2003marchapril

March/April 2003

A Bright Future for Medicine HIPAA Compliance

In this issue

•

MMA selects new CEO

•

Congress Updates Medicare

Don't Shred Money to be HIPAA Compliant Simple & Cost Effective Document Destruction

HIPAA can be a bit overwhelming, but the document destruction component can be simple. Clary saves you money and assures your compliance with no worries. We specialize in serving Health Care organizations.

You may be paying more for document destruction than you should. Clary’s service is typically more cost effective than other providers. We offer both on-site and off-site service on a scheduled or an on-call basis.

Our HIPAA Compliance Certificates are delivered to you following the destruction of your material. Clary has been providing business solutions for over 50 years.

OUR T U ABO FER ASK RIAL OF T FREE Visit us online for convenient HIPAA resources. www.clary-shred.com 612-627-9828

We recycle today for a better tomorrow.

Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Charles G. Terzian, 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 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: bauerfamily@earthlink.com.

For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com.

MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy.

Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Doreen Hines at (612) 362-3705.

MetroDoctors

CONTENTS VOLUME 5, NO. 2

2

LETTERS

3

Classified Ads

4

FEATURE

MARCH/APRIL 2003

Gaining Insight into the World of Today’s Resident Physicians

8

COLLEAGUE INTERVIEW

Brent Asplin, M.D.

13

Durenberger Provides Health Policy Update

14

MMA Announces Robert Meiches, M.D. Will Be New CEO

15

“D-day Compliance” A Quick Way to Meet the Priorities of HIPAA

17

A Medicare Victory in Congress

18

PHYSICIAN’S SOAP BOX

Health Care in Japan

20

AMA Code of Medical Ethics

22

Societies Host Lunch n’ Learn Program for Medical Students RAMSEY MEDICAL SOCIETY

23 24 25 26

President’s Message 133rd RMS Annual Meeting Silent Auction/Silent Auction Donors/New Members RMS Alliance HENNEPIN MEDICAL SOCIETY

27 28 31 32

Chair’s Report New Members In Memoriam/Shotwell Award Presented HMS Alliance

The Journal of the Hennepin and Ramsey Medical Societies

On the cover: A Residents Roundtable provided an opportunity for six young physicians to discuss what it’s like being a resident today.

Feature article begins on page 4.

March/April 2003

1

LETTERS

To the Editor: In his recent letter to the editor (“Future Restrictions on Physician Practice”) Dr. Thomas Flynn asks physicians and the medical societies to oppose certificate of need legislation and self-referral restrictions. Dr. Flynn is concerned about limits on efforts to pursue an integrated model of care. This type of legislation certainly adds to the limits on our freedom to practice as we wish. However, the public and our legislators feel, as a recent editorialist in the Star Tribune notes (Boyd, 1/5/03), that the “U.S. health care system is broken” and wonder “how can the uninsured be covered and explosive growth in healthcare costs be controlled?” Perhaps our medical societies should be looking at the bigger picture.

Dr. Flynn does not mention PET scans, but I believe his letter was precipitated by his oncology group seeking approval for a PET scanner. As a retired physician who trained in the 60s and practiced in Minnesota, I’ve seen the explosive growth of imaging techniques and marveled at their ability to help with diagnosis and treatment. However, I’ve also clearly seen excessive use of imaging and note that we now appear to have excessive capacity. A recent issue of Minnesota Monthly has at least three advertisements for heart, lung, and colon scans as well as other CT and MRI procedures aimed at the general public.

One ad even makes the incredible statement that if you have a family history of heart disease “the first step is to make an appointment for Electron Beam CT.”

Our medical societies should be promoting appropriate use and capacity of our imaging procedures. I wonder how many PET scanners are in our community, are they being used to capacity, and are there good controlled studies showing that PET scans made a significant difference in the outcome for cancer patients? Our medical societies have no real means of enforcement, but our professional societies must take a stand on appropriate use of resources and controlling costs, or our politicians will do it for us.

Dr. Lyle Swenson, in the same issue of MetroDoctors, nicely outlines some of the problems with Medicare and politics. I’m afraid we have only seen the beginning. ✦ Sincerely, James A. Zeese, M.D.

2325 Prior Avenue North, Roseville, MN

(651) 636-6060 BRED FROM THE VEHICLES YOUR MILITARY BUYS! H2, THE NEW 2003 KID ON THE BLOCK! (now in stock) THE FEW, THE PROUD, THE SUCCESSFUL!

FOR DETAILS AND TEST DRIVES CONTACT STEVE ALLEN AT MCCARTHY’S HUMMER.

2

March/April 2003

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

March/April Index to Advertisers Dear Editor: The recent (January/February 2003) letter to the Editor by Dr. Thomas P. Flynn raises some interesting points. My general impression is that his concern about possible additional state legislation on “self-referral” may more accurately relate to “income enhancement” for his large oncology group practice. Existing federal (Stark) restrictions on self-referral are based on solid evidence that when physicians have a financial interest in ancillary diagnostic and therapeutic services, the utilization of those services is significantly increased. Not only are more services offered, but also the fees charged may be more generous than made by an independent professional service. Human nature is immutable; if a physician has a financial interest in an ancillary service, whether overt or subconscious, over-utilization is inevitable.

Further, not only is utilization excessive, but the quality of those “self-referred” services may be compromised. If remuneration is the prime motivation, quality may be a secondary consideration. Selection of the best available ancillary reference facility may be compromised. Citing “patient convenience” may represent a convenient rationalization for profit-motivated practice.

A more basic argument about oncology care is rarely mentioned. Why is there this huge disparity between oncology costs and patient benefit? With the rate exceptions of success treating pediatric and embryonic tumors, the treatment of solid tumors, beyond the value of primary surgical excision, exhibits a modest or minimal improvement in survival or quality of life. We do a lot; where are the results? Although painful to accept, the tumor determines the outcome, not the care.

Despite the miniscule benefit, almost every patient with recurrent tumors is offered or encouraged to receive chemotherapy. Do patients with pancreatic cancers benefit from adjuvant or palliative chemotherapy? Are nonMetroDoctors

resectable lung cancers, other than small cell carcinoma, improved by chemotherapy?

Oncologists enthusiastically quote the most recent report, demonstrating a two month survival benefit. Why do they discount the other 20 studies showing no benefit? What are the justifications made for chemotherapy in obviously futile situations? I hear “If I don’t treat, someone else will;” “you have to give the patient hope;” “the family insists;” “it is the standard of care;” etc., etc.

The important and outstanding work of John Bailar (1985 and 1997, NEJM), in appraising the yield of cancer care, is disquieting cancer mortality, age and population adjusted, is unchanged for 50 years. In this time period, the public was bombarded with media claims of “amazing cures,” “great advances,” etc., all of which is unfounded. Bailar was personally attacked (the fallacy and hominum) for his report in 1985; his follow-up paper in 1997 refuted the original criticisms. Breast cancer mortality is the same as 80 years ago. Yet, despite the absence of improvement, we spend 100 times as much on therapy. We have created an industry, both in therapy and screening for early detection, much of which provides no benefit. The industry benefits the providers more than the patients.

And now Dr. Flynn is concerned about self-referral legislation, much of which will address only the most egregious economic aspects of oncology. Oncologists should more appropriately address the yield, or lack thereof, of oncology activity. If they did, perhaps we might slightly reduce the frightful escalation of health care costs. ✦ Respectfully, Seymour Handler, M.D. Retired Pathologist

The Journal of the Hennepin and Ramsey Medical Societies

Clary Document Destruction .......................

Inside Front Cover Classified Ads ............................................. 3 Crutchfield Dermatology .......................... 21 Custom RX Compounding Pharmacy ...... 13 HealthEast Vascular Center ......................... 7 Methodist Hospital .................................. 14 Minnesota Healthcare Network ................ 29 MMIC ...................................................... 22 Raymond James Financial Services ................

Inside Back Cover RCMS Inc. ............................................... 12 Red Pine Realty .......................................... 6 Southdale Internal Medicine ..................... 21 U of M CME ................. Outside Back Cover Wally McCarthy Cadillac ... Inside Back Cover Wally McCarthy Hummer ............................ 2 Weber Law Office ..................................... 13

Classified Ads HIPAA Resources? Billing Headaches? Let Medical Billing Professionals help! Full Practice Management Billing Center. Offering: full insurance and patient billing, fee & code analysis, superbill development, HIPAA implementation assistance, consulting services, credentialing and much more. Call 320-963-8034 to discuss how we can help YOUR practice! www.medical-billing-professionals.com.

NEED OFFICE SPACE? If you are looking for a pleasant atmosphere to see your patients, but only need office space one to two days a week, we have room for you.

We can offer: Two exam rooms; One consultation room; Professional secretarial assistance; and Conveniently located next to Mercy Hospital.

Please call if interested: 763/427-8547.

March/April 2003

3

FEATURE STORY

Gaining Insight into the

Residents Roundtable World of Today’s Resident Physicians

For these residents, life is a delicate mix of long hours treating patients, formal learning, family, and preparing for the future.

MetroDoctors talks with six insightful young physicians about being a resident today, the quality of their training and mentoring, and their worries about the age old question: How do you do all you can for your patients and live a balanced life?

B

BEFORE STARTING MEDICAL SCHOOL, David Satin, M.D., was the focus of an intervention. Concerns that he was partying too much? Not at all. Satin had decided to become a doctor, and his “interveners” were his own physician father and partners, all trying to convince him that he should not follow in their footsteps. Terrible hours. Disrupted home life. Long years of training. Six-figure school loans. Diminishing, if not uncertain, financial returns.

Their best efforts fell on deaf ears. “I love family practice,” says Satin. “We do what we do. We have a calling. You take the difficult with the good.”

We have a calling. You take the difficult with the good. Satin’s statements reflect the timeless truths as to why one becomes a doctor, as well as the continual balancing act that is life for today’s medical residents. For these residents, life is a delicate mix of long hours treating patients, formal learning, family, and preparing for the future. MetroDoctors hosted six metro-area residents in mid-December 2002 for a group discussion about their worlds.

Jack Davis, chief executive officer, Hennepin Medical Society, facilitated the discussion; selections from that discussion are highlighted here. The resident participants were:

•

Jeff Brace, M.D., a North Dakota native who trained at the University of South Florida, Tampa, and is in his fourth year of residency in radiology at the University of Minnesota;

•

Nicole Dean, M.D., of Bloomington, trained at the University of Minnesota, is a third year Ob/Gyn resident at the University with rotations to Hennepin County Medical Center, Fairview-University Medical Center and Regions Hospital;

•

Bradley Linden, M.D., a Minnesotan trained at the University of Minnesota and currently a seventh year general surgery resident at the University who also rotates to Twin Cities area hospitals;

•

Melody Mendiola, M.D., of Burnsville, who trained at the University and is a first year resident in internal medicine at Hennepin County Medical Center.

•

John Mrachek, M.D., also a native Minnesotan trained at the University who will specialize in anesthesiology and is now a first year intern in general medicine at Hennepin County Medical Center; and

BY MARY SMALL

4

March/April 2003

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

•

David Satin, M.D., of Quebec, trained at the University of Western Ontario and a second-year resident in family practice at Fairview-University Medical Center and Smiley’s Point Clinic in Minneapolis.

Asked if their residencies are meeting their expectations, and if prior training prepared them for where they are today, the group was unanimous in their praise of their schooling, their mentors and their current colleagues.

Brace: “How prepared you are for the next level is the test. From medical school to internship to residency, my experience has been very good. I took my first moonlighting gig in a smaller community recently and I felt very prepared by all that I’ve been exposed to – at the University, at HCMC and the VA, I see 70 to 100 patients a day. I’ve been exposed to lots of situations.”

Satin: “I am really impressed with the competence of the docs in our clinic [Smiley’s Point]. They work every bit as hard as we do. Our patient population is fantastic, with enough of the needy stuff of life to learn from and gain experience.”

Back from left: John Mrachek, M.D., Nicole Dean, M.D., Melody Mendiola, M.D., and Jeff Brace, M.D. Front from left: Bradley Linden, M.D., and David Satin, M.D.

Mrachek: “HCMC’s training is very thorough. I could have picked a program that is easier, but this will be my last chance in general med [before specializing], and this is the place. HCMC is the last open door for some people, which can make it more difficult, but prepares you as a physician.”

Linden: “The University of Minnesota’s surgical residency is the best in the country, period. It has evolved over the past years and improved dramatically. We do big, complex surgeries and rotate to nearly all area hospitals. Cases are assigned to residents based on experience. It is a big commitment, general surgery, with a five to nine-year residency. It prepares you well.”

