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Doctors MetroDoctors THE BULLETIN 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.

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MetroDoctors

CONTENTS VOLUME 4, NO. 2

2

Editor’s Message Index to Advertisers

3

SOAPBOX

MARCH/APRIL 2002

Get Engaged in Public Safety Efforts

4

FEATURE

Six Sigma: A Tool for Leadership in Health Care

7

Minnesota Medical Association Patient Safety Task Force

8

Safest in America: A Patient Care Initiative

10

Minnesota Alliance for Patient Safety

11

MHHP Taking a Leadership Role in Patient Safety Initiatives

12

ICSI: Collaborating to Improve Minnesota Health Care

14

Intensivists Provide Unique Dimension of ICU Care

16

COLLEAGUE INTERVIEW

Kathleen D. Brooks, M.D.

19

Highlights of the AMA Code of Medical Ethics

23

Bioterrorism Seminar Mentoring Program RAMSEY MEDICAL SOCIETY

24 25 27

President’s Message

28

RMS Alliance

132nd Annual Meeting New Members/In Memoriam/ Call for Delegates and Resolutions

March/April 2002

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

HENNEPIN MEDICAL SOCIETY

29 30 31 32

Chair’s Report New Members

DO NO HARM Initiatives for Patient Safety

In Memoriam/Call for Delegates and Resolutions HMS Alliance

The Journal of the Hennepin and Ramsey Medical Societies

On the cover: Initiatives for patient safety are gaining momentum. Related articles begin on page 2.

March/April 2002

1

Editor’s Message

A

AS I FACE THE POSSIBILITY of knee

surgery, I am acutely reminded of the Institute of Medicine’s 1999 report on errors in health care. We know better than anyone that the coordination of patient care is dauntingly complex, dependent on components that sometimes don’t fit well together, and that errors are a frequent occurrence. The Institute report was a splash of cold water in our collective face. We physicians share the responsibility and must not be defensive. At the same time, I am reminded of Mark Twain’s comment about “lies, damn lies, and statistics;” i.e. you can prove anything you

March/April Index to Advertisers Allina Education and Research .............. 20 Sally Bradford Realtor ........................... 13 Brainerd Medical Center ......................... 9 Classified Ad ......................................... 22 Corporate Express (formerly US Office Products) ................ Inside Front Cover Financial Network .................................. 2 Hamm Clinic ....................................... 23 Hazelden .............................................. 26 HealthEast Care System ........................ 21 Hennepin County Medical Center ........ 15 I-Retrieve ...................... Inside Back Cover Methodist Hospital .............................. 11 Minnesota Medical Foundation ............. 6 MMIC .................................................. 19 Multicare Associates .............................. 14 RCMS Inc. ............................................. 8 Riverway Clinics ................................... 15 U of M CME ............. Outside Back Cover Wally McCarthy Cadillac ........................ 3 Wally McCarthy Hummer .................... 18 Weber Law Office ................................. 27

2

March/April 2002

want with numbers. A few years ago, we heard from a Harvard professor that some one-third of Americans use alternative health care—but in the fine print, his definition of “alternative” included the use of vitamins. A more recent article put the actual use of alternative health care practitioners at about 4 percent. So how broadly or narrowly does the Institute define “error”?

My point is that the assumptions and definitions are all-important to understanding the magnitude and severity of the problem, and most importantly, to crafting appropriate, proportionate responses. We physicians are

the most ethical and devoted and trained stakeholders; we must volunteer for the discussions or risk being politicked or “sixsigma’d” out of decisions. It’s all about leadership and keeping the process heading in the right direction. Please read about the MMA Patient Safety Task Force in this issue.

Now excuse me while I tattoo “this side” on my left knee. ✦ Richard J. Morris, M.D., Co-Editor

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The Journal of the Hennepin and Ramsey Medical Societies

PHYSICIAN'S SOAP BOX

Get Engaged in Public Safety Efforts

A

AT THE END OF ONE OF MY FAVORITE movies, “Top Gun,” the

character played by Tom Cruise hears the call, “Get Engaged!”

This is an appropriate message for physicians.

The release of the Institute of Medicine report on medical errors generated myriad news articles. As a result, the public is acutely aware of the issue of patient safety. Troubled by the possibility of medical errors, they look to physicians to assure them that their safety is a high priority.

Various groups are seeking concrete ways to reduce errors. We physicians must make sure we are at the table, proposing our own

BY PAUL S. SANDERS, M.D. CEO of the Minnesota Medical Association

solutions, and doing our part to bring a culture of safety to health care.

This is an issue that cries out for physician leadership and expertise.

How can you become engaged?

1) Participate in the Minnesota Medical Association Task Force on Patient Safety.

2) Become a physician participant in the Minnesota Alliance for Patient Safety (MAPS) through membership on one of its committees: Best Practices; its subcommittee, Technology; Communication and Education, or Data: Privacy, Management, and Measurement.

To become engaged in patient safety efforts, please contact me at 612-362-3722 or psanders@mnmed.org. ✦

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March/April 2002

3

FEATURE STORY

A Tool for Leadership

Six Sigma in Health Care

P …performance must be managed on three levels to produce long-standing excellence: 1) organization; 2) process; and 3) job/performer.

“PLEASE, TAKE BACK LEADERSHIP OF YOUR INDUSTRY!” This was the plea I heard recently from a corporate human resources leader of a Fortune 100 company. He was encouraging a group of leading health care organizations to step up to the plate and address the important issues in health care. We have all heard the pleas from corporate buyers about the cost of health care many times before. Yet, this man’s comment haunted me for days. Are we not leading already? If not, what would strong leadership look like?

I have to admit that there is a vacuum of leadership in health care today. If strong leadership existed, I do not think we would see the frustration that is evident in everyone involved in health care, from patients, to payers and providers.

With strong leadership, we would see innovation directed at anticipating and meeting the needs of people regarding safety, service, effectiveness and cost. Instead, health care lags behind the expectations of people, payers and providers. Safety is a top-of-mind concern with employers, as evidenced by the Leapfrog group’s advocacy for specific methods to lower risks. Costs continue at double-digit annual increases, threatening the ability of companies to pay both wage increases and health care premiums. Additionally, clinicians practicing well-accepted medical treatments are being challenged to demonstrate the effectiveness of their treatment. Today’s health care consumer is savvy, and notices where improvements in process could save them time, money, and worry.

In health care today, there are problems with performance and the marketplace. Both must be improved before the health care industry can assume a leadership position. For purposes of this article, we will limit ourselves to an examination of performance issues and leave the more complex issue of the marketplace for a later date.

What does it take to create strong performance in a system? Improving Performance, by Rummler and Brache (Jossey-Bass, 1995), presents the theory that I have found to be most workable in a health care setting. According to the authors, performance must be managed on three levels to produce long-standing excellence: 1) organization; 2) process; and 3) job/performer.

Organization, in this context, means the way working teams are formed, how they are led, the goals they set, and how the working teams are managed. Process is the extent to which processes are identified, named, owned and managed. Job/performer is the way an organization supports its people by creating an environment that offers a high likelihood of success. Organizations that successfully manage all three levels create a synergism that allows them to achieve their organizational goals.

Health care services usually have significant gaps when evaluated against this model.

BY DAVID K. WESSNER

4

March/April 2002

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

The strongest level has been the job/performer level. Intense professional education and systems of licensure have produced knowledgeable and principled practitioners who can manage the care of their patients. The other two levels, organization and process, are managed more or less depending on each individual situation. While most health care services today are provided within some type of organizational context (hospital, group practice, etc.), the care of any patient or resolution of any problem usually involves many groups with varying goals and methods. The result is a fractured experience for the patient with redundant data gathering, significant communication costs and a more-than-average chance that something will fall between the cracks.

The least developed level in health care services is process. For the most part, processes in health care are not identified or named, ownership has not been established and management of process per se does not occur. This situation is attributed in part, I believe, to the traditional model where strong physicians manage each situation for the benefit of their patients. This model is under increasing scrutiny as the complexity of our contemporary health care calls for more medical professionals to be involved in each case, and greater reliance upon technology. It is no longer enough for one strong individual to define and manage a process. In today’s health care environment, processes require an organizational context in order for them to be managed.

This is where the concept of Six Sigma comes in. The term was coined by Mikel Harry, a Motorola statistician in the 1980s. Harry articulated a method to systematically and dramatically improve the performance of processes within an organization. The concept was soon adopted by Larry Bossidy at Allied Signal and Jack Welch at GE with results that got the attention of Wall Street and corporate America.

Six Sigma can be defined on several levels. On a technical level, Six Sigma is a measurement of variation that achieves no more than 3.4 defects per million opportunities for failure. (A “defect� is defined as any missed target or non-conformance to standard. Examples of Six Sigma performance include fatalities per flights taken in commercial aircraft.)

On a cultural level, Six Sigma is an expectation that work be designed and managed in a manner that creates reliable, defect-free results from any process. Six Sigma has raised an expectation and belief that work can be engineered to be totally safe and totally reliable.

Six Sigma is also a methodology that uses statistically valid data and analysis to accomplish breakthrough improvements within an organization. These improvements can be in many dimensions, including increased capacity, productivity, reliability, effectiveness or efficiency. This method, which is very well known to students of quality improvement, is called D-M-A-I-C (Define, Measure, Analyze, Improve and Control).

On a cultural level, Six Sigma is an expectation that work be designed and managed in a manner that creates reliable, defect-free results from any process.

(Continued on page 6)

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2002

5

Six Sigma (Continued from page 5)

Lastly, Six Sigma is a management system that is capable of producing cash return within the initial year of implementation, and continued financial returns and compounded return on key metrics over multiple years. When implemented well, Six Sigma not only funds itself, but also throws off benefits for customers and shareholders alike.

The way Six Sigma delivers these spectacular results is by focusing on management of processes in order to remove the vast waste, redundancy and rework that exist in most unmanaged processes. Most work operates at a sigma or defect level far below Six Sigma. In fact, the published literature measuring the reliability of health care points to a performance level of somewhere between three and four sigma. At that level, a defect can be expected once in every one hundred opportunities. (In other words, greater than 10,000 times more

likely than if that process was performing at Six Sigma levels.)

Health care professionals are well aware of the waste and rework that they deal with on an hourly basis in caring for patients. In fact, experience has shown that when the processes of a system are performing at a three or four sigma level, 25 to 30 percent of the organization’s costs come from reworking and dealing with defective output.

I have discussed this with health care professionals and have yet to find anyone who takes issue with that statement.

Can Six Sigma — a movement that has been focused in large, publicly traded corporations — work in health care services? That has yet to be determined. I believe the answer is yes, but only when key factors exist that allow Six Sigma to realize its full potential.

The first factor is organizational context. In order for a process to be successfully managed, it must exist within an organizational structure. Once an improve-

ment is identified, organizational commitment to implement the improvement must be made and supported. This way, resources can be focused on improvement, and participants within the process can participate in these improvement efforts. Those involved must train in the methodology and dedicate time to the improvement effort.

Maintaining performance requires a tracking system and ownership of the process.

