a guest lecturer about quality systems. Dr. Deming was the father of quality systems analysis, and was a recipient of Japan’s highest honor for his instrumental role in turning around Japan’s auto industry. Dr. Deming’s work is the basis of T.Q.I. in all industries today, including medicine.

While in town, Dr. Deming sought medical consultation from Mitchel L. Bender M.D., a Twin Cities dermatologist. Dr. Bender, who was president of the Minnesota Dermatological Society at the time, learned about Dr. Deming’s expertise and invited him to speak about quality improvement in medicine. While unable to accept the invitation, he wrote to Dr. Bender his expression of gratitude for his care and the following comment: “There are (over) 2.5 x 10 9 medical interventions per year in this country. Suppose that 100,000 of the medical interventions gave trouble owing to some medical mishap on the part of the physician. This proportion faulty would be 100,000/ 2.5 x 10 9 = 1/25,000. This would be performance difficult to match in almost any industry.

(True, in the manufacture of some items, people talk about so many faults in a million, or in ten million.) I think that mistakes in bills from department stores, mistakes in bank statements, in telephone bills, far exceed 1/25,000, though I have no figures. Nearly every automobile has something wrong with it. The human body is far more complicated. No system, whatever, will be free from mistakes and accidents. True, we must work to reduce them, but reduction to zero is an idle dream I fear.”

Every few years, when the medical cost hyperinflation cycle begins anew, panicked policymakers seek to bully the health care system. Their battle cry is the perceived lack of quality that exists in the status quo.

What they create in the name of reform is often uglier than what they started with. Today we experience the consequences of the 19921994 legislative reform agenda (part of which

The Journal of the Hennepin and Ramsey Medical Societies

was business’ agenda for Healthright): a significant decrease in patient choice, autonomy, and satisfaction. It also resulted in the emergence of a powerful payer oligopoly that is requiring the action of our Attorney General to tame.

In this edition of MetroDoctors, Dr. Crimmins outlines some measures that Minnesota business executives, as a part of the larger Leapfrog Coalition, are taking to drive quality into the health care system. Any positive support that can be given by business is much appreciated; as Dr. Deming understood, our profession is exceptional in its commitment to quality. Indeed, Leapfrog’s recommendation that computerized systems be implemented for registering and monitoring physician orders is already being adopted in many if not most Twin Cities hospitals. His other recommendations are a little more problematic. How do you admit to “preferred hospitals” when the hospitals face nightly bed shortages? How do you staff intensive care units when you are unwilling to adequately compensate intensivists?

Sadly, our large business community does not have a great track record for positively influencing the delivery of health care in Minnesota. While aligning early with the largest payers, the ones given special dispensation under MinnesotaCare, they share responsibility for creating a system that is barely capable of meeting the needs of our citizens.

The irony is that the contraction of medical service that we have observed over the past decade has occurred during a period of record growth and profit in the business sector.

Perhaps business will be more successful the next go-around. The leadership of outstanding HMS and RMS members like Dr. Crimmins can only help.

We strive to do better, always. Maybe we’ll do it by leapfrogging. Let’s try not to leapfrog over the edge of the precipice. ✦

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Hennepin Medical Society

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 IN ACTION JACK G. DAVIS, CEO

HMS in Action highlights activities that your leadership and executive office staff have participated in, or responded to, between MetroDoctors issues. We solicit your input on these activities and encourage your calls regarding issues in which you would like our involvement.

A health plan contract alert was mailed to members of HMS, RMS, and MMGMA on the PreferredOne contract amendments, effective November 1, 2001. These “alerts” are designed as a starting point to consider the contractual decisions that could make a significant impact on your practice, but should not be considered legal advice.

(See page 18.)

Dr. Michael Tedford, HMS President and Jack Davis, along with MMA and RMS leadership and staff, met with James Woodburn, M.D. and BCBSM staff

on November 14. This is the first time HMS and RMS have been invited to this MMABCBSM annual meeting to discuss areas of mutual concern relating to the health plan and its physician providers.