The legendary fatigue of residency, caused by untold hours on site and on call, remains a reality. But recent efforts to provide some limits on residents’ hours, through new policies by the Accreditation Council for Graduate Medical Education (ACGME), brought mixed responses from the group. For some, long hours means exposure to patients and learning, and limits to those hours is not a welcome change. Others question how realistic such policies are, but appreciate their intent: offer some measure of balance in a resident’s daily life.

Linden: “These policies have come forth because of some lawsuits in New York and the public perception that resident fatigue plays a major role in medical errors. It is a chance to police ourselves, before more legislation is passed, with rules that no resident can spend more than 80 hours in a seven-day period, averaged over four weeks. There are several

(Continued on page 6)

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2003

5

Feature (Continued from page 5)

other complex patient care stipulations set forth by the ACGME as well. The idea is to optimize the educational experience and give residents time to develop as people, to be with their families.”

Mrachek: “I want balance, I want to be a good doctor and a good dad. But I am very hesitant to say we’re working too much.

Docs ahead of us worked very hard.”

Satin: “No question about it, we are working very hard, too. Patients are very demanding. Our clinic is very humane, with the neediest of the needy. The one day my agoraphobic patient comes in he needs everything, all in a 15 to 20 minute appointment. All my patients need more time.”

Mendiola: “The number one thing I like about my residency program is that I am Large Lake Escape—Greenwood Lake

This historic cabin is perched on the edge of this huge wilderness lake and has a deep-water harbor and boathouse. You can’t replicate this today! The 1200 feet of pristine shoreline has pines, boulders, crystal clear water and outstanding views. There are a number of excellent sites for a new lake home.

There is also frontage on the Greenwood River, an excellent brook trout fishery. Good road access. Truly a one of a kind property! MLS#14016. $1.4 million.

Mike Raymond, Realtor P.O. Box 938 Grand Marais, MN 55604 e-mail: Info@RedPineRealty.com 800/387-3585 / 218/387/9599 www.RedPineRealty.com

6

March/April 2003

responsible for my patients, so I need to be there, available to them. I want to be able to attend conferences regardless of how many hours I’ve already put in. The best learning can be at 3:00 a.m. I have three years to learn to be a doctor. I need to see these patients. If I’m not in the hospital [because of policies setting maximum hours], I won’t see them and I won’t learn from them.”

Dean: “And in the surgical fields, you expect to take call, and you don’t have any leniency that might be in non-surgical fields. With these new policies we will be okay because we are a big enough program [to cover] but I worry about smaller programs with, say, four residents. How can they limit their hours? It is a bad reputation in the surgical fields, that residents are worked to death. Perhaps residencies could be longer [to relieve the pressure]. This could result in better recruitment into the surgical fields.”

Linden: “In order to be a competent surgeon you have to be where the sick patients are. You have to learn judgment and make decisions and then take that patient into surgery and act on that decision. How can you do that if you aren’t present? And in the hospitals, surgery residents are very depended on. While the U of M Surgery program has done an exceptional job of planning to ensure patient safety in this new model, if hours are limited, hospitals will have to staff up with physician extenders and nurse practitioners or things are going to be missed. Those missed lung sounds will become pneumonia.”

What needs to be changed? The group identified troubling, systemic trends as well as areas where today’s residency programs could be strengthened.

Mrachek: “Doctors do not know how to manage themselves in the business side of their work. It is unfathomable that in any other sector or profession incomes would MetroDoctors

be cut by 20 percent. But it happens to docs.

Medical school and residency does not teach you the business side. How do you review a business contract? How do you prepare yourself for these realities? We are not given these skills.”

Linden: “More and more physicians are being treated as employees, but are still expected to behave as professionals. I think the professional sentiment among physicians is dwindling because of this. Why accept liability, lie awake and worry about the patients we are caring for when we are being treated like employees? Because we are physicians, not employees, and the public and the health care industry need to remember this.”

Mendiola: “Cut down on the paper work.

Not the documentation, but the repetitive requirements. Perhaps there will be improvement through the electronic medical record. And for those thinking about this career, if you see yourself happy in anything else, do something else. This is a total commitment. You have to love it.”

Satin: “Invest in faculty a little more, and stop the disincentives. All our faculty took a pay cut and are working harder than ever.

Private practice is too lucrative, and people won’t go into (teaching).”

Mrachek: “ Up front, medical education is kind of a lousy investment, and that is quite depressing. We accrue huge debt and have no fringe benefits. We are way behind our peers in retirement savings by the time we go into practice. More and more people are feeling taken advantage of, thinking ‘I can’t believe I did this.’ What would help? Flat out pay them more. These people would be successful at whatever they do—so pay them like the professionals that they are.”

Brace: “Our first priority is to do the right thing for the patient. But it would be nice if occasionally there was acknowledgement of my training and what I have done, of what I know and can do.”

The Journal of the Hennepin and Ramsey Medical Societies

Not one of these residents is interested in giving up the other dream that they share: family life that includes them. Many are married to professionals, and children are an essential focus for several. How do they do it today? And where do they see themselves in five years?

Dean: “They say that in residency there’ll be no life, but that isn’t true. Many of my colleagues already have children and are thriving. In five years you’ll find me here in Minnesota practicing general Ob/Gyn, with my husband, Aaron, and possibly with children of our own.”

Mrachek: “I would like to go away and do a fellowship and then come back here and do a mix of critical care medicine and surgery as an anesthetist. I want to be a decent person, be a good partner in marriage, be a good dad, be a hockey coach.”

Brace: “In five years? A small to mediumsized group practice in either Minnesota or Florida. Have more kids, get a mini-van.

Mendiola: “In five years I will be in my second year of what I hope will be an inner city practice that combines clinic and hospital work. If Hennepin Faculty Associates has an opening I would jump on it in a minute.”

Linden: “My wife is in advertising and marketing. She’s my balance – I couldn’t do it without her…I love what I do, but it is harder to get people to be general surgeons.

People get the feeling the respect that is their due isn’t there, that their commitment and sacrifice is not appreciated. As far as five years from now I see myself as a junior level faculty member in an academic setting.

Where? Minnesota, of course, the birthplace of the surgeon scientist.”

Satin: “What you said about having some self doubt, I see this in my colleagues, getting up in the middle of the night, people getting sick on you, feces, smacking you when their out of their heads. I see them wondering why they are doing this. And yet, in five years I want an inner city practice, where people would need me, and working with a community of colleagues.

And I want the balanced, medical triad: clinical, teaching and research. Where we land depends in part on my wife, who is studying orthodontics at the University. We came to Minnesota so she could go to dental school.”

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

We want the 1950s family. I did go into medicine to give my kids a better start. I will be a radiologist by day. But I will be a dad by night.” ✦ Mary Small, a Minneapolis writer and communications strategist, has more than two decades of experience writing about medicine and health.

®

SHARING A SINGLE FOCUS

At HealthEast® Vascular Center, our services are designed to augment your clinical expertise with that of specialists.

• Peripheral Arterial Disease • Carotid Stenosis • AAA (Abdominal Aortic Aneurysm) • Dialysis Access Device • Wound Care

• Venous Insufficiency/Stasis • Lymphedema • DVT (Deep Vein Thrombosis) • Renal Stenosis • Uterine Fibroid Embolization

Partner with us. We offer an integrated program of diagnostics, treatment, follow-up and disease prevention education focused only on vascular patients.

651/232-2550 www.healtheast.org Gallery Professional Building, Suite 600, 17 W. Exchange St., St. Paul, MN 55102

March/April 2003

7

COLLEAGUE INTERVIEW

Brent Asplin, M.D.

Editor’s Note: Brent Asplin, M.D., is an emergency physician at Regions Hospital and research investigator at HealthPartners Research Foundation. Dr. Asplin is a researcher with nationally recognized expertise in hospital capacity and access issues.

Q A

Many hospitals are running at or near capacity. How does the Twin Cities metro area determine its overall hospital bed capacity?

In the early 1990s, the consensus was that there were too many hospital beds in the U.S. This was probably true at the time. Policymakers, health care leaders, and purchasers all generally agreed that a reduction in hospital bed capacity was needed to help control health care expenditures.

During the 1990s, the expansion of managed care, growing scrutiny of health care costs by large employers, and cuts in payments from public programs all reduced bed capacity in the U.S. So in some respects, the policy plan of the last decade worked—we wanted fewer beds and that is what we have today. But have we gone too far?

The Twin Cities area lost 1,500 hospital beds between 1989 and 1999, a period in which the population grew by 12 percent. And over the past two years, the demand for hospital inpatient care has risen steadily as utilization controls have been loosened. But even in the face of these trends, which would appear to point to an emphatic “yes,” the best answer is that right now we don’t know if we need additional hospital beds.

I think the more important issue is raised by the follow-up question— how do we determine our overall hospital bed capacity needs? In order to do this, we need to consider several factors: 1) Capacity Data We need better data about fluctuations in real-time hospital occupancy rates on a 24-hour basis. Several hospitals in Boston were criticized for going on ambulance “diversion status” (when emergency departments (EDs) temporarily ask ambulances to go to a different hospital) when they were reporting census rates in the mid-70 percent range. Unfortunately, these census data reflected staffed bed occupancy at midnight.

When the same hospitals measured their census at mid-day, they had occupancy rates over 96 percent! Because hospital census is a dynamic process, there may be opportunities to improve “surge capacity” at peak periods without building new beds. But this can’t be done without collecting and using real-time data. Some local hospitals have begun using data systems that allow them to adjust to changes in patient flow. I suspect that all hospitals will have a better understanding of real-time cen8

March/April 2003

sus in the near future, and this will put us in a better position to forecast capacity needs.

2) Operational Efficiency Before we begin constructing new hospital beds, it is imperative that we use our existing capacity as efficiently as possible. There is no question that hospitals can significantly improve functional capacity by managing patient flow more efficiently. Several hospitals around the country have successfully improved functional capacity and decreased (or eliminated) ambulance diversion. Gains in functional capacity of 10-15 percent are not uncommon. These hospitals all share some common characteristics: a) The senior leadership decided that improving functional capacity was one of the highest priorities for the hospital. b) They established a culture of routine measurement and accountability. If a care process is important enough to redesign, then it’s important enough to measure. Many hospitals spend a great deal of time trying to redesign patient flow without measuring specific time intervals to find out where bottlenecks exist. Without a routine “dashboard” measurement system, it is impossible to provide feedback and hold key stakeholders accountable for results. c) They identified bottlenecks in patient flow, redesigned care processes, and established back-up systems for periods of peak demand. d) They understood that the key to improving operational efficiency is to develop better systems. If providers are working within inefficient systems, asking them to work harder will never produce the desired results.

3) Demand Forecasting Part of the uncertainty in predicting our hospital capacity needs is that it is unclear how well this country will manage the chronic care needs of the baby boomer generation. If we do not improve the organization and delivery of chronic care in the near future, particularly in the Medicare program, then it is very likely that we will need more hospital beds durMetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

ing the next three decades. The connection is very clear: poor management of chronic conditions leads to preventable hospitalizations. Improving the quality of chronic care is a complex challenge that will involve both patients and the care delivery system. But unless we intend to hospitalize our way to better health, I don’t believe we have any choice other than rising to the challenge.

The other major wildcard in predicting demand is whether there will be a resurgence of utilization control in the U.S. The recent explosion in health care costs has set the stage for another discussion about how to control spending. The last time this discussion occurred, managed care was the answer. But strict utilization control by insurers was largely rejected by the public and policymakers, and now insurers are passing along the cost of unchecked demand to employers and patients.

The question is not whether the current trends (health care costs increasing 3-4 times faster than GDP) are sustainable. Ultimately, they are not.

The question is, what will we do about rising health care costs? The list of options isn’t that long: a) Administrative costs Whenever the cost of U.S. health care is challenged, people are quick to point out high administrative costs in the system. While this may be true, it is a direct result of the desire of Americans to have multiple choices in health care. Yes, we could potentially reduce administrative costs in some areas, but these savings will not be dramatic. The only option for dramatically reducing administrative costs is to move to a single payer system, an option that has been rejected multiple times in our history and is not politically viable today. The recent increase in professional liability premiums is another area where costs may potentially be reduced—but we’ll have to save that discussion for another day. b) Technology The biggest driver of health care costs over the long-term is new technology, including prescription drugs. With the recent doubling of funding for the National Institutes of Health, as well as large research and development expenditures by the biotechnology and pharmaceutical industries, there is no question that this trend will continue. c) Demand for services Rapid growth in the volume of health care services has been one of the most important factors in recent health care cost increases. Consumer demand is particularly important for ambulatory services and prescription drugs. On the hospital side, loosening of utilization controls has been a factor, as has the growing burden of chronic disease. d) Reimbursement If the potential for reducing administrative costs is limited, and the demands for services and new technology are increasing, then the only area left for controlling health care costs is to decrease reimbursements to providers. Of course, this is exactly what we’re seeing in public programs like Medicare and Medicaid. Although providers (hospitals and physicians) have had very limited success improving public program reimbursements, they have done somewhat better negotiating payments with private payers. This is one reason why health insurance premiums have increased so sharply in the past two years. Unfortunately the consequence of higher premiums is MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

that employers drop insurance coverage. That is exactly what we are seeing today as the number of uninsured is once again rising.