Six Sigma can be applied within any organization. In health care organizations, however, it is important to note that complex care processes require an organizational level that goes beyond the current scope of many health care organizations. Chronic disease management, for example, requires highly reliable support people, along with physicians and other resources (educational and hospital) that are not presently the norm.

The second condition needed to successfully apply Six Sigma to health care is leadership commitment. Six Sigma is a complicated and costly undertaking that requires resources and strong internal support.

The commitment of resources to Six Sigma will not be successful unless leadership is convinced that progress at the process level is imperative.

At Park Nicollet, we are convinced. We have committed eight teams to a first wave of Six Sigma projects designed to vastly improve the reliability of processes that patients and staff deal with every day. We are also committed to implementing a truly integrated medical record across the continuum of care. These process improvements provide us with the hope that dramatic improvements in health care services are not only possible, but they are also close at hand. It is our goal to be part of a larger effort to take back the leadership of our health care industry. The next few years are going to be exciting. ✦ David K. Wessner is President and Chief Executive Officer of Park Nicollet Health Services.

6

March/April 2002

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Minnesota Medical Association Patient Safety Task Force

A

AS THE PATIENT SAFETY EFFORTS gather

momentum, it has been recognized by the Minnesota Medical Association (MMA) leadership that physician-specific issues are not receiving sufficient attention. Despite development of various forums (e.g. Minnesota Alliance for Patient Safety, otherwise known as MAPS), hospital committees and executive councils, physicians have not been fully engaged in the discussions.

In 2000, the MMA House of Delegates passed a resolution, 408, on patient safety: “Resolved, that the Minnesota Medical Association continue to work with local and national efforts to reduce medical errors and improve patient safety; and be it further Resolved, that particular attention be paid to the issues of: 1) need for and methods to identify root causes of errors; 2) data privacy and confidentiality; 3) mechanisms to reduce the culture of blame in the healthcare industry; and 4) mechanisms for the equitable distribution of associated costs.”

In response to the need for physician input, the MMA formed its Patient Safety Task Force during the spring of 2001. The charge of the task force is fourfold: • Identify those physician-specific issues in which physicians play a key role in patient safety; • Identify key policy issues that physicians need to incorporate into practice; • Assure the voice of physicians is heard in the appropriate patient safety efforts (Minnesota Alliance for Patient Safety, National Patient Safety Foundation, the public arena, etc.); and

•

•

Develop strategies to approach safety and demonstrate a willingness to lead.

Over the course of the first three task force meetings, material regarding malpractice, risk management, doctor-patient communication, and key current efforts were reviewed. The task force has identified its key initiatives for the near future. These initiatives are designed to coordinate with community-wide efforts and assure physician input. The initial efforts of the MMA Patient Safety Task Force will focus on: • Disclosure of medical errors that directly affect patients and the physician responsibilities for participating in facility disclosure policies; • Reductions in medication errors and support of other efforts to improve medication safety; • Medical school and residency education of patient safety issues, medical harm reduction and physician communication skills; • Clarity and legibility of medical orders and the elimination of confusing and illegible orders; and

BY ROBERT C. MORAVEC, M.D.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Identification and dissemination of “best” patient safety-focused practice parameters.

The task force has also expressed significant interest in the regulatory environment and is showing that the Minnesota Board of Medical Practice and other regulatory agencies create a culture that encourages the identification and correction of medical errors and harmful episodes instead of one that suppresses reporting of errors for fear of punitive review.

Members of the MMA Task Force for Patient Safety include: Robert Moravec, M.D., Chair Charles Rich, M.D. Scott Tongen, M.D. (representing the Minnesota Board of Medical Practice) David Larson, M.D. Robert Beck, M.D. Ken Dedeker, M.D. Eric Knox, M.D. Sam Levine, M.D. Steve Rousey, M.D. Margaret MacRae, M.D. Richard Carlson, M.D. Tom Arneson, M.D. Ray Bonnabeau, M.D. Each of these physicians has demonstrated a significant interest in patient safety and is participating both through organized medicine and at their local facilities to significantly improve the delivery of care for all patients. Through this task force and through other collaborative efforts, the MMA will take a leadership role to facilitate the roles of physicians in promoting patient safety. You may feel free to contact any members of the task force to forward ideas and state what patient safety issues may be of particular interest to you. ✦ Robert C. Moravec, M.D., serves as chair of the MMA Patient Safety Task Force, and is medical director of HealthEast Care, Inc. March/April 2002

7

Safest in America A Patient Care Initiative

S

SETTING COMPETITION ASIDE, health

system participants of a unique new collaboration have forged a powerful vision to improve local health care. Called Safest in America, this group of local hospitals has set out to make our communities the safest place in America for patients to receive hospital care.

The initiative is exciting because cross-system collaboration on patient safety at a senior level, and in such specific detail, hasn’t existed before in this part of the country.

BY ALISON PAGE

“While there is much good work occurring in the community with regard to patient safety, this collaborative is unique in that it provides the venue for member hospitals to share sensitive information confidentially,” said Tom Schmidt, M.D., medical director, inpatient care, Park Nicollet Health Services.

The chief executive officers of nine Minnesota hospitals and health care organizations signed a memorandum of understanding in 2001, agreeing to collaborate on process improvements to enhance patient safety. Participating organizations include Allina Hospitals

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March/April 2002

MetroDoctors

and Clinics, Children’s Hospital and Clinics, Fairview Health Services, HealthEast, HealthPartners, Hennepin County Medical Center, Mayo Clinic Rochester, Park Nicollet Health Services and North Memorial Medical Center.

“This effort marks the beginning of a new relationship between health care systems in the community, said George Halvorson, CEO of HealthPartners, and chair of the CEO group sponsoring the initiative. “Although we compete in many ways, we have agreed to set competition aside and work collaboratively to improve and standardize high risk processes in our systems.”

Participating CEOs have agreed to set a collective vision for hospital patient safety; provide broad direction and oversight; learn jointly about safety issues, barriers and solutions; share learning and to hold each other accountable for action. A task force of chief operating officers, chief medical officers and safety officers from member hospitals lead a task force of groundwork activity. The CEOs will continue to meet regularly to provide oversight and support to the operations group.

“We have intentionally not sought publicity for this initiative,” Halvorson added. Any celebration will follow results from our work.”

The Institute for Clinical Systems Improvement (ICSI) is providing staff support for the collaborative. ICSI is facilitating topic-specific work groups for Safest in America. According to Gordon Mosser, M.D., executive director, “ICSI is pleased to have the opportunity to contribute its expertise in managing cross-organizational collaboration. Hospital safety is an ideal topic for collaborative improvement work. The effort will be strengthened and accelerated by the synergy that we have gained from joining together.”

The Journal of the Hennepin and Ramsey Medical Societies

Clinical and operational leaders from member organizations have met to identify potential projects. Ideas selected for initial work relate to such high-risk processes as operating room procedures and medication administration—efforts that would make the region safer if standardized across organizations. The operations group will continue to meet monthly to oversee the work of the teams and guide the development of future projects.

The first project will focus on reduction of harm from medication errors. The second project will focus on the elimination of wrong site surgeries. The group has identified potential future projects as well.

The medication error reduction project launched January 24. Mark Thomas, M.S., R.Ph., Children’s Hospital and Clinics pharmacy director, will lead the collaborative. Teams from each organization include a cross section of clinicians and hospital staff who will develop common outcome measures.

“We hope to identify and implement initial changes very quickly,” says Thomas. The group plans to reduce harm related to medication errors by working collaboratively to standardize protocols and processes related to: • The use of high-risk drugs (one or two will be selected to start); • The use of medication ordering abbreviations; • And, the use of pediatric medications frequently associated with dosing errors.

In addition, the group plans to establish a mechanism to use local expertise among collaborating hospitals to conduct a peer-reviewed assessment of an identified list of practice recommendations at participating hospitals.

Plans are underway to roll out the surgical site marking collaborative this spring. Goals include eliminating harm to surgical patients resulting from clinicians performing the wrong procedure, performing the procedure on the wrong surgical site or on the wrong person.

Toward that end, the group will seek to create and implement standard processes to: • Identify the correct surgical site; • Identify the correct level or body part; and • Identify the intended procedure.

In addition, each hospital will define a patient identification process that is consistent with the needs of their organization.

Since the publication of the Institute of

MetroDoctors

Medicine’s reports, To Err is Human in 1999 and Crossing the Quality Chasm in 2001, patient safety has become a high priority for the public and within the health care industry. The organizations involved in Safest in America are committed to working together for the benefit of all patients. As Hugh Smith, M.D., chair of Mayo Clinic’s Board of Governors put it, “We

all believe patient safety is a critical issue. We are rolling up our sleeves and doing something about it in a coordinated way.” ✦ Alison Page is Fairview Vice President, Patient Safety, and Chair, Operations Group, Safest in America.

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March/April 2002

9

Minnesota Alliance for Patient Safety

I

IN JUNE 2000 the Minnesota Hospital and

Healthcare Partnership, the Minnesota Medical Association, and the Minnesota Department of Health joined forces to create the Minnesota Alliance for Patient Safety (MAPS), a statewide forum of key patient safety stakeholders to coordinate and further advance patient safety in Minnesota. MAPS is a public-private initiative, which includes more than 50 Minnesota health care organizations representing academia, health plans, provider networks, accrediting organizations, regulators, peer review organizations, professional associations, pharmacy, license agencies, and other organizations that work together in a noncompetitive fashion to improve patient safety practices in the delivery of health care.

MAPS was created to promote optimum patient safety through collaborative and supportive efforts among all participants of the health care system in Minnesota.

MAPS serves as a network of organizations for gathering and disseminating patient safety information relevant and pertinent to Minnesota. MAPS members share patient safety information about the work within their organization. The key to MAPS success is its ability to serve as a leadership forum to encourage dialogue and discussion among such a diverse group of stakeholders about issues and solutions that affect patient safety.

MAPS identifies and coordinates specific projects that significantly impact patient safety.

The following are some of MAPS accomplishments: • Developed and disseminated the brochure Redefining the Culture for Patient Safety, which explains the key concepts in the study of patient safety and offers changes

to our language regarding patient safety.

The patient safety brochure, now being used in 15 states, is available on MHHP’s website at www.mhhp.com.

• Developed MAPS website to disseminate patient safety resources and tools throughout Minnesota (www.mnpatientsafety.org).

• Supported amendments to the peer review statute, which was instrumental in getting the revisions signed into law during the 2001 Legislative Session, which will prevent medical accidents by allowing organizations to learn from one another.

• Successfully assisted national organizations with planning the Annenberg III conference Let’s Talk-Communicating Risk and Safety in Healthcare held May 16-18, 2001.

• Successfully convenes key patient safety stakeholders to focus on changing and improving the culture for patient safety of its representative organizations.

It is encouraging to reflect on the successes of MAPS, but the work is just beginning. As the coalition looks ahead it will begin focusing

on future projects that will impact patient safety.

Some of these projects include: • Commission an expert panel task force to review the Vulnerable Adult Act and recommend revisions as appropriate to enhance the culture of patient safety and reporting.

• Develop a patient/consumer educational brochure to fully inform patients and encourage full participation with health care decisions.