The ad hoc Contract Coalition is moving right along with suggested legislation for this upcoming session. We have come up with a “wish” list of issues that we would like addressed and a bill drafter is working on the language. Our initiative has been fashioned along the lines of the Illinois legislation.

Another successful Community Internship Program, jointly sponsored with RMS, was held in November. (See article on page 22.) This continues to be viewed as a great experience by the interns and one that does change the view of medicine by community decision makers.

HMS and RMS participated in two more medical student “lunch ‘n learn”

programs this past fall. One was directed at the do’s and don’ts when applying for 30

January/February 2002

residency programs. Drs. Ken Kephart and Virginia Lupo were among the featured speakers and, as usual, did a great job. More than 200 students participated in the lunch and the residency fair. The second “lunch ’n learn” was held November 26 with the topic of tracing the process of creating and sponsoring a resolution going to the AMA House of Delegates. The students then discussed the resolutions proposed by the medical student section for consideration at the AMA Interim meeting, held in early December. Dr. William Jacott led the discussion along with the medical student delegates.

Jack Davis attended the AMA Interim Meeting, November 30-December 3.

Jack Davis and Roger Johnson met with Frank Cerra, M.D., Senior Vice President,

Academic Health Center, to discuss the possibility of conducting a “brain drain” survey and the use of the University’s public health department to improve the science of the survey. He has great concerns about the future labor pool for the health sciences; therefore, he was very enthusiastic about this opportunity.

Due to the fact that Dr. Paul Kettler is our new Treasurer, Michael J. Walker, M.D., a general surgeon in Fridley, is the new Board representative from Unity/Mercy.

Two seminars on “bioterrorism”

were jointly sponsored by HMS, RMS, MMA, and Hennepin County Medical Center. A third seminar addressing some of the ethical considerations encountered during a catastrophic disaster, will be held January 15. (See article on page 2.)

The HMS Senior Physicians Association also had a speaker on bioterrorism. John Hick, M.D., chair, Minnesota Department of Health Clinical Care Workgroup, spoke about the role of the senior physicians in the event of a bioterroristic attack. Many volunteered to be put on a call list in the event of a catastrophic event.

Dr. Paul Sanders, Roger Johnson, and Jack Davis met for a second time with Dr. William Parham, Medical Director, and Jane Rollinson, CEO, of Medica, to discuss the downsizing of their staff and reiterate our recommendation that there be a strong physician presence on their Board.

The Hoban Scholarship Committee awarded three scholarships in October to some very impressive and motivated scholars.

(See article on page 31).

MetroDoctors

Nancy Bauer has been participating on a TriCounty Healthy Communities Collaboration focusing on the needs of the south metro area (Burnsville, Eagan, Apple Valley) organized by the Park Nicollet Foundation. An early success is the development of a communication tool in which parents provide their consent for release of health information from the health care provider to the schools. This document has now been endorsed by the Academy of Pediatrics, Minnesota Chapter, Minnesota Academy of Family Physicians, and the Minnesota Department of Health.

Benjamin Whitten, M.D. made a presentation to the Abbott-Northwestern Department of Medicine on behalf of HMS and MMA, delivering the message of value in membership in organized medicine.

The Hennepin Medical Foundation held its annual meeting in November and, consistent with the mission of the Foundation, distributed grants to organizations and projects seeking funding. Marvin S. Segal, M.D. currently serves as the president of the Foundation. ✦ The Journal of the Hennepin and Ramsey Medical Societies

HMS NEWS

ELECTION RESULTS President-Elect: Michael B. Ainslie, M.D. Treasurer: Paul A. Kettler, M.D.

Swanson is New HMS Chair was held at the Edina County Club on November 1.

In addition, Drs. James LaRoy and William Conroy were recognized as out-going members of the HMS Board.

2001-02 HMS Officers: David L. Swanson, M.D. Chair T. Michael Tedford, M.D., President Michael B. Ainslie, M.D., President-Elect Richard Gebhart, M.D., Secretary Paul A. Kettler, M.D., Treasurer ✦

In Memoriam

David Swanson, M.D., Incoming Chair, presents the Chair’s Sculpture to Virginia Lupo, M.D.