If one is to predict future demand for hospital beds, it is important to consider the public policy dynamics of growing health care costs. Looking at the list above, we aren’t likely to find dramatic savings with administrative costs. Technology will continue to drive cost increases as we demand promising (and expensive) new services. And right now it isn’t clear who, if anyone, will step up to slow the growing demand for services. So that leaves us with reimbursement.

The worst case scenario would be a continuation of current trends: flat or falling reimbursement to providers from public programs and growing numbers of uninsured people due to surging health insurance premiums. These trends could create a situation where a clear need for new hospital beds exists, yet there aren’t any resources to build and/or staff the beds. Unless we begin to focus demand on those health care services that are most likely to improve the quality of patient outcomes, the outlook for controlling health care costs is rather bleak. The transformation of utilization control to a quality paradigm rather than simply a cost-controlling paradigm is one of the key challenges we face in health care. This transformation cannot take place without the shared commitment of key stakeholders: physicians and other providers, patients, hospitals, payers, employers, manufacturers, and policymakers. Our success in controlling utilization will be a key factor in forecasting the need for hospital beds.

4) Hospital Financing We can discuss a variety of operational issues and demand forecasting models, but at the end of the day, hospitals face a stark reality in today’s health care marketplace. They simply cannot make money unless they maintain a high patient census. A combination of public policies and private competition has forced hospitals to operate in a capacity range that routinely exceeds 80 percent of staffed beds. In other industries with variable demand, suppliers raise prices, improve productivity, and/or add capacity when demand routinely exceeds 80 percent of capacity. Hospitals do not have the option to raise prices for their biggest payer (i.e.

Medicare), and there are limits to the increases that will be tolerated by private payers and large employers. Therefore, hospitals cannot simply add capacity without taking the risk of losing money. Policymakers view this as the best way to create “efficiency” in a sector of the economy that routinely experiences market failures. Whether or not it is efficient is a matter for debate. But the direct consequence of operating with census rates over 80 percent is that hospitals will be unable to meet the demand for emergency admissions during peak times. In other words, EDs will often be full of admitted patients and ambulances will be diverted.

The discussion of all of these issues—capacity data, operational efficiency, demand forecasting, and hospital financing—is a long answer to a simple question. Do we need more hospital beds? Hopefully this discussion illustrates why the answer depends on many dynamic factors.

Over the short-term (three to five years) I think we need to improve the operational efficiency of our hospitals and collect better data to understand the hourly variability in demand for hospital services. In the Twin Cities, I would not recommend major expansions in bed capacity in the (Continued on page 10)

March/April 2003

9

Colleague Interview (Continued from page 9)

next few years. During this time period, hopefully we will begin to get a better outlook on the complex factors that affect the long-term demand for hospital beds. We may be in a better position then to decide whether or not new beds should be built. So I wouldn’t call the architects today, but we may need to when the baby boomers begin to retire.

Given that metro area hospitals are at or near capacity, how is it determined that hospitals will be able to respond to a terrorism or natural disaster event?

I was glad to see this question, since I believe that the lack of hospital capacity is a key aspect of emergency preparedness that has been largely overlooked. The biggest problem is that our hospitals have little, if any, “surge capacity.” The implications of the surge capacity deficit vary with the type of disaster. If the event unfolds over a period of days (e.g. smallpox, anthrax), then hospitals and clinics will have time to transition out of normal practice modes and into a disaster footing. This doesn’t mean that they would not have problems with capacity—a smallpox outbreak would undoubtedly cause horrendous capacity problems. It does mean that the immediate capacity status of the ED at the time of the outbreak is not the most important predictor of the health system’s ability to respond to the crisis.

On the other hand, a chemical attack or traditional mass casualty event has the potential to expose the serious consequences of routinely operating the emergency care system without surge capacity. The problem is that organophosphate poisonings and trauma patients can only be effectively treated in EDs and trauma centers. If patients have critical injuries, they should only be treated in a trauma center. If our EDs are routinely operating at or above capacity, where does the surge capacity come from to treat these patients? Right now I believe that the health system’s capacity to deliver emergency care for sudden surges in patient demand is extremely limited, and this issue has not been discussed with the sense of urgency it deserves in today’s climate. Hopefully the link between capacity and preparedness will be explored much more thoroughly in the near future.

What do you see as the major limiting factor in patient access to hospitals besides the obvious issue of insurance coverage?

It really isn’t the lack of access to hospitals that has driven the utilization patterns we have seen in recent years. In contrast, inadequate access to primary care and poorly organized chronic care delivery have led to higher demand for ED and hospital services. Because of the Emergency Medical Treatment and Labor Act (EMTALA), hospital EDs are mandated to medically screen and stabilize all patients regardless of their ability to pay. By mandate and mission, EDs have become core safety net providers in the U.S. health care system. In the ambulatory care system, patients face access barriers that extend far beyond insurance coverage 10

March/April 2003

(though that is certainly one of the major barriers). Inadequate capacity for unscheduled care is certainly a major problem. With the extremely tight schedules in today’s ambulatory care environment, physicians often do not have the time or resources to care for a complex patient with an acute problem. Some clinics reserve time in the schedule for walk-in patients, but these appointment slots often become saturated. It is particularly difficult for new patients to access clinics for the first time if they have an acute problem and need an urgent appointment. Other access barriers exist because of cultural, transportation, language, financial, and scheduling barriers. For instance, job and/or educational conflicts may prevent patients from accessing ambulatory care during normal clinic hours. When barriers to care exist in other settings, the hospital ED often ends up being the only open door.

What are the impacts of nursing and other hospital staffing shortages in hospital bed capacity? Are there any solutions in sight?

The nationwide shortage of nurses is certainly one of the key contributing factors to hospital and ED crowding. There is nothing more frustrating than knowing that a bed is available, but there’s no nurse to take care of your patient. This issue deserves more detail and expertise than I can offer, but here are a few comments.

A) The Nursing Work Environment Some people have pointed out that we don’t truly have a shortage of nurses in this country, but we do have a critical shortage of nurses who are working at the bedside. One could debate whether this statement is technically correct or not; however, I think it is clear that there are serious problems with the work environment for hospital nurses, and that these adverse working conditions are driving nurses out of clinical positions. Although financial issues are certainly important, this problem is about much more than money. I recently conducted a site visit at an urban public trauma center in Florida during a national study of ED crowding. An ED nurse who was clearly beyond the point of mere frustration offered this telling quote about efforts to retain nurses in her ED: “Money is what becomes important after everything else has failed.”

Lifestyle considerations, patient safety, nursing workload, professional respect, and the ability to deliver quality patient care are all very important to nurses. I wish I could point out a simple roadmap for improving the work environment for clinical nurses, but I think this is a complex issue that defies simple solutions. That being said, if the dissatisfying aspects of the work environment for bedside nurses are not addressed in the near future, we could reach a point where even the most generous financial incentives will be unable to prevent nurses from leaving hospitals.

B) Nurse Staffing Ratios California has recently mandated very specific nurse/patient staffing ratios on hospital units. Likewise, the nursing settlement in Minnesota hospitals has allowed inpatient nurses to refuse admissions when they believe that nurse/patient ratios will be insufficient. The policy rationale behind capping nursing ratios is reasonable, and recent studies MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

have confirmed the relationship between patient outcomes and registered nursing care hours. The only question is, what happens when there are more patients who need care than there are nurses to maintain the ratios? Unfortunately the effect of these policies could fall on the shoulders of the ED, which by definition cannot close its doors. If inpatient units refuse to accept patients because of staffing ratios, and there are no nurses available to call in, then what does the ED do? It makes little sense to maintain normal staffing ratios throughout the entire hospital and concentrate all of the excess patient demand in the ED, yet that is exactly what could happen as these policies are adopted. In the same Florida hospital that I referred to earlier, staffing ratios in the ICUs were consistently held at two patients/nurse. They increased this to three patients/ nurse on rare occasions. At the same time, nurses in the ED were responsible for up to seven critical care patients, some of whom were being actively resuscitated. If quality of care is our ultimate goal, there has to be a better way of distributing the workload.

C) Agency Nursing A concerning trend is the rapid growth in agency nursing. On one hand, it’s good that these agencies exist, otherwise where would hospitals turn when they can’t find a nurse? On the other hand, the growing ranks of agency nurses around the country are exacerbating the financial predicament of hospitals. The cost of agency nurses is much higher for hospitals than employee nursing rates. Furthermore, agency nurses are usually not familiar with the hospital’s policies and procedures. So even if they are talented individuals, the lack of familiarity creates problems with patient flow and the cohesiveness of care teams.

Agency nursing jobs are very attractive to nurses because they offer higher pay, greater flexibility, and the option to travel. This raises the stakes for hospitals when it comes to nurse recruitment. They not only have to compete against other hospitals, they also have to compete against agency and traveling nurses organizations.

D) Solutions?

Hospitals and educational institutions have already begun to adapt to the long-term need for nurses. Educating more nurses is an important part of the long-term solution to this problem, and we have to start today. Over the short-term, I think the most important issue is to address the work environment for clinical nursing. The key challenge is to provide incentives for nurses to be promoted and rewarded for staying at the bedside. Meeting this challenge will require a multidisciplinary effort and flexibility by everyone involved: nurses, physicians, and administrators. Unfortunately, the short-term likelihood is that the nursing shortage could get worse before it gets better.

Do you see any hope in the near future regarding the shortage of psychiatric beds?

Despite all of the problems with hospital and ED capacity that I’ve discussed above, the reality is that Minnesota is in much better shape than other parts of the country when it comes to medical and surgical beds.

We certainly have a problem with capacity, but in contrast to many areas MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

of the country, we are not in a state of crisis. I only wish I could say the same thing about psychiatric care. Unfortunately, the word “crisis” is entirely appropriate when describing psychiatric bed capacity in Minnesota.

Acute care psychiatric hospitals have found themselves in a vice grip between the ambulatory behavioral health system and long-term psychiatric care. As the capacity for care disintegrates on both the ambulatory and long-term ends of the behavioral health care spectrum, the only remaining options are hospital EDs and inpatient psychiatric units. The consequence of this capacity crisis is that psychiatric patients routinely sleep in EDs waiting for inpatient psychiatric beds. It is not at all surprising to hear that every psychiatric bed in the Twin Cities is full. The problem is particularly severe for child and adolescent psychiatry, where patients can wait for days to find a bed. Psychiatric patients of all ages are routinely transferred out of the metro area and out of the state for inpatient care. The situation is so extreme that it raises safety concerns for both patients and staff, and often limits the ability of the ED to serve new patients. How can this be quality care?

The looming threat for this issue over the short-term is the state budget deficit. I am very concerned that there will be further cuts in long-term psychiatric care, including the possibility of state psychiatric hospital closures. If these cuts occur, the burden will fall directly on the shoulders of the acute care system. Undoubtedly this would exacerbate the severe capacity shortages that already exist in psychiatric hospitals, and make the situation in EDs even worse. Hopefully policymakers will see that the behavioral health care system is already in crisis, and protect this sector of state spending from budget cuts. But given the magnitude of the budget shortfall, it is likely that this area will be affected.

There is some hope on the horizon. Attorney General Hatch, Mary Brainerd (CEO of HealthPartners), and other health care leaders have identified the behavioral health crisis as a high policy priority within the health care system. Their involvement in this issue is very encouraging, and I hope it leads to some solutions. They have specifically addressed the need to improve access to urgent outpatient behavioral health services. Because it is difficult to send some patients home if they do not have reliable access to follow-up care, it would be extremely helpful to have the option of referring patients to urgent behavioral health followup appointments. If this type of access were improved, many psychiatric hospitalizations could potentially be avoided. This is a very promising development in an area that is otherwise in a state of crisis.

What is the effect of the limited hospital bed capacity on the training of future physicians in residency programs?