• Collaborate with Midwest Medical Insurance Company and National Patient Safety Foundation to disseminate Annenberg III learnings through an educational video to assist caregivers in communicating with patients and families after unanticipated outcomes.

• Develop a white paper with recommendations on a data reporting and measurement strategy for patient safety in Minnesota.

• Enhance MAPS website to be a primary patient safety resource for Minnesota health care organizations.

• Identify and disseminate proven safe practices statewide.

• Identify and disseminate principles for procurement and use of technology as it relates to patient safety.

MAPS recognizes that there are many specific patient safety initiatives underway locally and nationally as well as specific hospital programs. MAPS role is to coordinate and collaborate with these efforts and offer its unique features, such as the benefits of a public-private partnership and its broad-based membership and expertise, in order to facilitate patient safety efforts throughout Minnesota. ✦ Tania Krueger is coordinator for the Minnesota Alliance for Patient Safety.

B Y T A N I A K R U E G E R , M . B . A . , P. T.

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March/April 2002

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

MHHP Taking a Leadership Role in Patient Safety Initiatives

P

PATIENT SAFETY IS A MAJOR priority for

Minnesota hospitals. The publication of the Institute of Medicine report, “To Err is Human: Building a Safer Health System” released November 1999, strengthened the mandate to improve patient safety and reduce the number of preventable events. Minnesota hospitals’ commitment to safety and quality was demonstrated when Minnesota ranked fourth in the nation for providing quality care to Medicare patients.1 The Minnesota Hospital and Healthcare Partnership (MHHP) has committed to improve patient safety through efforts such as implementing a Patient Safety Committee and participating in the Minnesota Alliance for Patient Safety (MAPS).

The MHHP Patient Safety committee, chaired by Steven Kleinglass, acting director and chief operating officer at the Veterans Affair Medical Center, include key patient safety stakeholders from MHHP facilities. The committee will effect change by developing public policy to advise and advance policies, taking a leadership role in Minnesota and championing leadership to improve the culture in MHHP member facilities, and collaborating with MAPS to disseminate successful practices and patient safety resources.

Some successful activities to date include: • Developed a standardized model communication policy to guide care providers with communicating unanticipated outcomes to the patient and family.

• Supported revisions to the Minnesota Peer Review Statute that were signed into law May 17, 2001. This law paves the way for MHHP’s web-based patient safety regis-

•

•

try. This registry will allow hospitals to learn from one another with complete confidentiality. Aggregate data will be analyzed and trends identified in order to learn and prevent patient harm.

Developed and disseminated patient safety tool kits for leaders, management, and staff that includes valuable resources to create and sustain safety within health care institutions.

Established statements of belief on reporting systems for medical accidents.

•

Commissioned a task force to make recommendations on public reports to engage consumers with health care decisions. ✦

Tania Krueger is a director of health policy for the Minnesota Hospital and Healthcare Partnership.

MHHP is a trade organization representing Minnesota’s 142 hospitals and 20 health systems.

1

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MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2002

11

ICSI: Collaborating to Improve Minnesota Health Care

I

IN 1992 HEALTHPARTNERS (then Group

Health), Mayo Clinic, and Park Nicollet Clinic joined together to plan a new approach to improving health care in our state. HealthPartners and the Buyers Health Care Action Group supported the project financially. Within a few months, they inaugurated the Institute for Clinical Systems Improvement (ICSI), embodying their commitment to collaborate in the use of evidence-based medicine and continuous improvement methods to improve health care.

Over the past nine years, ICSI has grown.

Twenty-eight medical groups and 18 hospitals are now members. Half of Minnesota’s physicians practice in member organizations, which range in size from Family Practice Medical Center in Willmar—with seven physicians—to Mayo Clinic in Rochester. Metro area members include Park Nicollet Health Services, HealthPartners Medical Group, Family HealthServices Minnesota, Allina Medical Clinic, Quello Clinic, North Clinic, and many others. Recent joiners include St. Mary’s/Duluth Clinic Health System, Grand Rapids Clinic, and MeritCare in Fargo.

ICSI’s sponsorship has also expanded. Last March four additional health plans joined with HealthPartners to support the program. ICSI now has three principal sponsors— HealthPartners, Blue Cross Blue Shield of Minnesota, and Medica—and two associate sponsors—PreferredOne and UCare.

ICSI is governed by a board dominated by representatives from the member medical groups and hospitals. Eleven of the 17 board members represent organizations that provide health care directly. One board member represents patients, one represents an employer, and three represent

BY GORDON MOSSER, M.D.

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March/April 2002

the three principle health plan sponsors. The board hires the executive director, who is the seventeenth board member.

The primary purpose of ICSI is to accelerate improvement of the health care that its members provide to their patients. This is achieved through an annual cycle of commitment and action, required of all members as a condition of continued membership. Typical targets for

The primary purpose of ICSI is to accelerate improvement of the health care that its members provide to their patients. intensive improvement work are diabetes, coronary artery disease, preventive services, and waiting time to get appointments. Members that are not able to mount an organized program and make progress are asked to depart.

In their improvement efforts, the members are supported by each other and by the staff at ICSI. This support takes several forms. All new entrants participate in an 18-24 month orientation and training program that includes 32 classroom hours for physician leaders and quality improvement staff members. In accordance with each medical group’s and hospital’s wishes, this training may be followed up indefinitely with coaching by ICSI staff. ICSI also produces videotapes, audiotapes, and written materials for use by members. Many of the written materials are available on ICSI’s website at www.icsi.org.

MetroDoctors

The continuous improvement methods taught and fostered by ICSI are those pioneered

by Walter Shewhart, W. Edwards Deming, and J. M. Juran in arenas other than health care.

These methods emphasize the use of improvements to systems and processes, and not attempts to change individual physician behavior, as the most effective route to better health outcomes. Within the past 15 years these methods have been introduced into health care by Paul Batalden, M.D., who hails from Minnesota and now works at Dartmouth Medical School— along with Donald Berwick, M.D., of the Institute for Healthcare Improvement in Boston, Brent James, M.D., of InterMountain Health Care in Salt Lake City, and others. Within the past two years, the systems approach to health care improvement has received widespread attention in health care and in the general press in response to the Institute of Medicine’s two reports on the quality of health care in America, To Err is Human: Building a Safer Health System and Crossing the Quality Chasm.

As the ICSI members pursue care improvements, they often join together in topic-specific collaboratives, called “action groups.” The most popular action groups have been those aimed at achieving same-day access for physician appointments, and twelve member medical groups have achieved this goal in some or all of their clinics. ICSI has also conducted action groups on care for diabetes, hypertension, asthma, lipid disorders, and other diseases—as well as action groups on patient safety, preventive services, and management of change in organizations. Each action group follows a sequence of meetings, telephone conference calls, progress reports, and exchanges of information on improvement methods that have been successful. ICSI staff arrange for experts from around the country to meet with the participants.

The Journal of the Hennepin and Ramsey Medical Societies

The centerpiece of ICSI’s work on evidence-based medicine is the guideline program.

ICSI is best known for its guidelines, and many physicians have the impression that the guideline program is the whole ICSI program. Guideline production was, in fact, the whole of ICSI’s program in the early 1990s, but the balance of effort since 1997 has shifted from producing guidelines to using them for system-oriented improvement work. About two-thirds of ICSI staff time is now spent on using the guidelines as opposed to creating and maintaining them.

However, despite this shift, the guidelines continue to be the foundation for the rest of the program.

The collaboration has produced 50 clinical practice guidelines, which are publicly available on ICSI’s website. Topics include breast cancer treatment, atrial fibrillation, simple cystitis, and other commonly encountered clinical conditions. They are written by physicians, nurses, and other professionals in the ICSI member organizations. ICSI staff provides project management, document preparation, and other forms of support. All guidelines are updated at least every 18 months. All sponsoring health plans have endorsed the ICSI guidelines and ceased production of separate guidelines on topics covered by ICSI. The ICSI guidelines serve as reliable scientific statements of best health care practice, providing the basis for setting the aims to be pursued through systems improvement.

ICSI also provides clinicians with technology assessments, that is, syntheses of the medical evidence on given items of technology such as CT scanning for lung cancer screening, electron-beam CT for diagnosis of coronary artery disease, and genetic testing for breast cancer risk.

Ordinarily the topics of these reports are emerging items of technology about which clinicians in member organizations have requested systematic reviews of the literature in order to determine whether the items are effective and safe.

ICSI provides a venue for sharing and collaboration for improvement across all interested medical groups and hospitals in Minnesota and immediately adjacent areas. It is no longer an experiment. The success of ICSI members in improving care is demonstrated in over 20 articles published in peer-reviewed journals. ICSI continues to grow and to provide a model for how to improve care in other parts of the United States. Programs in Pittsburgh, upstate New MetroDoctors

York, Denver, and Seattle have been patterned in part after ICSI. In a time of commercially motivated competition and fragmentation, the effective collaboration realized through ICSI is a refreshing reminder of the collegiality and mutual support that used to be more common in medicine. The health care landscape has changed substantially over the past two or three decades, but we are regaining some of what was lost. There remains a great deal more to do and a great deal more to regain. ✦ Gordon Mosser, M.D., is Executive Director of the Institute for Clinical Systems Improvement.

Editor’s Note:Results of improvement efforts in ICSI medical groups can be found in the articles listed below. In all cases, the work was done using ICSI guidelines and methods of improvement taught by ICSI. However, the work was done by the medical groups and hospitals and not by ICSI or ICSI staff. The successes noted should be attributed to the member organizations of ICSI and not to ICSI itself.

Anderson RS, Healey ML. Immunization rates in children receiving diphtheriatetanus-pertussis and measles-mumpsrubella vaccines simultaneously. Journal of Clinical Outcomes Management 2000; 7(1):27-30. Park Nicollet Clinic.

Nyman MA, Murphy ME, Schryver PG, Naessens JM, Smith SA. Improving performance in diabetes care: a multicomponent intervention. Effective Clinical Practice 2000; 3(5):205-12.

Mayo Clinic.

O’Connor PJ, Quiter ES, Rush WA, Wiest M, Meland JT, Ryu S. Impact of hypertension guideline implementation on blood pressure control and drug use in primary care clinics. Joint Commission Journal on Quality Improvement 1999; 25(2):68-76. MinnHealth (St. Paul) and Northfield Family Physicians.

practice guideline on outcomes and costs of care in an HMO. Joint Commission Journal on Quality Improvement 1996; 22(10):673-82. HealthPartners Medical Group Clinics.

Rolnick SJ, Hyer B, Jackson J, Loes L. Implementation of an active management of labor guideline in a managed care setting. Quality Management in Health Care 1998; 6(3):35-42.

Sperl-Hillen J, O’Connor PJ, Carlson RR, Lawson TB, Halstenson C, Crowson T, Wuorenma J. Improving diabetes care in a large system: an enhanced primary care approach. Joint Commission Journal on Quality Improvement 2000; 26(11):61522. HealthPartners Medical Group.

Stroebel RJ, Broers JK, Houle SK, Scott CG, Naessens JM. Improving hypertension control: a team approach in a primary care setting. Joint Commission Journal on Quality Improvement 2000; 26(11):623-32. Mayo Clinic.