Hennepin County District Judge Kevin Burke, provided the keynote address on the parallels between medicine and the courts.

CHARLES A. HABERLE, M.D., died November 22 at the age of 81. He graduated from the University of Minnesota Medical School. Dr. Haberle began his medical career as a family physician and later moved to psychiatry. He was one of the founding partners of the Minneapolis Clinic of Psychiatry and Neurology. Dr. Haberle joined HMS in 1958. ✦

Hoban Scholarships Awarded to Graduate Students IN HONOR AND RECOGNITION of the

extensive and exemplary career of Thomas Hoban, the former CEO of the Hennepin Medical Society, the Thomas W. and Mary Kay Hoban Scholarship was established in 1994. H. Thomas Blum, M.D. chairs the selection committee. Tom Hoban’s success as a respected health care executive was based on his commitment to partner with physicians to better understand and address the issues facing the practice of medicine. To date, 23 scholarships have been awarded to graduate level students pursuing a master’s degree in health care administration, building on the model of informed and effective health care leaders.

MetroDoctors

On October 19, three more “Scholars” were named and awarded $3,000 scholarships to continue their masters degree programs.

• Gebra B. Buyun Grimm, Public Health Nutrition – University of Minnesota; • Christine M. Taddy, Health Administration, University of Minnesota School of Public Health; • Eric Nielsen, Medical Group Management, St. Thomas University. ✦

The Journal of the Hennepin and Ramsey Medical Societies

H. Thomas Blum, M.D., chair, Scholarship Selection Committee; Hoban Scholars Christine Taddy, Eric Nielsen, Gebra Buyun Grimm; and Paul Bowlin, M.D., member, Scholarship Selection Committee.

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Hennepin Medical Society

DAVID L. SWANSON, M.D., dermatologist practicing at North Clinic in Robbinsdale, is the new HMS chair, succeeding Virginia Lupo, M.D. Although the official transition takes place on October 1 to coincide with the fiscal year, the awards ceremony and passing of the gavel

Foundation Board Members re-elected: Eugene W. Ollila, M.D. Marvin S. Segal, M.D. John J. Stoltenberg, M.D. Joseph Tombers, M.D.

HMS ALLIANCE NEWS K AT H Y L A R S O N

A

ARE YOU FEELING THANKFUL? Thanksgiving has come and gone but our reasons to be grateful remain. We depend on our family, friends and faith communities for support in times of uncertainty and trouble as well as to share with them during times of joy and celebration.

I think of the Hennepin Medical Society Alliance as our extended family and am thankful for the members and the concerns they have for each other and this community.

Our annual Holiday Tea and Silent Auction was held December 7. This is our fundraiser to support Body Works, the health fair for Minneapolis public school third graders, to be held April 8-12, 2002. This will be our 19th year when nearly 100 volunteers will bring this

popular and educational event to 2,500 children to help encourage them to keep their bodies healthy.

We’re thankful for: • the volunteers who make Body Works a reality; • Lutheran Brotherhood that continues to generously donate the use of their auditorium for this event; • the Hennepin Medical Society Foundation that has again generously partnered with us to help fund Body Works; and • the Minneapolis Public Schools that value Body Works and the support of the teachers and staff who use the materials for follow-up health education.

Alliance members, young and old, gathered to celebrate the holidays

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January/February 2002

MetroDoctors

Another of our health education projects is well underway with the recent distribution of more than 31,000 HIV/AIDS education folders to Minnesota school health educators.

We’re thankful for: • school health educators who are dedicated to providing information to students to help them make healthy choices; • both Hennepin and Ramsey Medical Societies and their Foundations for generous support of this program; • several County Medical Society Alliances that have made donations of support; and • the tireless work of program coordinators Diane Gayes and Dianne Fenyk as well as the many hours of assistance from Kathy Dittmer and Tracey Hallin of the HMS staff with guidance and support from Nancy Bauer, HMS Associate Director.

We are truly grateful and send our heartfelt wishes for peace, good health and happiness to all in the New Year of 2002. ✦

The Journal of the Hennepin and Ramsey Medical Societies