Limited hospital bed capacity has mixed effects, but on balance, I believe that it compromises education. From the ED’s perspective, there is often less time for teaching when the clinical environment is crowded. Also, based on everything we know about patient safety, the risk of medical errors goes up as normal operating capacity is exceeded. The biggest concern is that we are teaching young physicians that it is “normal” to practice in an overburdened environment. This is concerning, because it will (Continued on page 12)

March/April 2003

11

Colleague Interview (Continued from page 11)

inevitably produce a generation of clinicians that expect to work in an environment that is operationally inefficient.

There are some positive aspects of the bed capacity problem for training. Emergency medicine residents are getting a great deal of critical care experience. Unfortunately, this experience is gained because ICU patients wait in the ED for hours (and in some areas of the country, days) for a bed. This is far from an ideal model for teaching critical care skills to emergency medicine residents. Hopefully, as hospitals begin to address operational inefficiencies in an aggressive manner, residents will be taught how to change systems to make them more efficient. This is important not only because efficient systems can improve functional capacity, but also because these systems are the foundation for improving the quality of care.

What does your research indicate for the future role of hospitals in our health care system?

The future role of hospitals will be heavily influenced by the health policy issues discussed above—financing, the uninsured, workforce issues, the demand for care, chronic care organization and delivery, and quality improvement initiatives. Each of these issues has the potential to change the role of hospitals. As new diagnostic and therapeutic technologies are developed, I suspect that more conditions will either be managed on an

outpatient basis, or with brief hospital stays in an observation or clinical decision unit setting. The inevitable consequence of this trend is that the average acuity of patients in traditional inpatient units will continue to increase. Hospitals will likely evolve into centers that offer two major types of care: critical care and rapid diagnostic services.

The other trend that will affect the role of hospitals in many parts of the country is the development of specialty hospitals such as heart or orthopedic hospitals. These facilities are typically for-profit hospitals, and as such, they have not gained a foothold in Minnesota. The obvious concern for hospitals is that these for-profit centers will attract the most lucrative patients, leaving traditional hospitals with their longstanding burdens of uncompensated care but no resources to cover the costs. Interestingly, these specialty facilities often do not have an ED; therefore they do not have to share the community burden of providing emergency services under EMTALA. Hospitals will always play a critical role in the health care system.

But at the end of the day, we cannot hospitalize our way to better health.

Hopefully, problems such as the capacity crisis will motivate us to examine the fundamental problems in the health care system. We must ask ourselves: what kind of system do we want? There is no question that health care reform is complex and politically challenging. But ultimately the health care system is ours—we are not powerless to change it. The road to finding more room in our hospitals winds through nearly every major health policy challenge we face today. Since we have no choice but to travel down that road, we may as well solve some of these problems along the way. ✦

Membership Advantages for Metropolitan Physicians and their Practices AmeriPride Linen Service has recently partnered with HMS and RMS to provide our members with group purchasing power. They offer our members discounts on their products and services, including medical garments, linens, among other things. Visit our website at www.metrodoctors.com. If you are an existing customer, you can still benefit from our discounted pricing.

Berry Coffee Service has recently partnered with HMS and RMS to offer our members up to 25% discounts off of their popular products and services.

To get a free comparison of your current program to Berry Coffee Service’s program, simply call Bob Dilly, Berry Coffee at (952) 937-8697.

Code GREEN is a powerful standalone application for PALM OS devices that provide you with a simple tool to capture, verify and Business AdvantEdge offers our submit charges all with just a few clicks on your Palm. members discounts on virtually everything you will Shouldn’t you collect every dollar from every patient need to run your offices — computers, printers, fax encounter? Code GREEN can help you do that. To machines, copiers, cell phones, office supplies through learn more, call us, or visit Code GREEN’s Office Depot, courier services, and local and long website at www.mdvision.net. distance phone services.

CHECK OUT OUR WEBSITE AT WWW.METRODOCTORS.COM TO LEARN MORE ABOUT ANY OF THESE VALUABLE MEMBER BENEFITS.

Call HMS or RMS at 612-623-2889 for details.

12

March/April 2003

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

CUSTOM-RX COMPOUNDING PHARMACY A COMPOUNDING ONLY PHARMACY

Durenberger Provides Health Policy Update

Bio-identical, Natural Hormone Replacement Therapy Special Dosage Forms & Strengths Injectables & Ophthalmics Pain Management Pediatric Formulations Hospice Compounds Consultations Available Shipping Available

T

THE HONORABLE David Durenberger, United States Senator from 1978 to 1995 and current Chairman of the National Institute of Health Policy, presented at a recent meeting of the Metropolitan Hospital Physician Leadership (MHPL) Committee. MHPL is a group convened by the Hennepin and Ramsey Medical Societies and includes medical staff presidents, presidents-elect, and vice presidents for medical affairs for metropolitan hospitals. During his presentation Senator Durenberger made the following observations: (1) Health care spending was a $3.6 billion “crisis” in 1929, a $60 billion “crisis” in 1970, an $800 billion “crisis” in 1980, a $1.542 trillion “crisis” in 2002, and doubles every five years.

(2) Cost containment strategies such as supply regulations in the 1970s, price regulation in the 1980s and behavioral modifications in the 1990s have all failed.

MetroDoctors

Custom-made compounded medications for Humans and Animals

Custom-RX Compounding Pharmacy Verne Betlach R.Ph., FIACP Compounding Pharmacist 6519 Nicollet Ave. S., Suite 201 Richfield, MN 55423 612-866-2211 Fax: 612-866-9717 Toll Free: 888-303-9033 www.customrx.com

(3) The latest “solutions” appear to be consumer-driven health care, more cost containment, patient safety, and tax policy. But none of these actions will change the health care system.

Senator Durenberger feels that only an “inside-out reform” will change the system. He feels that the keys to true health care reform include: (1) Evidence-based medicine; (2) Evidence-based operations (i.e. electronic medical records); (3) Lowered transactions costs by removing unnecessary complexity; and (4) A model consumer, who uses new information sources, is sensitive to price and value, and who engages in prevention and healthy lifestyles.

The National Institute of Health Policy, a partnership of the University of Minnesota and the University of St. Thomas, provides an opportunity for physicians to participate in this important debate. Their web site is www.nihp.org. ✦

The Journal of the Hennepin and Ramsey Medical Societies

WEBER

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

• Licensure • Employment Law • Trial Work • Wills and Estates • Regulatory Compliance

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

612-296-8080 www.weber-law.com “Committed to the Best Legal Outcome Possible Through Diligence and Resourcefulness!”

March/April 2003

13

MMA Announces Robert Meiches, M.D. Will Be New CEO

T

THE MMA BOARD OF TRUSTEES on January 18 unanimously accepted the recommendation of its ad hoc CEO Search Committee selecting Robert Meiches, M.D. as the MMA’s new CEO. The CEO Search Committee, working with Korn/Ferry International had considered many qualified candidates throughout the country before recommending Dr. Meiches. He will replace Paul S. Sanders, M.D., a family physician in Cambridge, who has served as the MMA’s CEO for 12 years. The Minnesota Medical Association represents more than 9,000 physicians throughout the state.

Dr. Meiches, a Minneapolis physician who specializes in internal medicine and geriatrics, served as chair of the Minnesota Medical Association Board of Trustees from 1999 to 2002.

In addition, he served as a delegate to the MMA from the West Metro district from 1993-2002, a West Metro Trustee from 1993-2002, and he chaired the Hennepin Medical Society caucus for three years. An MMA/HMS member for 15 years, he has been active on many health care issues including those related to Medicare and Medicaid.

Do you need support treating patients with eating disorders? We can help.

The Eating Disorders Institute (EDI) offers residential, inpatient, partial-day and intensive outpatient programs in a newly expanded space. EDI is a partnership with Methodist Hospital and University of Minnesota physicians.

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

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

14

March/April 2003

MetroDoctors

Currently, Dr. Meiches is the vice president of medical affairs and operations at FairviewUniversity Medical Center and Fairview Health Services in Minneapolis and a clinical associate professor at the University of Minnesota’s Department of Family Medicine and Community Health.

Dr. Meiches is a member of the American Medical Association, the Minnesota Medical Association, the Hennepin Medical Society, and the American Geriatrics Society. He is a board member of Medical Alley of Minnesota and the Minnesota Center for Health Care Ethics, as well as a past president of the Minnesota Medical Directors Association.

Dr. Meiches received a bachelor of arts degree from Carleton College in Northfield, a doctor of medicine degree from the University of Illinois Abraham Lincoln School of Medicine, and a master’s degree in business administration from the University of St. Thomas in St. Paul. He completed his residency at Hennepin County Medical Center. He is board certified in internal medicine and geriatric medicine. ✦ The Journal of the Hennepin and Ramsey Medical Societies

“D-day Compliance” A Quick Way to Meet the Priorities of HIPAA If your practice is not yet HIPAA compliant, how can you get there quickly and within the required timeframe?

A

AS THE APRIL 14, 2003 DEADLINE for

compliance with the HIPAA Privacy Rule approaches, how can the individual provider determine the best strategy to become and remain compliant with the HIPAA regulations?

Let’s deal with the compliance issue in five parts: • Why should you actually work toward compliance?

• What is required to become compliant?

• What are the possible strategies?

• What do you actually need to do?

• How should you start?

Why actually work toward compliance?

Besides the obvious risk of government fines, there is the much greater certainty that your health plans, business partners and malpractice insurers will require that you self-certify compliance – to guard their own compliance efforts. Since these larger organizations will be more in the public (and the regulator’s) eye, these organizations will be very cautious about their own compliance and will consequently be concerned that their partners maintain the privacy of the patient data that they share.

The greatest threat to the individual small organization is potential lawsuits for breach of privacy. HIPAA does not allow individuals to sue for breaching HIPAA; in legalese, there is no “right of private action.” However, HIPAA establishes minimum standards for the way any provider handles protected health information (PHI) and, thus, an individual can sue a provider for breach of privacy and the HIPAA stanBY LEWIS LORTON AND TOM PINGER

MetroDoctors

dards will be used as the measure of how well the organization has protected the patient’s information. Your evidence of compliance is the best defense against these kinds of suits. In the reverse, the lack of documented effort to comply would be an embarrassing, perhaps disastrous, admission in court.

What is required to become compliant?

The Privacy Rule, and indeed all of HIPAA, is meant to be scalable and requires only that “reasonable” responses be made. You don’t have to build sound-proof rooms or buy new filing systems, but only make reasonable efforts to safeguard the privacy and security of your patient data. The Privacy Rule has a certain simple baseline of requirements: • Appoint a Privacy Officer or Official who is responsible for compliance; • Evaluate your practice against the individual “standards” in the Rule; • Make “reasonable” decisions about how your organization will comply with the standards – and document these decisions; • Develop and circulate HIPAA-compliant policies and procedures to your staff; • Train your staff – and document their training; • In the event of any privacy breach, do your best to repair any damage, evaluate your policies and procedures to see if changes need to be made to ensure it doesn’t happen again; • Maintain awareness of any changes in the HIPAA rules; and • Retrain your staff as needed.

The actual amount of effort is really dependent on how much change will be needed.

The Journal of the Hennepin and Ramsey Medical Societies

The most crucial issues in the long-term are keeping current with the HIPAA regulations as they change and documenting everything.

What are the possible strategies to achieve and maintain compliance with minimum impact?

There are four basic approaches to this effort: develop in-house expertise; hire consultants; use software tools; or any combination of the above.

The challenge in the do-it-yourself approach is making sense of all the information and ensuring that you’ve accessed all the necessary information to become compliant. Where do you begin? How do you sift through all of the available information to determine what you need to know? How much time will this require? What expertise does your assigned staff member(s) have to understand the regulations without outside assistance? How practical are these options and how cost effective are they for your practice? After all of this is accomplished, how do you stay current and remain compliant when the regulations change?

The challenge in hiring outside consultants is two-fold. The first is finding a consultant that is knowledgeable, trustworthy and worth the cost. The second challenge is managing the recommendations from the consultant. Many consultants, like attorneys, are conservative and will be ultra-cautious in their recommendations because they don’t want to take the chance of under-diagnosing solutions.

Their reputation is built on not letting you fail, thus their recommended solutions may not be the most reasonable for your organization. It is (Continued on page 16)

March/April 2003

15

HIPAA D-day Compliance (Continued from page 15)

crucial that each provider evaluate the gap assessment prepared by the consultant and make her/his own decisions about the reasonable solution.

Choosing software tools is an equally daunting task. The provider organization must ask: is this tool aimed at my type and size of practice; is it usable by my staff; is it convenient and cost-effective; will the tool be current with changes in the regulations; does the tool provide help with all the HIPAA requirements; and, most important, how can I be certain that the information is complete and good?