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The Journal of the Hennepin and Ramsey Medical Societies

March/April 2002

13

Intensivists Provide Unique Dimension of ICU Care

O

OVER THE LAST 50 YEARS, intensive care

units (ICUs) have dramatically improved care for critically ill patients. In 1958, only about a quarter of larger community hospitals in the United States had an ICU. By 1997, more than 5,000 ICUs were in operation across the country, according to the Society of Critical Care Medicine. More recently, ICUs have begun

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March/April 2002

implementing intensivist programs to provide more consistent, specialized care teams in the complex area of acute care.

HealthEast Care System, along with Pulmonary & Critical Care Associates (PCCA), recently rolled out an ICU Service Line, commonly referred to as an intensivist program. It offers a higher level of patient care, with boardcertified critical care physicians, or intensivists, managing and staffing the ICUs at St. John’s Hospital in Maplewood and Woodwinds Health Campus in Woodbury. These intensivists are board certified in internal medicine, pulmonary disease and critical care medicine. At Woodwinds, the care provided by intensivists is complemented by acute care nurse practitioners (ACNP) staffing the ICU 24 hours per day.

ACNPs specialize in critical care, and have extensive experience in critical care nursing. The intensivists also help establish a cohesive ICU team that, in addition to ACNPs, includes social workers, pharmacists, nutritionists, nurses, respiratory therapists, and chaplains.

In numerous studies, intensivist care in the ICU has been proven to enhance patient outcomes, according to Linda Funk, M.D., president of PCCA. “Most ICUs don’t have intensivists managing care. When they do, the data is clear that patients have fewer complications, spend less time in the ICU, and have lower mortality rates.” Due to positive results of intensivist programs across the country, a national patient safety initiative, led by Fortune 500 companies, recommends the intensivist model as a standard for ICU patient care.

“Studies have shown that around 500,000 patients die in ICUs every year,” says Dr. Funk.

“By implementing intensivist models in cities around the country, around 50,000 lives could be saved each year.”

With the increasing complexity of care being delivered in our ICUs, along with the limited number of beds, we need to make sure we are utilizing them as effectively as possible. This is the goal of the intensivist program.

By providing care only in the ICU, intensivists help save valuable time for ill patients. In a traditional ICU, nursing staff would have to call the attending physician, and then wait for a return call before treatment changes could be made. Intensivists at HealthEast have committed to returning stat pages within five minutes during off-hours, reducing lag time before patients are able to receive evaluation and treatment.

The role of the intensivist is to enhance the care of the patient, not replace the role of the primary physician. The intensivist program operates under a “mandatory consult model of care,” which allows critical care physicians to determine patient placement and care priorities. Primary care physicians are encouraged to participate in the co-management of the patients’ critical needs, while the intensivists continue to collaborate with other specialists.

“We won’t infringe on the primary care physician’s role, and the degree of our involvement will be determined on a case-by-case basis. Primary care physicians will continue to have the input they desire. They also have the option of handing off care while their patient is in the ICU as it is difficult to make multiple daily rounds necessary on the critically ill. We will be involved with each patient throughout their ICU stay and manage multidiscipline team rounds, conducting family conferences, etc. We will have some level of involvement in the care of all non-cardiac patients at St. John’s and Woodwinds,” explains Dr. Funk.

Two areas of focus for intensivists include

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

continuity of care and improved communication with primary care physicians. Throughout a patient’s stay and at the time of discharge from the ICU, there is continued communication with the primary care physician, whether or not the physician has been involved in the ICU care.

Also, the intensivist gives the primary care physician an assessment when each patient leaves the ICU. The intensivist model supports frequent family conferences, which improve communication between the health care team, the patient and the family. Rebecca Wong, Clinical Director at St. John’s ICU says, “The model provides an environment for continuous learning, by using research-based practice, ongoing teamwork, and quarterly critical care conferences, with case studies. The intensivist model is based on best practice. Improving patient outcomes is why we are all here.” ✦ Robert J. Beck, M.D., is the vice president of medical affairs at HealthEast Care System.

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The mission of Hennepin County Medical Center’s CME program is to provide organized, planned education activities to help physicians improve the delivery of medical care.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2002

15

COLLEAGUE INTERVIEW

Kathleen D. Brooks, M.D. Editor’s Note: Kathleen Brooks, M.D., is the Minnesota Carrier Medical Director for Part B Medicare, Wisconsin Physician Services. She continues to do part-time clinical work for HealthPartners Medical Group. Dr. Brooks teaches at the University of St. Thomas in the Physician Leadership College, and is a Clinical Associate Professor in the Department of Family Practice at the University of Minnesota.

The questions for this interview were provided by Drs. Thomas Dunkel, Carl Burkland, Blanton Bessinger, Robert Moravec, and Lee Beecher.

Q A

What are any real chances for correction of the geographical disparity between states in regard to Medicare payments?

This has been a major issue for Minnesota providers since the program’s inception. The AAPCC payments were established based on historical medical costs that were considerably less in Minnesota than in other states such as Florida. In simplest terms, in order to correct the geographical disparity, either the total pot of money available for Medicare payments increases, or the existing pot is reallocated.

If the formula were changed to reallocate money in a manor more favorable to Minnesota, other states would lose money. The formula change would require Congressional action, and would logically be vigorously resisted by states such as New York, Florida and California, that have large Congressional delegations. Therefore, Minnesota has been unable to affect change.

In this time of economic downturn, the pot of money available for Medicare is limited. Short of a large infusion of money into Medicare by Congress, the pot will not be increasing. With all the competing demands on federal dollars, it is unlikely that Congress at this time would choose to infuse large amounts of cash into the program specifically to correct the disparity. Therefore, I don’t see this correction happening soon.

What are your insights into how Medicare will look in five to ten years?

In 2001, Medicare spent approximately $238 billion. This accounted for approximately 13 percent of the federal budget, and about 19 percent of the total national spending for personal health services. Currently the program involves 40 million beneficiaries. In the next decade, due to the

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March/April 2002

baby boomers, there will be a substantial acceleration in the number of Medicare beneficiaries. The first wave will become eligible in 2010. Thereafter, increasing numbers of seniors will become eligible.

Actuarially, we can calculate the increased costs to the program for the entrance of the baby boomers. However, another significant pressure is the development and dissemination of new medical technology. The financial impact on the Medicare program of evolving technology is substantial, but not easily calculable. The American public has a prodigious appetite for this technology.

This will create enormous financial pressures on the program. It appears that we will be operating with deficit federal funding for close to the next decade, according to economists today. Therefore, it is extremely unlikely that the Medicare program will receive any substantial increase in funding, and the money available will have to be spent across a much larger population.

Given these financial realities, it is unlikely we will see any kind of substantial expansion of benefits. It is questionable whether Medicare will be able to cover the range of services currently covered. Despite its unpalatability, Congress will need to consider instituting cost control measures such as stringent utilization review, case management, and protocol-driven medicine. Instead of fairly automatic incorporation of new technology into the benefit set, the Medicare program will have to institute more careful evaluation of such technologies, including much more emphasis on cost-benefit analyses than exist today. New technologies will also be compared to existing less expensive modalities.

In the next five to 10 years, the Medicare program will likely phase out local contractors, and contract with a few large companies to administer the program across the country. The original premise of administering Medicare locally to ensure that the program reflects local standards of practice will no longer apply. National Coverage Decisions will replace the current Local Medical Review Policies developed in individual states.

This will be necessary to exert financial order and control on the program.

Instead of a program where medical practice drives the finances, it appears we will move to a program where finances will heavily influence the medical services offered.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

The 2nd IOM Report “Crossing the quality Chasm” recommends changing our methods of health care delivery—especially for the top 20 chronic conditions. This includes coverage for group care, e-mail or phone care, etc.

I would like to know what you think of this recommendation and what role the government programs like Medicare can play in this change. What is your influence as a practicing physician representative and medical director?

Can you speak out on the recommendations or are you somewhat restricted?

Medicare, as a defined benefit plan, established payment structures for physician services based on prevailing patterns of care delivery at the time.

The model was one of acute illness management based on direct face-toface contact with the patient. It operated on the premise that the physician personally performed the billable services. Medicare payments were made for illness management, not preventive service.

As medicine has evolved, Congress has attempted to “retrofit” the Medicare payment system to encompass modern practice patterns. Increasing types of preventive services have become benefits. Payments for independent services of midlevel providers, including physician assistants, nurse practitioners, and certified nurse specialists have been incorporated into the program. The use of “incident to” provisions has been expanded to allow payments for auxiliary personnel performing services within certain rules. Telemedicine payment rules have been developed.

The medical community can certainly argue that the Medicare program has moved very slowly and cautiously in these areas, and has not shown great flexibility in allowing latitude for the rapid development of creative care models. However, perhaps health care providers have sometimes had unrealistic expectations of a large government program that pays 900 million claims per year for 40 million patients. It must operate in a deliberative fashion.

Looking forward, health care delivery continues to evolve, focusing now on issues such as quality of care, chronic care delivery, patient safety and new technology development. The Medicare program continues to assess how to incorporate new models of care delivery into the payment structure. Currently CMS is evaluating group visits, as there is no ready payment structure for such care, and it has been shown to be effective in chronic care management.

My role as Carrier Medical Director allows me to influence this process in several ways. First, as a practicing physician and representative of Medicare in this community, I am expected to keep current on evolving care delivery patterns. I give input to CMS directly and through national Carrier Medical Director meetings and workgroups. I respond to draft regulatory changes before they are finalized. I inform CMS of program restrictions that may affect access to care. Conversely, my job involves interpreting Medicare regulations for the medical community and applying them in coverage and policy decisions. As the Medical Director for the contracted Medicare carrier, I make decisions about coverage in ambiguous areas where CMS has not issued definitive rulings. This gives me the opportunity to engage in the process of setting and administering policy for evolving health care issues.

Do you think there is a too strict interpretation of the definition of home bound? In that a client will not be considered home bound and therefore eligible for Medicare services if they leave their apartment for any reason—i.e. to go downstairs in their apartment to eat at a congregate dining site or just walk around the block for exercise.

This benefit was designed for Medicare beneficiaries who are truly unable to leave their homes. It was not designed for a larger, less restrictive definition, which would include patients able to walk around the block. That would be a different benefit, requiring a very significant increase in allocation of overall dollars to Medicare spending. At this time, the public and Congress do not appear interested in allocating substantially more money to the Medicare program. Alternatively, decreasing spending in other areas of the Medicare program could fund that broader benefit.

Why doesn’t Medicare Part B cover home making services, which are essential for home bound client’s well-being and recovery? (i.e. doing the laundry, changing the bed, going to the grocery store or pharmacy?)

Medicare Part B benefit covers skilled nursing care and home health aide services for help with personal care. The other services outlined in the question are not covered under this medical benefit. Medicare is a defined benefit plan. If the program’s benefits were expanded to cover a broader range of services, the same alternatives discussed in the above question would have to be considered – either expansion of funding or reallocation of resources.

Why aren’t home bound blood draws covered by Medicare especially in northern climates during the winter months?

If the Medicare beneficiary is eligible for skilled nursing care visits, the nurse may draw blood. However, if the patient simply needs blood draws and not any other skilled nursing service, this implies that the patient has a higher level of function and the program does not include this benefit.

We have seen a delay in receiving payments from secondary payers—with Medicare primary—stating delay in receiving information from Medicare, is this true?

Wisconsin Physicians Service was implementing a new process with the Coordination of Benefits Contractor for Medicare. Service provided by the Coordinator of Benefits Contractor was affected by the disaster to the World Trade Center on September 11, 2001. They were located in lower Manhattan and required to evacuate and move operations to a different location. As of 10/22/01, all COB activities have returned to normal at their Manhattan facility, so we anticipate the problem to be resolved.

(Continued on page 18)

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2002

17

Colleague Interview (Continued from page 17)

as the Part B Medical Directors for Wisconsin, Illinois and Michigan. We have very active Carrier Advisory Committees composed of physicians from most of the specialties. We try to use that combined medical knowledge to make rational medical decisions within the boundaries of the Medicare program.

Having been on both sides of medicine, as a practicing physician and now as a medical director, how has your medical background and experiences contributed to your current position?

My experiences both past and present as a family physician help ground me in this job. I understand the frustrations of providers trying to do their best to be their Medicare patients’ advocates. I value that role. I have been an owner of a six-doctor practice and remember regulatory burden. I know the frustration of trying to understand the expectations of a myriad of payers.

I’ve also had the privilege to spend time during a Bush Fellowship with a group of very impressive government colleagues. They helped me understand the constraints and ethical obligations inherent in managing large government programs with significant Congressional oversight. That knowledge helps me as an employee of a government contractor.

I sit on the edge, representing and defining the Medicare program to my medical colleagues. Conversely, I represent a medical perspective to my government colleagues. In this middle ground, I am called upon to interpret and provide coverage and policy decisions. I believe my background and previous work experience helps me to define issues and better understand the impact of my decisions.

I am fortunate to collaborate with three other physicians who serve

Closing Comments: I’ve enjoyed the opportunity to address these questions. They have ranged from broad philosophical concerns to specific Medicare coverage issues.

Originally, when I began to venture away from regular family practice, it intrigued me to do a combination of work. Some of my days would be filled with patient care. Some would involve administrative duties where the goal involved creating a better system and infrastructure for delivering care. From that vantage point, I became fascinated by the role of government in the delivery of healthcare, and that led to my Bush Fellowship.

Now the main thrust of my work is to operationalize health policy. This position allows me to be an insider into the workings of a huge public program, and to try to provide a solid medical perspective to the decisions made. In order to be competent at this job, I need to collaborate with the medical community and to retain my grounding and roots in medicine. I need to be able to call on my medical colleagues for advice. I will continue to ask for this help as we address payment issues for evolving healthcare systems and technologies. ✦

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MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Highlights of the Code of Medical Ethics of the American Medical Association Section E-5.00: Opinions on Confidentiality, Advertising, and Communications Media Relations In this article on the AMA’s Code of Medical Ethics, we turn to the section of the Code that encompasses a wide array of issues related to communication between physicians and patients, colleagues, and the public. Specifically, Section 5.00 includes guidelines on confidentiality, advertising, and media relations. For each

of these three topics, we will trace a brief historical evolution of ethical guidelines and discuss their current application.

Confidentiality and the Code Central to communication involving physicians is the concept of confidentiality, which is often held to be the basis of patient trust in the medical profession. It is not surprising that the Code discusses the obligation to protect the confidentiality of patient information in considerable

detail, along with an exploration of instances when a breach of confidentiality may be permissible. The legal issues surrounding confidentiality and privacy are of great concern to many physicians, particularly since the release of the Health Insurance Portability and Accountability Act (HIPAA) regulations. Although these legal issues warrant further discussions, the focus of the Code is to specifically provide guidance for physicians from an ethical perspective.

Confidentiality had a prominent place in the 1847 Code of Ethics where it was identified

BY FRANK A. RIDDICK, JR., M.D. AND AMY M. BOVI, M.A.

(Continued on page 20)

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The Journal of the Hennepin and Ramsey Medical Societies

March/April 2002

19

AMA Code of Ethics (Continued from page 19)

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as an important duty physicians owed to their patients: “Secrecy and delicacy, when required by peculiar circumstances, should be strictly observed; and the familiar and confidential intercourse to which physicians are admitted in their professional visits, should be used with the most scrupulous regard to fidelity and honor.” Given its roots in the Hippocratic tradition, confidentiality is a concept with a rich history unlike any other ethical principle in the Code. In fact, looking at the Hippocratic Oath, the similarity to the 1847 Code is striking: “And whatsoever I shall see or hear in the course of my profession, as well as outside my profession in my intercourse with men, it is be what should not be published abroad, I will never divulge, holding such things to be holy secrets.”

In the early development of medicine as a profession, physicians also were greatly concerned with their interaction with colleagues and the original Code provided detailed guidelines on consultations. Confidentiality also played an important role in this context, such that “All discussions in consultation should be held as secret and confidential” and the presence of another physician should never compromise the confidential nature of the patient-physician conversations.

When the Code was re-structured in 1957 such that ten basic Principles were identified from which all other guidelines flowed, Principle 9 contained a statement very similar to the 1847 language: “Confidences concerning individual or domestic life entrusted by patients to a physician…should never be revealed unless their revelation is required by the laws of the state.” However, it is important to note that unlike the 1847 version, circumstances in which a physician could disclose information also were identified: “Sometimes…a physician must determine whether his duty to society requires him to employ knowledge obtained through confidences entrusted to him as a physician, to protect a healthy person against a communicable disease to which he is about to be exposed.” This particular exception to confidentiality marks a clear concern for public health that was not so expressed in the original Code.

Also, the 1957 edition advised physicians that, in determining the extent to which confidentiality should be protected, they should con-

The Journal of the Hennepin and Ramsey Medical Societies

sult the laws governing the jurisdiction in which they practiced. This statement illustrates another considerable change since the 1847 Code— when medical ethics does not yield clear guidance, physicians should defer to the law.

In the current edition of the Code, confidentiality continues to be at the basis of the patient-physician relationship. Principle IV states in part that “A physician shall… safeguard patient confidences and privacy within the constraints of the law.” This statement highlights the importance of confidentiality but also acknowledges the existence of legal limitations.

This balance between ethics and law is reiterated in Opinion 10.01, “Fundamental Elements of the Patient-Physician Relationship,” which generally highlights what a patient should expect when seeking treatment from a physician, and specifically states that “The patient has the right to confidentiality. The physician should not reveal confidential communications or information without the consent of the patient…”

In some situations, the patient should be aware that the law or welfare of the patient or public interest may require the physician to divulge confidential patient information.

Finally, Opinion 5.05 “Confidentiality” echoes previous editions of the Code: “The information disclosed to a physician during the course of the relationship between physician and patient is confidential to the greatest possible degree.” Similar to 1957 edition, the current Code also identifies circumstances in which a physician may have to breach confidentiality, namely when the patient presents a probable threat of serious harm to him or herself or others, or when the condition being treated is a communicable disease or results from gun shot or knife wounds. The specific examples that are given remind us of the general public health exception and again recognize the importance of law and its enforcement. Seven other Opinions in Section 5.00 address more specific aspects of confidentiality, from confidential care for minors to HIV status on autopsy reports, as well as the protection of health information when using electronic means of communication.

It is interesting to note that, until recently, the Code was silent on privacy. Yet, privacy and confidentiality are commonly interchanged.

Generally, a distinction can be drawn between privacy as a legal right that protects a person against unwanted intrusions and confidentialMetroDoctors

ity as an ethical concept that protects the special nature of information that is shared between a patient and a physician. Recently, however, the concept of privacy was included in the 2001 revision of the Principles of Medical Ethics and last December the AMA adopted a Report of the Council on Ethical and Judicial Affairs on “Privacy in the Context of Health Care.” These new developments are another manifestation of the interplay between ethics and law.

The Journal of the Hennepin and Ramsey Medical Societies

Advertising and the Code Section 5.00 also includes guidelines regarding advertising as a means by which physicians relay information to the public. Although the Code contains only three policies on this matter, ethical guidelines on physician advertisement have a long and tumultuous history.

(Continued on page 22)

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March/April 2002

21

NATIONAL DOCTORS DAY March 30, 2002 marks the 69th anniversary of Doctors Day. The setting aside of a day to honor physicians is credited to Eudora B. Almond, the spouse of a physician, who suggested that the Barrow County (Georgia) Medical Society Auxiliary recognize the hard work and dedication of the physicians in her community.

Since that time, Alliances and health care organizations throughout the nation continue to show their appreciation on this day for the role physicians play in caring for patients, their dedication to medicine, and to improving the public health.

The date, March 30, was purposefully selected to commemorate the first use of ether anesthesia in surgery on March 30, 1842 by Dr. Crawford W. Long. The red carnation is the official flower of Doctors Day.

HAPPY DOCTORS DAY MARCH 30, 2002

Your staff at the Hennepin and Ramsey Medical Societies,

22

March/April 2002

AMA Code of Ethics (Continued from page 21)

In 1847, the Code was unambiguous and stated that many public advertisements were “derogatory to the dignity of the profession” when directed toward patients with specific diseases, offering free advice and medicine to the poor, inviting laymen to be present at operations, boasting cures and remedies, or flaunting certificates of skill or success. Such advertisements were viewed as highly reprehensible or only worthy of practitioners without scientific training — or “empirics.”

By 1957, there was a different stance on advertising, which became viewed as the act of making information known to the public and was not in itself unethical. Telephone listings, office signs, or professional cards were all identified as means that physicians could use. However, the 1957 Code considered solicitation to be unethical and barred physicians from using persuasion or influence to obtain patients, a practice that was viewed as commercializing the nature of medical services and, therefore, undermining physicians’ professionalism.

Of the three current policies related to advertisement, Opinion 5.02, “Advertising and Publicity,” has the most notable history as it stemmed from a 1980 order from the Federal Trade Commission (FTC) to the AMA to stop imposing restraints which were considered a violation of anti-trust laws. Another concern that continues to be expressed in the Code relates to the direct advertisement of drugs to consumers. In fact, this issue may be reminiscent of physicians’ suspicion of non-medically trained providers seeking to make a profit at the expense of patients in need of medical attention.

Media Relations and the Code Finally, section 5.00 includes some guidance on the dissemination of information to the media.

In the 1957 edition of the Code, there were strict guidelines against patient solicitation but also an acknowledgement of the value of accurate health and medical information. This tension led to a resolution from the Judicial Council urging local societies to establish a “publicity committee” that would give to the press accurate medical information of interest to the public.

Opinion 5.04 in the current edition of the Code considers a much narrower aspect of me-

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dia relations, namely the dissemination of patient information to the media. The Opinion emphasizes that before any personal information can be released, the patient’s consent generally must be obtained.