What do you actually need to do?

This list is an overall “to-do” list that will lead you, incrementally, to a compliant office – and an organization that understands and honors the responsibilities towards your patient’s health information.

• •

•

•

•

• •

•

Choose and train a Privacy Officer.

Perform a baseline assessment of your office activities in regard to the standards of the Privacy Rule.

Create a list of changes required, and develop and implement a schedule for making the changes.

Create HIPAA-compliant policies for the office – HIPAA requires a specific policy, the Notice of Privacy Practices, be available to your patients at the first interaction after April 14, 2003.

Create a list of all of your Business Associates and get started on executing HIPAA-compliant Business Associate agreements.

Train your staff about their responsibilities – and document the training.

Start documenting any disclosures of patient health information that are not for treatment, payment, or operations.

Document any incidents and the mitigating actions taken.

• •

Audit your office periodically.

Retrain the staff periodically.

How should you start?

Compliance will take some time so your organization should start working toward compliance immediately by evaluating the issues, fixing the most obvious problems first, and developing a new corporate culture that understands the importance of protecting PHI. Complying with the HIPAA regulations can appear to be an insurmountable task but in reality most well-run offices are actually living up to most of the standards already and need only to understand their responsibilities and document their actions. ✦ Lewis Lorton, DDS, MSD is a nationally known expert in the area of HIPAA compliance and the founder of HIPAAdocs Corp. Tom Pinger, President, PingTech, Inc., is an independent representative of the HIPAAsteps™ program, and specializes in IT solutions for healthcare organizations.

Looking for a HIPAA Compliance Program?

HMS and RMS have partnered with HIPAAdocs to provide our members with a 20 percent discount off of their nationally recognized HIPAA compliance program. The beauty of HIPAAdocs is that their program is easy to use, very thorough, and is priced very reasonably.

The HIPAAdocs program is: • Fast: You can move through the questions and answer format very quickly and find out exactly what is required for your practice to comply with HIPAA. • Complete: All training and policies are included so you can save time and money on expensive consultants, attorneys and seminars.

• Secure: The content of the program is provided by experts you will recognize and endorsed by the best-known and largest medical associations and organizations in the country.

• Easy: You don’t need to be a HIPAA expert. You only need to answer questions about your practice and the HIPAAdocs program does all the rest!

• Permanent: Your compliance will never slip because regulatory changes are automatically reflected in updates to your compliance program.

The HIPAAdocs staff answers questions via toll-free phone and email access and keeps you up-to-date with what is going on with newsletters and alerts.

16

March/April 2003

The cost for a small practice is about one-half a consultant’s day and less time than sifting through manuals and attending seminars all while trying to decide how to accomplish compliance.

By the end of 2002, HIPAAdocs had approximately 1,800 user organizations with clients in all 50 states.

HMS and RMS recently sponsored two seminars for our members to introduce them to the HIPAAdocs program. Nearly 60 participants attended and both sessions were very informative and interactive. Another seminar will be held prior to the April 14 deadline. If you are interested, please contact us at 612-623-2889, or email us at rms@metrodoctors.com. ✦

More than 35 physicians and clinic staff members listen to a presentation on HIPAAdocs hosted by HMS and RMS.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

A Medicare Victory in Congress

I

IT’S A WIN! I hope you all have been celebrat-

ing the significant victory for organized medicine that occurred Thursday, Feb. 13, when the House and Senate passed the Conference Report on the Omnibus Appropriations package (H. J. Res. 2). This bill includes language authorizing HHS to correct the 1998 and 1999 projection errors. The House approved the Conference Report by a vote of 338 to 83, and the Senate passed it by a vote of 76 to 20. The Congressional Budget Office projected that the physician payment provision would increase baseline spending by $54 billion over 10 years.

At a House Ways and Means hearing that day, CMS Administrator Tom Scully indicated that as a result of congressional action he intends to implement a +1.6 percent update for the Medicare conversion factor effective March 1, 2003. Logistics with Medicare carriers need to be worked out and there may be some lag time in payment adjustments.

The Omnibus provision is a huge improvement for physicians over current law. Elimination of the projection errors lifts physicians out of a huge budget hole and increases our ability to pursue other policy objectives. However, this does not mean we are done by any means with the Medicare physician payment formula.

gains will be much greater since other public and private insurance programs base their payments on the Medicare fee schedule.

Kudos for a Tremendous Grassroots Effort Again, this is a notable victory for all of us.

The AMA, county, state and national medical specialty societies along with group practice organizations, other health professional groups, the Association of American Medical Colleges and the Military Officers Association of America worked relentlessly and effectively to achieve this outcome.

In my speech to the House of Delegates at the Interim Meeting in December, I gave the metrics on the tremendous Federation grassroots effort that so far had gone toward resolving the Medicare mistake: the hits on the Washington web site, the calls to the grassroots hotline, the e-mails to Congress. At that time, we said that no Senator or congressional representative could say they didn’t know about the cuts. Since then, the contacts with Congress have snowballed — thanks to all of you, we made sure each of them was well aware of our issue, and its solution.

Background Information We have estimated the spending increases for all physicians and for individual physicians in Minnesota. State estimates reflect size of Medicare population, physicians per state, and enrollment in Medicare+Choice. These estimates reflect Medicare spending only. The positive

We also mustn’t forget the contributions made by AMA leaders, members, and staff.

Much excellent, often behind-the-scenes, work went into this victory. From personal visits to Capitol Hill, meetings with the Administration, advertising within — and outside — the Beltway, House Call visits in key states, and well-informed messages in many media — we made sure that we would complete that last pass. We never stopped throwing the ball.

Communicating the Victory When victory came, we immediately blitzed the public and the Federation with a major news release, and many calls/interviews with reporters from leading national and local newspapers and radio and TV stations. The victory instantaneously became the lead feature on the AMA web site, and became the top story in all the many communications vehicles we share with the Federation, our members, and our staff.

I also want to send my thanks to our many Federation partners who shared the credit and the celebration with us, communicating to their membership the enormity of the win and the solidarity of those who brought it about. Thanks to all of you for the victory for all of us! ✦

MEDICARE PAYMENT UPDATES Calendar Year 2003 Impact for Minnesota Total Increase $30 million

Increase per Physician $2,800

Aggregate 2003-2012 Impact for Minnesota

B Y M I C H A E L D . M AV E S , M . D .

Total Increase $698 million

Increase per physician $61,300

CEO of the AMA

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

March/April 2003

17

PHYSICIAN'S SOAP BOX

Health Care in Japan Editor’s Note: As part of an on-going series, MetroDoctors would like to encourage other physicians to write about their observations and experiences of health care delivery in other countries. Send articles to Nancy Bauer, Managing Editor, at bauerfamily@earthlink.net.

Dear Colleagues:

F

For the past six months, I have been a visiting associate professor of medicine at Keio University Medical School in Tokyo. This is Japan’s foremost private medical school. I am based at the flagship 1,100 bed University hospital that serves 5,000 outpatients per day. The MetroDoctors Advisory Board asked me to comment on my experiences. I am only too happy to do so because some of the contrasts are so fascinating.

First, let me share some basic details about Japan. This is an island country of 127 million people in a space about the size of California.

Space is at a premium: a typical Minnesota hospital room would be considered a luxury only royalty and billionaires could enjoy.

Cultural diversity is an unknown concept. Ninety-nine percent of the country is Japanese by ethnicity. The net migration rate is 0 per 1,000 population. Eighty-four percent of Japanese are both Shinto and Buddhist. Christians constitute 0.7 percent of the population.

Japan’s constitution guarantees access to health care for all. Japan has a strong primary care infrastructure. Of the 243,201 physicians, 184,910 are internists and 35,309 are surgeons. There are only 2,819 cardiovascular surgeons. Japan has the world’s longest life expectancy at 77.73 years for men and 84.25 years for women. Whereas the U.S. spends 14.1 percent of its GDP on health care, Japan spends just 7.1 percent.

What might we learn from Japan? Let me share some surprising statistics, which go against the conventional wisdom. Low costs are not because of inpatient care controls. The average length of stay for hospitalizations in Japan is 34 days. The length of stay for normal newborn deliveries is about two weeks. Furthermore, Japan has 16.2 beds per 1,000 population (vs. 4.0 in the U.S.) and has four times as many inpatient care days per person per year than the U.S. I have yet to meet a physician who has had any difficulties in admitting a patient. Many psychiatrists have thought my questions regarding inpatient mental health care access were insane! Medically indicated but restricted access is unfathomable.

B Y G R E G O R Y A . P L O T N I K O F F, M . D . , M T S

18

March/April 2003

Low costs do not appear to be due to difficulties in billing and reimbursement. According to Keio Hospital officials, less than 1 percent of claims are screened before being reimbursed. And of these, only a very small percentage is rejected for payment. Reimbursement requests are submitted on the 10th of every month for the preceding month. Claims are paid within one month.

This leaves four potential reasons for lower costs: prevention; medications; outpatient controls; and malpractice limitations. I will address each of these. Regarding prevention, all cause mortality in Japan is 539 per 100,000 versus 736 in the U.S. For males, the probability of dying between ages 15 and 59 per 1,000 is 144 for the U.S. and 97 in Japan. For females, the rate is 83 in the U.S. and 47 in Japan. Something works here in Japan.

However, it may not be what we consider to be traditional risk factor management. For example, “health clubs” are rare. Coffee and alcohol consumption are incredibly high. I sincerely doubt many in the population get eight hours of sleep a night. And Japan has among the highest smoking rates in the world with 52.8 -61 percent of all men smoking. This includes 27.1 percent of all male physicians (versus 3-10 percent in the U.S.) and 43 percent of male fifth-year medical students. Cigarettes are readily available in vending machines on every floor of the hospital.

Although Japanese men smoke heavily, drink heartily, and work incessantly, circulatory system mortality per 100,000 is just 178 versus 289 in the U.S. In Japan, out-of-hospital cardiac arrest is relatively rare and is rarely due to VF. The public is not routinely trained in CPR: EMT’s were only allowed to learn it three years ago. Defibrillators are not found in public forums.

This cardiovascular protective effect appears to be more cultural than genetic as Japanese-Brazilians in Rio and Japanese-Americans in California have much higher rates of obesity, hypercholesterolemia and diabetes than age and sex matched controls in Japan. Mortality rates for Japanese are also significantly higher outside of Japan. And although Japan also has significantly lower rates of hormone-dependent cancers including breast, ovary, prostate and colon as well as significantly lower rates of osteoporotic complications such as hip fractures, these lower rates are not true for second-generation or later Japanese-Americans.

There are undoubtedly many reasons for such stark differences.

However, lifestyle should be on the differential. Differences which are very apparent to me in Japan include: significantly more walking, more sun exposure, stronger social capital, less bread and high-glycemic

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

index processed food consumption, more dietary-supplement (i.e. vitamin) consumption and higher anti-oxidant consumption (flavanoids and carotenoids via vegetables and soy foods). Japan also has the highest per capita fish consumption in the world. As a result, their omega-3 fatty acid serum concentrations are about four times that of U.S. men. This makes me wonder if we should focus less energy on tobacco and more energy on nutrition.

Are the Japanese saving money on medications? Here are some interesting facts. Japanese physicians give only 21 prescriptions for antibiotics per 1,000 direct patient encounters. This is a fraction of the 192 per 1,000 rate in the U.S. The rate of antibiotic prescriptions per 1,000 patients per year is less than half of that of the Netherlands and one-fifth that of Poland. For cardiovascular drugs, the rate is 84 per 1,000 patient encounters versus 247 in the U.S. For narcotic pain management, the national formulary contains only morphine and fentanyl. And fentanyl is not legally allowed in cancer patients. Very few women use HRT or oral contraceptives. For all conditions, more than 10 percent of the population use relatively inexpensive pharmaceutical-grade traditional herbal medicines. Over 100 such formulas are covered by the national health insurance. They can only be prescribed by physicians: 70 percent of all physicians and 88-96 percent of Ob/Gyns do so.

Are lower costs due to outpatient controls?

Perhaps. The outpatient care expenses per capita are $1,079 vs. $1,298 in the U.S. This is despite an average of 16 ambulatory care encounters per patient per year versus six in the U.S. On my first day in clinic, I was stunned to find 40 patients on the schedule to be seen between 9 and 12. I commented to my mentor’s boss, the chairman of cardiology, about how impressed I was by the volume of patients seen that morning. His response: “Oh, I routinely see 90-100 patients per morning.”