Conclusion This brief historical review of ethical guidelines applicable to various means of communication and the analysis of current Opinions included in Section 5.00 once again illustrate that many of the ethical concerns confronting the medical profession have a long history, none more so than confidentiality with its roots in Hippocratic medicine. However, it is also interesting to see how social or economic changes in the practice environment affect ethical standards. For example, the medical profession cannot afford to overlook its responsibility toward public health or its need to adapt to new technological means of communication. Such evolution makes clear that a code of conduct is a living document that needs to be revisited from time to time. Finally, our exploration of the various sections of the Code of Medical Ethics continues to reveal a careful balance between ethical principles and legal standards, which together guide physicians’ conduct in meeting the expectations of their patients as well as those of the public at large.

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. Amy M. Bovi, M.A., is Staff Associate, Council on Ethical and Judicial Affairs.

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The Journal of the Hennepin and Ramsey Medical Societies

3rd Bioterrorism Seminar Held

B

“BIOTERRORISM AND THE New Triage: Ethical, Operational, and Policy Issues in Community Preparedness” was held on Tuesday, January 15, the third in a series of seminars on bioterrorism co-sponsored by the Hennepin and Ramsey Medical Societies, Minnesota Medical Association and Hennepin County Medical Center since the September 11 attack on America.

Additional sponsors of this seminar included the Minnesota Center for HealthCare Ethics, Minnesota Department of Health, Minnesota Public Health Association, and the Minnesota Emergency Medical Services Regulatory Board.

Kenneth Kipnis, Ph.D., Professor of Phi-

losophy, University of Hawaii at Manoa, was the keynote speaker, calling on the professions to “think differently” about how to handle the wounded in the event of a bioterroristic attack.

A panel discussion followed his thought-provoking presentation; the panel was comprised of Aggie Letheiser, MPH, Assistant Commissioner, Minnesota Department of Health; Linda Hart, RN, MPH, Director of Quality Improvement, Fremont Community Clinic; and John Hick, M.D., Chair, MDH Terrorism Clinical Care Workgroup and Emergency Medicine physician at HCMC. Karen Gervais, Ph.D., Director, Minnesota Center for HealthCare Ethics, served as the moderator. A videotape of all three seminars is available for loan through the Hennepin and Ramsey Medical Societies. Contact Nancy Bauer at 612623-2893 for a copy. ✦ The panel consisted of: Kenneth Kipnis, Ph.D., John Hick, M.D.,

Kenneth Kipnis, Ph.D., keynote speaker.

Aggie Letheiser, MPH, Linda Hart, RN, MPH, and Karen Gervais, Ph.D.

“Connections” Mentoring Program HMS and RMS Continue Participation in U of M Medical Alumni Society’s “Connections” Mentoring Program

Brian Ip, M.D., and Tori Myslajek, medical student.

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Jeanne Nugent, medical student and Mona Grotte, M.D.

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2002

23

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

Déjà Vu All Over Again RMS-Officers

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

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

Brenda Andrewson, Alliance President Brent R. Asplin, M.D., AMA Young Physician Section Blanton Bessinger, M.D., MMA Past President Kenneth W. Crabb, M.D., AMA Alternate Delegate Robert W. Geist, M.D., Ethics & Professionalism Council Chair *Michael Gonzalez-Campoy, M.D., Education Resource Council Chair Frank J. Indihar, M.D., AMA Delegate William E. Jacott, M.D., U of MN Representative Melanie Sullivan, Clinic Administrator Donald B. Swenson, M.D., Sr. Physicians Association President *Lyle J. Swenson, M.D., Public Policy Council Chair *Russell C. Welch, M.D., Communications Council Chair *Also elected RMS Board Member RMS-Executive Staff

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

24

March/April 2002

T

TO QUOTE A FAMOUS BAND, “What a

long, strange trip it’s been.” Of course, the Grateful Dead were referring to their own bizarre journeys but their words resound in my head every time I think about healthcare over the past 10 years. The business of healthcare is much like the weather, the only thing one can be assured of is that it is going to change. Also, like the weather, it seems that no matter how hard we try, we really don’t have much control over these changes. However, I think that we, as physicians, no matter how frustrating it may seem, need to continue to exert our influence on the forces behind these changes.

When I first came into practice 11 years ago, the medical landscape was still pretty much that of a cottage industry. There were a few large, multi-specialty clinics around but, for the most part, physicians practiced in small, self-owned groups. The scene was shifting from a traditional fee-for-service model to more and more managed care, with capitated contracts becoming more ubiquitous. Unfortunately, the cost of healthcare was escalating at ever increasing rates and there was pressure to try to drive these costs down. Health insurance companies began changing from traditional indemnity plans to managed care plans, with utilization review, prior authorization, and discounted contracts with selected physician groups and hospitals.

The Clinton administration tried and failed to restructure the healthcare industry and ultimately left that work to be done by the states.

In Minnesota, the Legislature, essentially behind closed doors and with no physician input (though with plenty of help from the HMO sector), created Healthright, which would eventually become MinnesotaCare. This created a very uneven playing field and allowed the healthcare business in Minnesota to consolidate into basically three superpowers with huge leverage over physician groups. This, coupled with the 1996 Balanced Budget Act (with its decrease in Medicare reimbursements), left many medical practices groping to stay in business. What followed was a huge movement to mergers and buyouts by medical practices to try to level the

MetroDoctors

playing field, and within a few years the cottage industry vanished. We now have huge numbers of physicians working either in an employed setting, i.e. HealthPartners, Allina, HealthEast, or as part of a large, single specialty group, i.e.

FSHM, Minnesota GI, Summit Orthopedics.

It is debatable whether the goal of “better quality at lower costs” was truly accomplished by this drastic re-structuring of the landscape.

Several forces are now acting on the healthcare market to bring about yet more change. The managed care model has picked most of the low hanging fruit and the cost savings of that model are no longer evident, as seen by double-digit rates in medical inflation. Much of this increase is being fueled by a combination of increased utilization by patients and by increased hospital and pharmaceutical costs.

Many patients are not satisfied with many of the restrictive clauses in their managed care contracts and their inability to seek care outside a small network of hospitals and physicians and are opting for broader reaching plans. There is a movement to try to make the patient more accountable in the costs of his/her care and Medical Savings Accounts (MSAs) are gaining more acceptance in the marketplace. The Attorney General has stepped in and taken a closer look at the practices of the superpower health plans and has acted to correct the deficiencies he found in those systems. Allina has been broken up into its original components of Medica Health Plan and the Allina Hospital System, and their respective roles in this marketplace will undergo changes. It is my understanding that the AG’s office is now looking at HealthPartners.

All of this leads to the conclusion that this will be a critical year in healthcare and the impact on physicians may be profound. Two arenas will need particularly close monitoring. First, (Continued on page 26)

The Journal of the Hennepin and Ramsey Medical Societies

132nd Annual Meeting of the Ramsey Medical Society Dr. Peter H. Kelly Installed as President Dr. Joseph H. Tashjian Receives RMS Community Service Award

R

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can College of Radiology. He is a frequent lecturer on detecting breast cancer and on chest diseases and he assists radiology residents with preparing for their oral exams.

The evening entertainment was provided by the Singsations who sang and danced to a wide range of sparkling Broadway songs to the swinging tunes of jazz and the blues. ✦ Dr. Peter Kelly (right) is installed as the new president by Dr. Robert Moravec.

Colleagues from St. Paul Radiology, P.A. and Dr. Peter Kelly congratulate Dr. Tashjian on receiving the Community Service Award.

(From left): David Kispert, M.D., Kay Savik (Dr. Tashjian’s spouse), Carl Bretzke, M.D., Joseph Tashjian, M.D., David Eckmann, M.D., Linda Bohn, M.D., and Peter Kelly, M.D. Outgoing President Dr. Robert Moravec receives the Presidential Plaque from Dr. Lyle Swenson, a past RMS president.

Dr. Tashjian also has a long record of contributions to the Guthrie Theater serving on the Board of Directors and on many committees including the Tyrone Guthrie Circle, the Capital Campaign Major Gifts Committee, and the Beth Jordan, M.D., James Jordan, M.D., Guthrie Heritage Society. His entire family is inJohn Mageli, M.D., with spouse, Louise, volved in supporting the Guthrie Theater. Jonna socialize together.

Kosalko represented the Guthrie Theater at the Annual Meeting.

Dr. Tashjian’s support of the arts is not limited to art and theater. He recently created “Docs in a Box,” a group of physicians who support the St. Paul Chamber Orchestra and he serves on the SPCO Board of Directors.

His work in medicine includes chairing the Radiology De- St. Paul Surgeons, Ltd. partners and spouses show their partment at Regions Hospital, support for their colleague, Dr. Peter Kelly, RMS president. serving on the Board of the Min- (From left): Kathy Wahlstrom, Kyle Wahlstrom, M.D., Madee Wilton, Andrew Fink, M.D., Peter Wilton, M.D., nesota Radiological Society, and Cheri Fink, Peter Kelly, M.D., Nancy Kelly, Jeffrey Hill, Diane serving as a councilor of the Ameri- Ogren, M.D., Debbie Rupp and William Rupp, M.D.

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2002

25

Ramsey Medical Society

RMS MEMBERS, Alliance members, spouses, children and guests enjoyed an evening of recognition, collegiality, and enjoyment at the Town & Country Club on Friday, January 25, 2002.

Dr. Lyle Swenson, a past RMS president from St. Paul Cardiology, presented the Presidential Plaque and a gift to outgoing President Dr. Robert C. Moravec, HealthEast Care, Inc. Dr. Swenson praised Dr. Moravec’s contributions and service to RMS during his term as president.

Dr. Peter H. Kelly, St. Paul Surgeons, was installed by outgoing President Dr. Robert C. Moravec as the 135th president of RMS. Dr. Kelly cited the rich history of RMS and the leadership skills of its physician officers in his acceptance speech. He reviewed the evolution of the large health care systems in the metro area including the restructuring of much of the health care system. He pointed out that the movement to give the patient a greater role in their own health care decisions has begun and that the State of Minnesota has once again created a Task Force on Health Care to look at the system. In conclusion, Dr. Kelly pointed out that physicians must be involved and must be informed about the issues. By working together and by working with the government and with the health plans, physicians can accomplish positive change.

The 2001 RMS Community Service Award was presented to Dr. Joseph H. Tashjian, St. Paul Radiology, for his many contributions to the arts.

For more than 10 years Dr. Tashjian has supported the University of Minnesota Department of Art by providing scholarships to graduate students in ceramics, by fundraising for the department, and by lobbying at the Minnesota Legislature for funding for the department.

Mark Pharis represented the University of Minnesota Joseph H. Tashjian Department of Art Dr. received the RMS at the RMS Annual Community Service Award for 2001.

Meeting.

President’s Message (Continued from page 24)

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26

March/April 2002

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Governor Jesse Ventura has commissioned the Governor’s Task Force on Health Care Costs to examine the current status of the health care system in Minnesota. This is being chaired by Health Commissioner Jan Malcolm. The group had their first meeting on 12/20/01. Their charge is: 1) to develop strategies to re-engage consumers in health care decisions; 2) examine and publicize components of health care costs drivers; 3) examine changes needed in health benefit design to address numbers one and two; 4) identify quality improvement strategies; and 5) propose new risk pooling arrangements.