I am not kidding. Patients are scheduled in batches and given a half-hour time frame in which they are likely to be seen. Patient encounters are very brief: 4-6 minutes seems to be the norm. A new patient may be a bit longer at 10-15 minutes.

Efficiency is helped by prescription records and laboratory results being on the physician’s computer screen, by the chart being available 100 percent of the time, by hand written consultation notes being glued onto the chart’s progress notes at the time of service, by handout information being used liberally and by low patient expectations for lengthy dialogues. Physical exams are at best brief and results recorded by drawings and other visual means. Most impressive to me was the briefness of chart notes: 4-6 lines. Charting is completed immediately. Extraneous charting for legal and reimbursement purposes does not exist. All visits are reimbursed at the same rate.

The last cost driver I should mention is malpractice. Annual premiums are less than $500. The annual number of medical malpractice suits was 629 in 1998. In 1997, nearly 35 percent of awards were for less than $300. Non-binding out-of-court review of claims is offered by the Japanese Medical Association professional liability program. This absence of litigation appears to be a distinctly Japanese

phenomenon. The total number of lawyers is limited by law to just 17,000. In the 50 years after the end of WW II, there were just 129 verdicts in consumer product liability cases. For comparison, in the U.S., there are 200,000 cases filed every year. The concept of “defensive medicine” does not exist in Japan.

However, if you think that you are ready to move here, let me share some additional thoughts. First, all physicians are paid the same salary at their respective medical center. A pediatrician is paid as well as an obstetrician is paid as well as a cardiologist. There are minimal financial incentives to engage in invasive procedures. All income is shared. Productivity remains high because of peer pressure and the extreme difficulty in finding a job if asked to leave. There is very little lateral movement allowed. Most University physicians have outside practices to supplement their low salaries.

Second, there are patient safety concerns. JCAHO regulatory burdens do not appear to exist. Laboratory certification is still voluntary. Blood borne infection rates such as hepatitis B and C are most likely still high. Hospital infection control committees were only required last year. And only this year did the government acknowledge that 15,000 medical errors had occurred in Japan’s top 82 hospitals over the past two years. This is no surprise to Japan’s nurses. They note overwork and chronic shortages: Japan has just 55.7 nurses per 10,000 population (versus 81.4 in the U.S.) despite significantly more inpatient beds per capita. Whereas the U.S. has the highest number of FTE employees per hospital bed in the industrialized world, Japan has among the lowest.

Additionally, Japan’s medical system is on the verge of bankruptcy. The government-mandated employer-financed insurance system has been in deficit spending for the past several years. Costs are climbing rapidly due to the aging population. From 1989 to 1999, the medical care expenditures for the elderly more than doubled to 11 billion yen. Costs for elderly care climbed in that period from 28 to 38.2 percent of all health care costs.

And this will only worsen. Currently, 18 percent of the population is greater than 65 years of age with just 14.5 percent less than 15 years of age. The fertility rate is just 1.42 with no signs of increasing (the replacement rate is 2.08). These demographic discrepancies translate to extreme pressures on government and business-financed health care for the next 40 years.

Change happens very slowly in Japan. However, April 2004 will see the following completely new programs: 1) required two year residencies for all physicians; 2) requirements for 50 hours per year of CME; and 3) the introduction of per diem style DRG’s. The first two will address significant concerns regarding the quality of care provided.

The last will encourage shorter stays. For a given diagnosis, after a certain time period, per day reimbursement rates will decrease.

I hope you have found this provocative. I look forward to sending future reports on health care in Japan that will be helpful in addressing our own challenges in Minnesota. ✦

The concept of “defensive medicine” does not exist in Japan.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Gambatte kudasai!

Gregory A. Plotnikoff, M.D., MTS GP_JAPAN@atg.miinet.or.jp March/April 2003

19

Highlights of the Code of Medical Ethics of the American Medical Association Section E-8.00, “Opinions on Practice Matters” Upon first consideration, Section 8.00 of the Code of Medical Ethics, “Opinions on Practice Matters,” appears to include guidelines on many unrelated topics. The Section addresses conflicts of interest, managed care, some limits to appropriate physician behavior within the therapeutic relationship, and medical decisionmaking. However, a close analysis of the Section reveals a most important theme of professionalism: physicians’ duty to place patients’ interests above their own.

Medicine has a long tradition of requiring physicians to commit their knowledge and expertise toward promoting patient welfare.

Whereas the original 1847 Code certainly emphasizes physicians’ duty to promote their patients’ interests, the 1957 version of the Code is far more explicit in requiring physicians to be sensitive to circumstances that could compromise this obligation, particularly when physicians must contend with competing interests.

The latter states, “A physician should not dispose of his services under terms or conditions which tend to interfere with or impair the free and complete exercise of his medical judgment and skill or tend to cause deterioration of the quality of medical care.”

Today, the Code’s guidance for physicians who face a financial conflict that could undermine a patient’s interest is unequivocal. Opinion 8.03, “Conflicts of Interest: Guidelines” states: “Under no circumstances may physicians place their own financial interests above the welfare of their patients. […] For a physician unnecessarily to hospitalize a patient, prescribe

BY SARA TAUB, AMY M. BOVI, MA, AND LEONARD J. MORSE, M.D.

20

March/April 2003

a drug, or conduct diagnostic tests for the physician’s financial benefit is unethical.” Several other Opinions in the Section clarify that this standard applies whenever physicians are caring for patients or more generally acting in a professional capacity that may affect patient care. (Opinions 8.02, “Ethical Guidelines for Physicians in Management Positions and Other Non-Clinical Roles,” 8.021, “Ethical Obligations of Medical Directors,” 8.031, “Conflicts of Interest: Biomedical Research,” and 8.0315, “Managing Conflicts of Interest in the Conduct of Clinical Trials”.)

Also, today’s Opinions on “Conflicts of Interest: Health Facility Ownership by a Physician” (8.032) and “Conflicts of Interest in Home Health Care” (8.035) discourage physicians from referring patients to health care facilities in which they have an investment but at which they do not directly provide services.

These Opinions are intended to curtail physicians’ involvement in commercial activities that rely on patients as customers, along with Opinions on “Sale of Non-Health-Related Goods from Physicians’ Offices” (8.062) and “Sale of Health-Related Products from Physicians’ Offices” (8.063).

Issued in 1990, Opinion 8.061, “Gifts to Physicians from Industry,” is perhaps the most widely disseminated Opinion in the entire Code. It provides physicians with guidelines regarding gifts from the pharmaceutical, device, or medical equipment industry that could influence prescribing habits or create the perception of having conflicted judgment. The guidelines constitute a balance between the importance of physicians being well informed about products that could significantly benefit their patients and the risk of physicians being inappropriately detracted from their primary responsibility to their patients by commercial practices. Ultimately, gifts and subsidies from MetroDoctors

industry “should primarily entail a benefit to patients and should not be of substantial value.”

A portion of Section 8 is devoted to medical practice in the managed care era. When feefor-service medicine still was the norm, earlier versions of the Code relied on Reports from the 1920s to conclude that “contract medicine” – the provision of medical care to a group for a defined sum or fixed per capita rate – was unethical if it decreased quality of care. Today’s Opinions on managed care remind physicians of their duty to act as patient advocates so that care is not compromised by personal or institutional interests. Clinical objectivity, not inducements, should guide physicians in the practice of medicine, if they are to fulfill their responsibilities to patients and preserve public trust in the profession.

Ironically, while the fee-for-service system fell under significant criticism for indirectly providing physicians with incentives for the over-utilization of their services, managed care has been blamed for creating incentives to withhold necessary services, compromising excellence in medicine. Each system illustrates the opposite side of the same conflict that can undermine patient care.

Another focus of Section 8 is on limits to appropriate physician conduct in the therapeutic relationship. Three behaviors – sexual misconduct, treatment of self or family, and patient neglect – are discussed in nearly identical terms as in the past. Sexual relations in medical practice, denounced at least since the Hippocratic Oath, are prohibited under Opinion 8.14, “Sexual Misconduct in the Practice of Medicine” since they could undermine the physicians’ objectivity and exploit patients’ vulnerabilities.

Concerns about objectivity are also raised in Opinion 8.19, “Self-Treatment or Treatment of Immediate Family Members.” The 1847 The Journal of the Hennepin and Ramsey Medical Societies

Code stated: “A physician afflicted with disease is usually an incompetent judge of his own case; and the natural anxiety and solicitude which he experiences at the sickness of a wife, a child […] tend to obscure his judgment, and produce timidity and irresolution in his practice.”

The Code has echoed these sentiments ever since.

In nearly identical terms as the 1955 Code, Opinion 8.11, “Neglect of Patient,” defines where a physician’s obligations to a patient begin and where they end. The Opinion notes, “Once having undertaken a case, the physician should not neglect the patient.” Though physicians may withdraw from a case, they must do so in a way that supports continuity of care for their patients. Opinion 8.115, “Termination of the Physician-Patient Relationship” stresses the need to notify the patient “sufficiently long in advance of withdrawal to permit another medical attendant to be secured.”

Finally, a significant departure from earlier versions of the Code can be found in Opinions that emphasize patient involvement in decisions related to their medical care and the requirement that patients be empowered with relevant information. Physicians have not always considered openness regarding a patient’s diagnosis or prognosis as the best way to further patient welfare. Indeed, the original 1847 Code of Medical Ethics acknowledges a preference for patient deception where information could discourage the patient or lower hope.

Prompted by the 1970s patients’ rights movement, medicine’s paternalistic model, according to which physicians’ medical expertise would enable them to know what was best for patients, was replaced by a model that attributed new importance to patient autonomy.

Patient health and well-being came to be understood as dependent upon a collaborative effort between physicians and patients.

Opinion 8.08 on “Informed Consent” defines physicians’ obligation to convey adequate, relevant information that will enable patients to make determinations regarding their care. Opinion 8.081, “Surrogate Decision Making,” offers guidelines for instances where an individual temporarily or permanently lacks decision-making capacity. More specific circumstances requiring attention to consent are outlined in several other Opinions. Also built on the notion of openness, Opinion 8.12, “Patient Information,” states that “Patients have a right to know their past and present medical MetroDoctors

status and to be free of any mistaken belief concerning their condition.”

At one time, the Code’s Opinions were organized under individual Principles of Medical Ethics to which they best corresponded.

Were this still the case, Section 8 would probably be incorporated under Principle VIII, which states: “A physician shall, while caring for a patient, regard responsibility to the patient as paramount.” Indeed, as the Section illustrates, medicine is fraught with competing interests for physicians to resolve. For the public to place trust in the profession and for physicians to uphold its standards, physicians must continue to place patients’ interests ahead of their own.

The content of the entire AMA’s Code of Medical Ethics is accessible online at www.amaassn.org/go/ceja. ✦ Sara Taub is a senior research assistant, Council on Ethical and Judicial Affairs, Amy M. Bovi, MA is a senior research assistant, Council on Ethical and Judicial Affairs, and Leonard J. Morse, M.D., is chair, Council on Ethical and Judicial Affairs.

A five physician, independentlyowned, primary care clinic, established in the 60 s, is seeking a full-time physician to assume the practice of a departing doctor.

Please contact:

Cami Swanson

Southdale Internal Medicine, P.A. 6545 France Ave. S., Suite 225 Edina, MN 55435

952-927-7079

Crutchfield Dermatology “Remarkable patient satisfaction from quality, service, convenience and excellent results” “Exceptional care for all skin problems” Charles E. Crutchfield III, M.D. Board Certified Dermatologist Experienced BOTOX Provider

Your Patients will Look Good & Feel Great with Beautiful Skin

The Journal of the Hennepin and Ramsey Medical Societies

www.CrutchfieldDermatology.com

1185 Town Centre Drive Suite 101 Eagan, MN 55123

Appointments 651-209-3600 Prompt Appointments via Physician Requests

March/April 2003

21

Societies Host Lunch n’ Learn Program for Medical Students

H

HENNEPIN AND RAMSEY Medical Societ-

ies were pleased to host another Lunch n’ Learn event for medical students on January 14, 2003.

The focus of this meeting was twofold—member benefits and an update on the Clinical Skills Assessment Exam.

Staff from HMS and RMS provided the medical students with some insight on some of the tangible benefits of membership including discounts on office supplies, cell phones, Palm Pilots, computers and printers.

Second year medical students, Stephanie Stanton and Drew Dietz then provided the group with an update on the Clinical Skills Assessment Exam. ✦

Kathy Hazzard from Business AdvantEdge addresses the students.

Drew Dietz provides an update on the Clinical Skills Assessment Exam.

Technology Solutions’ Billing Office Outsourcing Services Can Help Clear Your Plate We provide practical and cost-effective services that can help you get a handle on your business office processes and paperwork.

We can provide: • Flexible Accounts Receivable Services – including data entry, billing, collections, accounts receivable management.

• On-line Information System Access – you can obtain reports and perform specific functions using our feature-rich, ® Windows-based NextGen practice management and electronic medical record systems.

• Qualified and Experienced Staff – providing you with timely, professional and high-quality service.

• Numerous Benefits – including cost-effective practice operations, fewer management problems and excellent service.

For more information, contact Brian Salzman at 1–800–328–5532 or brian.salzman@mmihc.com.

Technology Solutions From A Name You Can Trust Experience • Quality • Service

22

March/April 2003

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

PRESIDENT’S MESSAGE J . M I C H A E L G O N Z A L E Z - C A M P O Y, M . D . , P h . D .

A Night of Firsts

O

ON JANUARY 24, 2003 I assumed the presi-

President J. Michael Gonzalez-Campoy, M.D., Ph.D. President-Elect Peter J. Daly, M.D. Past President Peter H. Kelly, M.D. Secretary Jamie D. Santilli, M.D. Treasurer Charles E. Crutchfield III, MMB, M.D.

dency of Ramsey Medical Society. It was a night of firsts...the first Hispanic physician to head the Society; the first endocrinologist (that I’m aware of) to head the Society; the first time a Latin band played for the Society; the first power point presentation at an annual meeting; and the first business expense for my new practice, the Minnesota Center for Obesity, Metabolism and Endocrinology (MN-COME), which bought the wine for the supper.

The annual meeting of the Ramsey Medical Society was also a time for me to reflect on the tradition of the Ramsey Medical Society.

RMS has been advocating for physicians in the east metro since it was founded on February 14, 1870. Although it has served a social role, sponsored research of great relevance for medicine, and at one point published a medical journal, its focus has always been to look after you and I, the physicians, and our profession. “Organized Medicine” is the only avenue that we each have, as physicians, to look after the best interests of our profession and our patients. It doesn’t meet the needs of any one group or specialty, it goes beyond that. It is a platform that allows all of us to present a united voice as the doctors of medicine.

RMS, in a sense, is much like my patients, and my students. It is not perfect. A significant shortcoming is that it does not give itself enough press for what it does. It also is like the middle child in a family, often going unnoticed for the good it does. I tell my patients this, “I am not perfect, and I know you are not perfect.” To spend any energy fretting about it serves no purpose. I also tell my patients, “the past was here and gone, never to be redone.” Move forward, use each day to be your best. And I tell my students that, “success is trying to be part of the solution, not part of the problem.”

Why bring these points up? Another first at this annual meeting was the first meeting of the Society after the announcement of the selection of Dr. Robert Meiches as the new CEO of the MMA. This year, with new leadership at

RMS-Board Members

Victor S. Cox, M.D., Specialty Director Gretchen S. Crary, M.D., At-Large Director Laura A. Dean, M.D., At-Large Director James J. Jordan, M.D., Specialty Director Robert V. Knowlan, M.D., At-Large Director Bradley C. Linden, M.D., Resident Physician Charlene E. McEvoy, M.D., At-Large Director Ragnvald Mjanger, M.D., Specialty Director Robert C. Moravec, M.D., At-Large Director Jane C. Pederson, M.D., M.S., Specialty Director Lon B. Peterson, M.D., At-Large Director Thomas D. Siefferman, M.D., Specialty Director Stephanie D. Stanton, Medical Student Lyle J. Swenson, M.D., MMA Trustee Charles G. Terzian, M.D., Specialty Director & MMA Trustee David C. Thorson, M.D., Specialty Director Peter B. Wilton, M.D., At-Large Director RMS-Ex-Officio Board Members & Council Chairs

Brent R. Asplin, M.D., AMA Young Physician Section Blanton Bessinger, M.D., AMA Alternate Delegate John M. Brown, M.D., Sr. Physicians Association President Kenneth W. Crabb, M.D., AMA Delegate Robert W. Geist, M.D., Ethics & Professionalism Council Chair *J. Michael Gonzalez-Campoy, M.D., Ph.D. Education Resource Council Chair Rebecca Gonzalez-Campoy, Alliance President Frank J. Indihar, M.D., AMA Delegate Neal R. Holtan, M.D., Community Health Council Chair William E. Jacott, M.D., U of MN Representative Melanie Sullivan, Clinic Administrator *Lyle J. Swenson, M.D., Public Policy 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

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

the MMA, you and I have a unique opportunity to learn from our past, and to make our Ramsey Medical Society a better advocate for the east metro physician community. We have the duty to maintain our tradition, and the obligation to continue to preserve the profession.

We have the privilege of addressing issues that affect all physicians, regardless of field of specialty, and regardless of work environment. We have nothing but future ahead of us. As we learn and grow from our mistakes, as we reinforce the good we have done, I look forward to providing solutions for the physicians in the east metro. I welcome the challenge ahead of us as a Ramsey Medical Society. I value the prospect of working closely with a Minnesota Medical Association that recognizes that in numbers there is strength, in dialogue there is growth and crossfertilization of ideas, and that in advocating for the profession at a higher level, it will be as strong as its components are strong.

I am poised to take the Ramsey Medical Society forward. I bring to it a background of diversity, the energy of a younger generation, and the wisdom of our mistakes. RMS will create more value by continuing its advocacy for the profession, and will remain strong by reaching more of our colleagues. Why be a member?

Because you are a physician. How do we get this message out to our colleagues? Let’s invite every one of our peers to stand with us...we can each be a part of the solution, and we can each avoid being part of the problem! ✦

March/April 2003

23

Ramsey Medical Society

RMS-Officers

R M S U P DAT E

133rd RMS Annual Meeting A Meeting of Firsts

A

AS DR. J. MICHAEL Gonzalez-Campoy so eloquently stated in his acceptance remarks, the 133rd RMS Annual Meeting was a meeting of firsts. More than 80 physicians, spouses, and children enjoyed the evening at the Town & Country Club in St. Paul.

The firsts included the first Hispanic physician to serve as RMS president; the first Si-

Dr. Thomas Dunkel displays his commendation.

lent Auction to benefit the Ramsey Medical Society Foundation; the first Power Point acceptance speech; the first booking of a Hispanic band, the Sabor Tropical; and, the first analysis of the use of familial names from Mexico.

Dr. Deborah Wexler was honored with the RMS Community Service Award for her work in organizing the Immunization Action Coalition. Dr. Thomas Dunkel was presented with a calligraphy of the resolution adopted by the MMA House of Delegates recognizing his many contributions to organized medicine and especially to the Ramsey Medical Society.

Dr. Peter Kelly placed the president’s medallion and handed the presidential gavel to incoming president J. Michael GonzalezCampoy, M.D., Ph.D., the 133rd president of the Ramsey Medical Society, as Dr. GonzalezCampoy’s family including his parents, Dr. Miguel Gonzalez Ahumada and Maria Consuelo Campoy De Gonzalez, proudly observed.

The evening of firsts was concluded with musical entertainment and dancing provided

by Sabor Tropical, an exciting Latin orchestra and their inspired singer, Maria LopezSantamaria. ✦

Dr. Peter Kelly passes the gavel to Dr. J. Michael Gonzalez-Campoy.

Dr. Deborah Wexler, recipient of the Community Service Award, was joined by her parents, Mark and Muriel Wexler, and her husband, Michael Mann.

Matt Feldkamp, Eleanor Goodall with husband William Goodall, M.D. and Miriam Kim, M.D.

Sabor Tropical providing a wonderful dancing opportunity.

Those in attendance enjoying the evening’s festivities.

24

March/April 2003

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

New Members RMS welcomes these new members to the Society.

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

Silent Auction a Success for RMSF

Silent Auction tables.

Thank You to the Following Donors ACME Comedy Club Austad’s Golf Store Bob Mitchell’s Fly Shop Cafè Latte Carmike Cinemas Chanhassen Dinner Theatres Charlene McEvoy, M.D. Chicago Floral Colleen Clarke Crutchfield Dermatology, P.A. Curves for Women Damon’s of Oakdale David Edwin’s Ladies Fashions Dr. & Mrs. Frederick Neher Dr. Ken & Carole Nimlos Dr. Mike & Becky Gonzalez-Campoy Dr. Walter & Ginger Bailey Dr. William and Eleanor Goodall Great American History Theater Gretchen S. Crary, M.D. Guthrie Theater Hillcrest Golf Club of St. Paul Hobbit Travel Jeanne Berget

MetroDoctors

Joanne Cameron Juut SalonSpa KDWB Lido’s Restaurant Minnesota Thunder Pro Soccer Minnesota Timberwolves Minnesota Twins Minnesota Vikings New Peony Farm - Dee Ann Crossley Nicki Hyser Norma Sommerdorf Northwood’s Organic Produce Pat Crutchfield Plymouth Playhouse Theatre Saint Paul Saints Science Museum of Minnesota Sgt. Peppers Grille & Bar Shakopee Mdewakanton Sioux Community Spalon Montage St. Paul Radiology Taste of Scandinavia The Phipps Center for the Arts The Saint Paul Hotel Troy Burne Golf Club

The Journal of the Hennepin and Ramsey Medical Societies

Lawrence D. Callanan, M.D. Duke University School of Medicine Internal Medicine Allina Medical Clinic -Internal Medicine Specialties Annika M. Crosby, M.D. University of Minnesota Internal Medicine Abbott Northwestern Hospital Yakup Ozbek, M.D. University of Wien, Austria Family Practice Allina Medical Clinic - Eagan

1st Year Practice Julie L. Ceno-England, M.D. American University of Caribbean Family Practice MinnHealth Family Physicians, P.A. - Maplewood Christopher W. Luhman, M.D. University of Minnesota Family Practice Multicare Associates

Residents Orlando Charry, M.D. Bogota, Colombia Physical Medicine & Rehabilitation/Pain Management Fairview Pain Management Center Daryll C. Dykes, M.D., Ph.D. SUNY - Syracuse Orthopaedic Surgery/Spine Surgery Summit Orthopedics, Ltd.

Medical Student (University of Minnesota)

Michael Broton April I. Miller ✦

March/April 2003

25

Ramsey Medical Society

THE FIRST-TIME SILENT AUCTION at and for making it a success. He also thanked the RMS Annual Meeting proved to be a sucthe individuals and the business firms for their cess raising more than $5,000 for the Ramsey generous donations of auction items. ✦ Medical Society Foundation.

More than 80 items were donated including a trip to Laughlin, Nevada donated by Hobbit Travel, a sheepskin rug donated by Dr. William and Eleanor Goodall, and numerous other items including tickets, books, and memorabilia.

Dr. Robert Moravec, president of the Foundation, thanked Eleanor Goodall and Joanne Cameron for co-chairing the event Physicians and guests enjoyed browsing the

Active Gregory A. Brown, M.D., Ph.D. Harvard Medical School Orthopaedic Surgery/Sports Medicine Regions Hospital

RMS ALLIANCE NEWS REBECCA GONZALEZ-CAMPOY

Get Out of Your Comfort Zone

I

IT SEEMED LIKE A GOOD IDEA at the time

when my friend, Pat Crutchfield, asked me to attend the Dr. Martin Luther King, Jr. breakfast on St. Paul’s west side. But when that frigid morning in January arrived, the last thing I wanted to do was get out of my warm bed and be anywhere at 7 a.m. The west side isn’t my neighborhood. I wouldn’t know anybody. I already admire Dr. King. And I already volunteer countless hours in my community, trying to do his work throughout the year. Why should I leave my comfort zone and venture out to face the unknown on this one chilly morning?

In the end, my commitment to friendship and the reservation I’d made to attend overruled my pre-dawn objections. And I’m glad I did go because I came away with renewed energy, excitement, and vision for what we as members of a community can do to strengthen its fabric. Listening to Dr. King’s “I have a dream” speech and then joining the main celebration in Minneapolis via teleconference was a privilege—and a challenge to do better. The importance of providing positive role models to young people and measuring success by how fully people can participate in their community are two themes that struck a chord with me.

At the end of the teleconference, participants at each table then discussed how race relations have changed in the neighborhood in the last 20 years and what we as individuals could do to keep the progress moving. Even though the conversation focused specifically on peace and race relations, the ideas and observations we generated that morning can be applied to what we do in RMS and the Alliance.

Pat Cruthchfield and Rebecca Gonzalez-Campoy.

26

March/April 2003

“Annapolis used to be the Mason-Dixon line,” a Hispanic man at our table pointed out.