Many of the people in attendance were the same as those present during the health care reforms of the 1990s. Senator Linda Berglin stated that she is particularly interested in two cost drivers: obesity, and the consolidation of providers — especially specialists and their impact on overall health care costs. As noted above, this consolidation was almost a direct result of the MinnesotaCare legislation of the 1990s. Déjà vu?

The second area of interest is the re-shaping of Medica Health Plan. Medica is now a totally separate entity from Allina. The Board of Directors has taken as its charge to re-examine Medica and its relationship with its members, the business community and physicians.

There is great optimism that a new direction will be found to allow for comprehensive care for the community while providing physicians the tools they need to continue to train, retain and recruit top-level doctors. This strategic planning will occur over the next six months. Medica covers about one million lives, mostly concentrated in the metro area, and any major changes will affect most physicians in this area.

Physicians need to be represented in these processes and the MMA along with RMS and other county medical organizations are actively involved at this point. However, the need for individual physicians to be involved and apprised of the current situation is more imperative than ever. We, at RMS, will work hard to keep our members up-to-date on these and other critical issues. It is my hope in the coming year that we physicians will be an integral component in helping to reshape this marketplace and be able to work with the government and the health plans to effect positive change and a winwin scenario for all. ✦ The Journal of the Hennepin and Ramsey Medical Societies

R M S U P DAT E

New Members RMS welcomes these new members to the Society.

Schools listed indicate the institution where the medical degree was received.

Jerald Barnard, M.D. University of Minnesota Obstetrics/Gynecology Woodbury Obstetrics & Gynecology Thomas F. Kraemer, M.D. University of Minnesota Physical Medicine & Rehabilitation Kraemer Clinic Joseph M. Lasnier, M.D. University of Kansas Pulmonary/Critical Care Medicine Pulmonary & Critical Care Associates, P.A. Monique M. Regard, M.D. Baylor University Obstetrics/Gynecology Parkview Ob/Gyn Joel J. Smith, M.D. University of Minnesota Orthopaedic Surgery/Trauma, Sports Medicine Regions Hospital Nickolas P. Tierney, M.D. University of Minnesota Obstetrics/Gynecology Kendall Center for Women, P.A. Todd M. Watanabe, M.D. UCLA School of Medicine Pediatric Ophthalmology St. Paul Eye Clinic, P.A. Mark V. Wedul, M.D. University of Minnesota Ophthalmology Lexington Eye Associates James T. Young, M.D. University of Minnesota Orthopaedic Surgery Summit Orthopedics, Ltd. MetroDoctors

Benjamin D. Suhr, M.D. Boston University General Surgery Minnesota Surgical Associates, P.A. Scott A. Uttley, M.D. University of New Mexico Ophthalmology St. Paul Eye Clinic, P.A. Resident Jon Fuerstenberg, M.D. University of Minnesota Jessica Nicholson, M.D. University of Minnesota

Medical Student (University of Minnesota) Brett W. Adams Melanie A. Dixon Amit P. Kachalia Josephine M. O’Gara Jessica M. Pike

In Memoriam JOHN ALDEN, JR., M.D., died January 9 at the age of 79. He graduated from the University of Minnesota in 1946. Dr. Alden was a Fellow of the American College of Surgeons. He was one of the founding partners of the practice that is now St. Paul Surgeons, Ltd. He joined RMS in 1948.

A Call for Delegates If you are interested in serving as a Delegate, please contact us at your earliest convenience.

A Call for Resolutions Resolutions are due at the Ramsey Medical Society no later than Friday, May 17.

RMS Caucus Dates and places to be announced (late May/early June) 7:00 – 8:30 a.m.

MMA Annual Meeting Wed-Fri, September 25-27, 2002 Northland Inn, Brooklyn Park, MN If you have any questions, contact Doreen Hines at 612-362-3705 or dhines@mnmed.org

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LAW OFFICE Focusing on the legal needs of the health professional!

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DANIEL L. FINK, M.D., died at the age of 87. He graduated from the University of Minnesota in 1939. Dr. Fink was one of the longest practicing radiologists in Minnesota.

He joined RMS in 1947.

Michael J. Weber, J.D.

P. THEODORE WATSON, M.D., died on January 1 at the age of 83. He graduated from the University of Minnesota in 1943. Dr. Watson practiced obstetrics and gynecology in St. Paul from 1946 to 1980 after serving two years as a Navy physician. The Watson Education Center at St. John’s Hospital was dedicated to Dr. Watson and his wife Jeanne in 1992. Dr. Watson joined RMS in 1948.

612-296-8080 www.weber-law.com

The Journal of the Hennepin and Ramsey Medical Societies

Ramsey Medical Society

Active M. Jennifer Abuzzahab, M.D. Eastern Virginia Medical School Pediatric Endocrinology Children’s Hospitals & Clinics

1st Year in Practice Nicholas M. Mittica, M.D. Jefferson Medical College Ophthalmology/Glaucoma St. Paul Eye Clinic, P.A.

• Former Attorney for the Board of Medical Practice • Over Six Years as an Assistant Attorney General

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

March/April 2002

27

RMS ALLIANCE NEWS BRENDA ANDREWSON

D

DID YOU KNOW THAT INVOLVEMENT

in your local Medical Society and Alliance is good for your health? Public health researchers have established beyond reasonable doubt that social connectedness, whether it be from close family ties, friendship networks, affiliation and involvement in religious and civic organizations, or participation in social events, is a powerful determinant of our well being. This is one of many fascinating facts that Robert D. Putnam presents in his book: Bowling Alone, the Collapse and Revival of American Community. Not only is this type of social involvement good for your health and sense of happiness, but it also can lead to: better educational systems and improve the welfare of children; safer, more productive neighborhoods; economic prosperity; and a more effectively functioning government. So, why aren’t more Americans involved in their communities? Finding the answer to this question is vitally important to the future of our local Medical Society and Alliance.

Putnam presents a mountain of data to support why what he calls social capital (which includes active involvement in local clubs and organizations) fell by more than one half in the last several decades of the 20th century. Years ago, people belonged to bowling leagues, but today they are more likely to bowl alone. “Bowling alone” is Putnam’s metaphor for disconnected individuals. While the causes of this civic disengagement are difficult to isolate, Putnam does make strong arguments that the main causes are pressures of time and money, sprawl, technology and mass media, and generational differences.

Time pressure is the excuse that I hear most frequently. We certainly seem busier now; we feel more rushed and life seems very hectic. But Putnam’s evidence seems to indicate that Americans have no less free time than earlier generations and may actually have more. The problem may lie more in how those gains in free time are distributed. Coordinating schedules has become more burdensome causing collective forms of 28

March/April 2002

civic engagement to decline more rapidly than individual forms (Have you ever tried to set up a meeting for three or more busy people?). Pressures of time and money, including the pressures on two-career families have contributed to the decline in our social and community involvement, but Putnam estimates that it accounts for no more than 10 percent of the problem.

Increased suburban sprawl is also suggested as a reason for the decline in civic involvement.

Regardless of your opinions of suburban sprawl, it does appear to impact civic disengagement due to the time involved in commuting (American adults have been shown to average 72 minutes a day driving), increasing social homogeneity within the suburbs, and the disruption of community “boundedness.” During the 1950s and 60s, political scientists showed that residents of “well defined and bounded” communities were more likely to be involved in civic affairs. But here again, Putnam estimates the impact of sprawl to account for no more than 10 percent of the decline in involvement within our communities.

The biggest culprits of the decline in civic involvement, according to Putnam, are two huge and overlapping influences: technology and mass media, and generational differences. Technology, especially television, has tended to make Americans more isolated, passive and detached from our communities. Studies indicate that Americans now watch three to four hours of television per day, absorbing an increasing proportion of our leisure time. We used to turn on the television to watch a particular program, now we turn on the television just to see what is on.

This increasing dependence on television is associated not just with less involvement in our communities, but also with less social communication of all types. Whether television and mass media (including the internet) are the causes of civic disengagement or a symptom is less clear, but their impact is astounding.

The impact of generational differences is

MetroDoctors

also fascinating. Putnam presents evidence to discount the idea that people of different ages behave differently because they are at different points in a common life cycle. He presents evidence that each generation since the 1950s has been less engaged in community affairs than its immediate predecessor. Studies seem to indicate that being raised after World War II was a different experience than being raised before it.

During WWII there was an increase in patriotism and collective solidarity within the U.S. and afterwards those energies were redirected into community life. Unfortunately, television was introduced in America around 1948, and within seven years 75 percent of American households were watching it.

All of these facts are fascinating, but don’t tell us what we need to do to get more involvement in our Alliance and Medical Society. Naming the problem however is an essential first step to solving it. Interestingly, during the past 10 years there has been an increase in volunteering and community service by young people in colleges and high schools, but whether this is a lasting phenomenon or a reflection of stronger encouragement (including graduation requirements and efforts to improve college admissions efforts) remains to be seen. We have also seen an increased sense of unity within the United States since September 11th as Americans try to understand and make a difference in our world.

Our President has called for increased volunteer efforts within our communities and abroad.

We all need to begin a dialogue on how we can adapt our organizations to the 21st century while still providing meaningful and regular service to our medical community. I welcome your thoughts and ideas. ✦

The Journal of the Hennepin and Ramsey Medical Societies

CHAIR’S REPORT DAVID L. SWANSON, M.D.

But it’s gonna take money —

Taking Health Care Costs to Task 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

MetroDoctors

But it’s gonna take money, A whole lot of spending money.

It’s gonna take plenty of money, To do things right, child.

—George Harrison

T

THE GOVERNOR’S TASK FORCE on Health

Care Costs is now realized and has met at least three times by the time you read this. The Task Force is chaired by Health Commissioner Jan Malcolm and is comprised of members of the house and senate as well as the Commissioners of Human Service, Commerce, Employee Relations, and Finance. The Task Force has been given authority to study and resolve the burden of rising health care costs. Those commercial costs have been rising in Minnesota at a rate of 11 percent per year over the past three years.

David Allen, a member of our Board, has attended the proceedings. The meetings are open to the public.

It comes as no surprise that health care costs are on the rise. What is interesting is how the numbers play out in Minnesota, especially compared to the nation as a whole.

In 1999, the per capita spending was $3,528, which is 82 percent of the national per capita spending of $4,309. We Minnesotans spend 9.7 percent of our state economic dollars on health care, while the rest of the country spends 12.7 percent. No astonishment here — we have always taken pride in our efficiency, although it has cost us dearly in reimbursement from Medicare and other Federal programs. (As you know, reimbursement rates for states are based on historical expenditures — efficient utilizers are punished with lower reimbursement rates.)

Of the cost increases that have occurred in the U.S., 42 percent of the increase was due to the increased payments to physicians. There is no data accounting for the reasons for the increase. It may all be increased utilization (see pharmacy utilization below). It may be due to a documented increase in the utilization of specialty services over primary care. It is possible that there has been a significant increase in phy-

The Journal of the Hennepin and Ramsey Medical Societies

sician reimbursement income in the past two years, right?

Pharmacy costs accounted for 22 percent of the increase costs: 48 percent of this increase is due to an increase in the total number of prescriptions written; 28 percent was due to an increase in the prices of novel drugs less than three years old; and 24 percent was due to an increase in the prices of old-timers more than three years old. So the expense of new-release drugs seems to be a relatively small part of the rise in pharmacy expense.

The average Minnesota health insurance premiums in 1999 were $6,218, which is 3 percent higher than the national average of $6,058.

High premiums and low spending, why might that be? Perhaps it is a consequence of cost shifting from the increasingly marginal Medicare reimbursement. Or, as some have suggested, it might relate to long-care benefits, which are perceived as “generous” in Minnesota. Or, as Attorney General Mike Hatch has indicated, perhaps HMO administrative costs are much higher than we have been generally led to believe in the past. The Minnesota Department of Health seems to think that this latter explanation is not the case.

The good news is that many on the Task Force feel that the long-term growth in health care spending has peaked and will likely decline in the coming years. To me, this seems surprising, given the new era of diagnostic imaging, minimally invasive but even more expensive interventional technology, and wondrous therapeutic devices like basal ganglia electronic pacers for Parkinson’s disease patients.

Predicting declines in health care spending seems like Wall Street making “buy” recommendations for Enron. For one thing, we (Continued on page 31)

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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 NEWS

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

Active Michael D. Alter, M.D. Medical College of Ohio at Toledo Pulmonary Disease Minnesota Lung Center Steven D. Anderson, M.D. University of Minnesota Medical School Family Practice Allina Medical Clinic-Woodlake

Amy J. Meath, M.D. University of Minnesota Medical School Obstetrics & Gynecology Lakeview Clinic, Ltd.

Steven P. Hanovich, M.D. University of Minnesota Medical School Internal Medicine Columbia Park Medical Group P.A. Brenda Jo Harris, M.D. University of Minnesota Medical School Obstetrics & Gynecology Oakdale OB/GYN, P.A. John R. Hering, M.D. University of Minnesota Medical School Family Practice Monticello Clinic

Azber A. Ansar, M.D. Al-Ameen Medical College, Kamataka University, Bijapur Internal Medicine

Maria Hoenack-Cadavid, M.D. Universidad del Valle, Division de Ciencias de la Salud, Call Psychiatry Hennepin County Medical Center

Mary Kay Barrett, M.D. University of Minnesota Medical School Family Practice Park Nicollet Clinic-Carlson Parkway

Michael Y. Hu, M.D. University of Minnesota Medical School Vascular Surgery General and Vascular Surgery

Lian S. Chang, M.D. University of Minnesota Medical School Psychiatry

Stefan D. Kramarczuk, M.D. University of Minnesota Medical School Pediatrics Park Nicollet Clinic-Bloomington

Yun-sen Ralph Chu, M.D. Northwestern University Medical School Ophthalmology Chu Laser Eye Institute, P.A. Gary D. Cravens, M.D. Indiana University School of Medicine General Surgery Ingenix Health Intelligence G. Scott Giebink, M.D. University of Minnesota Medical School Pediatrics University of Minnesota Medical School

Katarzyna Joanna Litak, M.D. Akademia Medyczna we Wroclawiv, Wroclaw Psychiatry Hennepin County Medical Center Christine M. McCarthy, M.D. University of Iowa College of Medicine Family Practice Park Nicollet Clinic-Wayzata Michael Patrick McCue, Sc.D., M.D. Harvard Medical School Neurological Surgery Neurosurgical Assoc., Ltd.

Richard J. Granger, M.D. University of New Mexico School of Medicine Internal Medicine Hennepin County Medical Center 30

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MetroDoctors

Mark R. Mount, M.D. St. Louis University School of Medicine Otolaryngology Southdale Otolaryngology Glennon K. Park, M.D. University of Minnesota Medical School Internal Medicine Veterans Administration Lorinda F. Parks, M.D. University of Minnesota Medical School Family Practice North Memorial Family Practice Clinic Lisa A. Posey, M.D. Michigan State University College of Human Medicine Otolaryngology Southdale Otolaryngology Judith B. Snook, M.D. University of Minnesota Medical School Pediatrics Metropolitan Pediatric Specialists, P.A. Robert W. Snook, M.D. University of Minnesota Medical School Pediatrics Metropolitan Pediatric Specialists, P.A. Michael W. Stanley, M.D. University of Alabama School of Medicine Pathology-Anatomic/Clinical Hennepin Faculty Associates Trond A. Stockenstrom, M.D. University of Minnesota Medical School Ophthalmology Eye Care Associates, P.A. John G. Strickler Jr., M.D. University of Virginia School of Medicine Pathology-Anatomic/Clinical Abbott Northwestern Hospital Maria Lynn Thrall, M.D. University of Minnesota Medical School Family Practice Park Nicollet Clinic-Shakopee

The Journal of the Hennepin and Ramsey Medical Societies

Kathryn A. Vidlock-Granley, M.D. University of Minnesota Medical School Family Practice Silver Lake Clinic, P.A. Michael D. Wengler, M.D. University of Minnesota Medical School Orthopedic Surgery Downtown Orthopedics, P.A.

Wang Ying, M.D. Lingham Medical College, Lingham UniversitySun Yat-sen, Canton Diagnostic Radiology Hennepin County Medical Center

Residents J. Kyle Anderson, M.D. University of Minnesota Medical School Urology/Urological Surgery James George Capes, M.D. University of Illinois College of Medicine Pediatrics Thomas William Flaig, M.D. University of Minnesota Medical School Family Practice Hennepin County Medical Center Tara A. Forcier, M.D. University of North Carolina School of Medicine Pediatrics University of Minnesota Medical School Anna D. Guanche, M.D. Louisiana State University School of Medicine Dermatology

In Memoriam JAMES T. GARVEY, M.D., died December 17 at the age of 77. He graduated from St. Louis University School of Medicine. Dr. Garvey was a founding partner of the Minneapolis Clinic of Psychiatry and Neurology. He was a past president of the Hennepin County Psychiatric Association, and a professor at the U of M Department of Psychiatry. Dr. Garvey joined HMS in 1955.

JEAN L. HARRIS, M.D., died December 14. She was 70. She graduated from the Medical College of Virginia Commonwealth University School of Medicine, Richmond.

Dr. Harris was acting mayor of Eden Prairie.

She joined HMS in 1994.

Patrick M. Ridgely, M.D. University of Minnesota Medical School Psychiatry

JOHN T. PEWTERS, M.D., died at the age of 89. He graduated from the University of Minnesota and completed his residency at King County General Hospital in Seattle.

Dr. Pewters was a co-founder of the American Association of Family Practice, and a charter member of the American Board of Family Practice. He joined HMS in 1939.

Students Maryam Beltran Shapland Matthew Robert Braasch Christine M. Braun

EDWARD SALOVICH, M.D., died November 8. He was 74. He graduated from the University of Minnesota Medical School.

Dr. Salovich joined HMS in 1961.

Alexander V. Panyutich, M.D. Byelorussia Medical Institute, Minsk Hematology Oncology

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Chair’s Report (Continued from page 29)

have been seriously neglecting our medical infrastructure in Minnesota. The population grows while the number of hospital and extended care beds has declined. In the next three decades, according to City planners, there will be at least a million additional souls needing medical care in the Twin Cities. Where is the plan to build hospitals and long-term care facilities? Where are the thousands of needed nurses, physicians, technicians, and support staff going to come from? How are we going to meet our future needs?

That’s gonna cost money, a whole lot of spending money. It’s gonna take plenty of money to do things right. ✦ David L. Swanson M.D., Board Chairman, Hennepin Medical Society can be reached at: Swans045@umn.edu.

A Call for Delegates If you are interested in serving as a Delegate, please contact us at your earliest convenience.

A Call for Resolutions Resolutions are due at the Hennepin Medical Society no later than Friday, May 17.

HMS Caucus Thursday, June 6 7:00 – 8:30 a.m.

Location to be announced.

MMA Annual Meeting Wed-Fri, September 25-27, 2002 Northland Inn, Brooklyn Park, MN If you have any questions, contact Kathy Dittmer, executive assistant, at 612-623-2885 or kdittmer@mnmed.org

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Hennepin Medical Society

Sandy Kay Wiita, M.D. University of Minnesota Medical School Family Practice Eating Disorders Institute

Erik Sean Carlson Sarah Elizabeth Carter Christoper G. Choukalas Michael Edward Darin Shelby L. Eischens Brant N. Hacker Brett Reed Hendel-Paterson Gary D. Josephsen Jonathan D. Kirsch Lindsay Jane Miller Joseph Igor Novik Amy Elizabeth Nygaard Michael T. Rhodes Christopher C. Rupp Kristina E. Trimble Khuong Minh Vuong Ty D. Weis Adam J. Weisbrod Steve J. Wisniewski

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

W

WE, AS MEMBERS of the Hennepin Medical

Society Alliance, are proud of “our” physicians and appreciate all they do for the health and well-being of our community. Besides supporting the goals of HMSA, which are defined in our mission statement as “working in partnership with others, to promote the health and wellbeing of its members and the community through education, advocacy and service,” we want to recognize the physicians who continue to deliver excellent health care despite the changes and challenges of medicine.

One specific way we can honor physicians this month is through our fund-raising efforts to support the AMA Foundation. Our current fund drive is designated as an emphasis to highlight March 30, Doctors’ Day. Again this year we’re planning a “no show” event with the goal of simply raising funds to support today’s medical schools and their students. We need to remember that the medical student of today will be our physician tomorrow. Donors can choose which of the nation’s medical schools to support and choose among a number of funds such

HMSA members gather at the Marsh for the 6th annual HMSA “Make Fitness Happen.”

Volunteers are needed for the

19th Annual Body Works (health fair for Minneapolis public school third graders)

the week of April 8-12.

If you are intersted in volunteering, please call Diane Gayes (952-935-8828) or Trish Vaurio (952-929-7360).

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MetroDoctors

as: The Medical School Scholars’ Fund for medical students in need of assistance; or The Fund for Better Health which promotes local public health programs.

We are looking forward to our possible involvement with one of the Kids Cafe sites this winter. It will be part of our SAVE (Stop America’s Violence Everywhere) project. Kids Cafes are located at four Twin Cities’ sites that provide nutritious meals to kids plus an opportunity to learn cooking techniques, manners, and other valuable life skills. This is part of a nationwide after school nutrition and self-esteem program for high risk and homeless youth and is part of America’s Second Harvest, a national network of food banks. HMSA member and WCCO Radio food personality, Sue Zelickson, founded the local Kids Cafes and recently was honored by Marquette Catering as the recipient of the first “Food Humanitarian of the Year” award.

Plans for the 19th annual Body Works (health fair for Minneapolis Public school third graders) are underway and we are in the process of signing up the nearly 100 volunteers that will be needed for the week of April 8-12. We are once again grateful to Lutheran Brotherhood for generously donating the use of their auditorium and to the Hennepin Medical Foundation for their continued financial support of this project. Diane Gayes (952-935-8828) and Trish Vaurio (952-929-7360) would appreciate it if you called them to volunteer before they need to call you.

An energetic group of HMSA members enjoyed Fitness Day at the Marsh in January. The day included choices of classes, a healthy lunch and a presentation of a nutrition lecture. It was a good way to start off the new year. ✦

The Journal of the Hennepin and Ramsey Medical Societies

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