“Now we can cross over into West St. Paul and see people who look like us working in the stores.” The comment made by this life-long west side resident made me think about leadership and membership of both RMS and the Alliance. Do we reflect today’s medical families? Do we really do enough to address the changing needs of physicians and spouses? Do they see people “like them” joining our groups?

Here’s another obstacle that occurred at the breakfast that I think applies to RMS and the Alliance: awareness of message. Organizers fretted about the low Hispanic turnout for the MLK breakfast held in a predominantly Hispanic working-class neighborhood. I reminded them that Dr. King likely means little to most Hispanics in this community—they probably don’t connect his message to their lives. He’s not part of their history or culture. Not yet.

RMS and the Alliance also must continue to work on message delivery. We’re not organizations that work on behalf of just one group of people. We exist to strengthen the medical profession for all physicians and to improve the health of each community. But how many people really know this? Or care?

This leads me to my next observation during the MLK breakfast. As I watched the Minneapolis event, I couldn’t help but desperately wish that the kids at Humboldt and Sibley High Schools—actually everyone attending school in ISD 197 and St. Paul’s west side—could see this program filled with strong African American role models. Many of the students in these communities come from struggling families who don’t “see themselves” reflected in the teaching staff. The keynote speaker was Dr. Ruth Simmons, president of the prestigious Brown University — the first African American president of an Ivy League school. That room was filled with hope, energy, and success.

Physicians and spouses must see the hope, energy, and success of RMS and the Alliance before they’ll buy into what we’re doing.

Lofty words for someone who’s heading down the homestretch of her presidency! I adMetroDoctors

mit it is and will be a slow process. However, I issue my own challenge—get out of your comfort zone!

Take time to mentor young physicians and their spouses. There undoubtedly is someone in your past who helped you get to where you are. In fact, alert readers will notice the new president of RMS is my spouse, Dr. J. Michael Gonzalez-Campoy. Finding ourselves in leadership positions in organized medicine is a direct result of fabulous mentoring on the part of several active RMS and Alliance members.

Connect with your colleagues and their spouses. Invite them to RMS and RMSA events —better yet ask them to help with a project you know they care about. Folks these days are more interested in projects—with a clear beginning and end—than long-term commitment, anyway. At the very least, contribute your membership dollars and let others put them to work for you!

As for the kid connection, the Alliance is meeting that challenge head on. We have added a new component to our Health Fair this year.

Each station will include information about the career options in that area.

I’ll also put a plug in here for what my spouse, Mike, does to help a handful of Hispanic middle school students at Humboldt. Every Tuesday at 7 a.m. he meets with these kids to talk about science, health care, whatever is on their minds. He’s just one person. They’re just a few kids. But great change comes from investments such as this.

I’ve always thought it was silly to have “Black History Month” (February) and “Hispanic History Month” (October). Who decided we’d designate just one month to focus on their contributions? We must keep the spirit of Dr. Martin Luther King, Jr. and other community activists like him alive all year long. The success of RMS and the Alliance depends on it.✦

The Journal of the Hennepin and Ramsey Medical Societies

CHAIR’S REPORT T. M I C H A E L T E D F O R D , M . D .

The Search for a New CEO for MMA HMS-Officers

HMS-Board Members

Michael Belzer, M.D. Jeffrey V. Christensen, M.D. Peter J. Dehnel, M.D. Drew Dietz, Medical Student Andrea J. Flom, M.D. Diane Gayes, Alliance Co-President Peggy Johnson, Alliance Co-President Ronald D. Osborn, D.O. James Peters, M.D. James A. Rohde, M.D. David F. Ruebeck, M.D. Richard D. Schmidt, M.D. Michael G. Thurmes, M.D. D. Clark Tungseth, M.D. Michael J. Walker, M.D. HMS-Ex-Officio Board Members

Paul F. Bowlin M.D., Senior Physicians Association Lee H. Beecher, M.D., MMA-Trustee Carl E. Burkland, M.D., Member-at-Large Karen K. Dickson, M.D., MMA-Trustee David L. Estrin, M.D., MMA-Trustee John W. Larsen, 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 Kathy Dittmer, Executive Assistant Sue Schettle, Director, Marketing & Member Services

MetroDoctors

O

OVER THE PAST SEVERAL months the Minnesota Medical Association Board of Trustees has engaged in a search process for a new chief executive officer. I was fortunate to be invited to participate in that process.

The search committee was composed of board members and other MMA leaders including current and past presidents of the association and representatives from stakeholder groups like the University of Minnesota and the MMA Alliance. Working with the search committee was a rare and very enjoyable opportunity to see experienced, intelligent, insightful, dedicated individuals discuss and analyze the options to move our association to the next level of effective representation and advocacy for the profession and our patients.

The committee engaged a consultant to undertake a national search. Fine candidates from Minnesota and the rest of the country, physicians and experienced non-physician association directors, were identified. Then the process of reviewing credentials, experience and professional accomplishments began. I thoroughly enjoyed seeing the accomplishments of other health care organizations and professional associations and learning how they work. And it was a genuine pleasure to meet so many talented candidates and to interview them about their work and leadership styles. During the process, I have come to appreciate the potential for the MMA, if we can find the courage to implement new policies and practices that the opportunity of new leadership offers. For instance, a candidate from another state society was able to dismantle the cumbersome House of Delegates process, while preserving the sense of membership-upward direction required by associations like ours. Many candidates had terrific ideas about strategic planning, done in conjunction with the House of Delegates, and understood how important widespread

The Journal of the Hennepin and Ramsey Medical Societies

participation and follow-up communication will be. One particularly strong candidate stated clearly that simply sending surveys to nonmembers and expecting meaningful responses is only the first step to serving the entire profession in the state. He had very effectively supported the medical specialty his society represented by following up surveys with phone call interviews and focus groups.

As reported elsewhere in MetroDoctors, Robert Meiches, M.D. has accepted the position as CEO of the Minnesota Medical Association. Those of you who have been HMS delegates to the MMA House of Delegates will remember the great job that Bob did for several years as our caucus chair. Bob also provided leadership for nine years as one of our MMA West Metro Trustees.

In our times, when society holds conflicting values — expecting the best and most advanced medical care for everyone, while simultaneously bemoaning rising health care premiums — we need strong physician leadership. The conflict is all the more acute in this period of government budget shortfall.

Our governor is facing the task of making deep cuts in the medical assistance budget— maybe by limiting eligibility, maybe by limiting benefits, maybe by reducing reimbursement. The MMA, HMS, and RMS will clearly oppose such cuts. I am optimistic that with continuing lessons, like those from the CEO search process, our organizations will use these threats to the best health care as a springboard for physician leadership creating a better system. ✦

March/April 2003

27

Hennepin Medical Society

Chair T. Michael Tedford, M.D. President Michael B. Ainslie, M.D. President-elect Michael B. Belzer, M.D. Secretary Richard M. Gebhart, M.D. Treasurer Paul A. Kettler, M.D. Immediate Past Chair David L. Swanson, M.D.

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

Active Mark N. Ahrendt, M.D. Univ. of Rochester School of Medicine-Dentistry General Surgery North Memorial Health Care Abdelwahaab Akef, M.D. Ra Cairo University, Egypt Interventional Cardiology Metropolitan Cardiology Consultants, P.A. Azam Ansari, M.D. Osmania Medical College, Institute of Medicine Sci, Hyderabad, Andhra Pradesh Cardiovascular Diseases Azam Ansari, M.D., FACC Christopher A. Armstrong, M.D. Case Western Reserve Univ. School of Medicine Internal Medicine Consultants-Internal Medicine, P.A. Thomas H. Ayre III, M.D. University of Minnesota Medical School Otolaryngology Minneapolis Otolaryngology Head & Neck Surgery, P.A. Jeanne Beattie, M.D. Rush Medical College Neurology, Clinical Neurophsly MINCEP Epilepsy Care Neeraj B. Chepuri, M.D. University of Minnesota Medical School Radiology Consulting Radiologists, Ltd. Cally Lawler Chermak, M.D. University of Minnesota Medical School Dermatology Dermatology Specialists, P.A. Melissa A. Clark, M.D. University of Minnesota Medical School Pediatrics Metropolitan Pediatric Specialists, P.A. Ellen M. Coffey, M.D. University of Minnesota Medical School Internal Medicine Hennepin County Medical Center 28

March/April 2003

Scott R Colson, M.D. Univ. of Nevada School of Medicine Sciences Family Practice North Clinic, P.A.

M. Feldkamp, M.D., Ph.D., FRCSC University of Saskatchewan College of Medicine Neurological Surgery Millennium Neurosurgery, P.A.

Monica M Colvin-Adams, M.D. Cardiology Fairview-University Medical Center University Campus

Isaac Felemovicius, M.D. Facultad de Medicina de la Universidad Nacional Autonoma de Mexico General Surgery Colon & Rectal Surg. Assoc., Ltd.

Annika M. Crosby, M.D. University of Minnesota Medical School Internal Medicine Abbott Northwestern Hospital

Sarah A. Freitas, M.D. University of Iowa College of Medicine Obstetrics & Gynecology Western OB/GYN, Ltd.

Robert J. Dado, M.D. University of Minnesota Medical School Anesthesiology Metropolitan Anesthesia Network

Padma Gadela, M.D. Internal Medicine Allina Medical Clinic - Nicollet Mall

Christian M Daleiden, M.D. University of Minnesota Medical School Family Practice Northwest Family Physicians, P.A.-Crystal

Gregory J. Gepner, M.D. Stanford University School of Medicine Family Practice Smiley’s Family Practice Clinic

Elizabeth A. Davis, M.D. Johns Hopkins University School of Medicine Ophthalmology

Nancy L. Guttormson, M.D. University of Minnesota Medical School General Surgery

Kevin Michael Deinema, M.D. University of Texas Medical Branch Anesthesiology Northwest Anesthesia, P.A.

William J. Hammes, M.D. University of Minnesota Medical School Family Practice Crossroads Medical Centers, P.A.

Christine M. Duncan, M.D. University of Minnesota Medical School Family Practice Geriatric Park Nicollet Clinic - St. Louis Park

Gregory S. Harrison, M.D. Loyola University Stritch School of Medicine Neurological Surgery Millennium Neurosurgery, P.A.

Suzanne E. Dvergsten, M.D. University of Minnesota Medical School Pediatrics Champlin Medical Center

Mary Julie Hestness, M.D. University of Minnesota Medical School Diagnostic Radiology Consulting Radiologists, Ltd.

Kristine L. Eskuchen, M.D. Rush Medical College Family Practice Northwest Family Physicians, P.A., Rogers

David G. Hurrell, M.D. Mayo Medical School Cardiovascular Diseases Minneapolis Cardiology Assoc. Minneapolis Heart Institute

Steven M. Falk, M.D. University of Minnesota Medical School Anesthesiology Valley Anesthesiology Consultants, P.A. Martha J. Fanning, M.D. University of Minnesota Medical School Internal Medicine North Memorial Clinic- Plymouth Internal Medicine

MetroDoctors

Fatima Rahim Jiwa, M.D. The Welsh National School Medicine, Cardiff Pediatrics Partners in Pediatrics, Ltd. Jon P. Kane, M.D. University of Minnesota Medical School Diagnostic Radiology Consulting Radiologists, Ltd.

The Journal of the Hennepin and Ramsey Medical Societies

Wayne R. Kaniewski, M.D. Michigan State University College of Human Medicine Family Practice Park Nicollet Clinic - Burnsville Richard E. Karulf, M.D. University of Minnesota Medical School Colon & Rectal Surgery Colon & Rectal Surg. Assoc., Ltd.

Nicholas P. LaFond, M.D. University of Minnesota Medical School Family Practice Long Lake Family Practice, P.A. Timothy A. Lander, M.D. University of Minnesota Medical School Pediatric Otolaryngology Pediatric ENT Associates Concepcion A. Laqui, M.D. Faculty of Medicine and Surgery University of Santo Tomas, Manila Anesthesiology Hennepin County Medical Center Casey Martin Lawler, M.D. University of Vermont College of Medicine Cardiovascular Diseases Minneapolis Cardiology Assoc. Minneapolis Heart Institute Caroline L. Levine, M.D. University of Vermont College of Medicine Dermatology North Clinic, P.A.

Kimberly K. McCollow, D.O. University of Osteopathic Medicine and Health Sciences Radiation Oncology St. Francis Radiation Therapy Center, Inc. Sultan G. Michael, M.D. Internal Medicine Saira Mitha, M.D. The Aga Khan University, M.B.B.S., Pakistan Pediatrics Southdale Pediatric Associates Suzanne Camille Moffit, D.O. Diagnostic Radiology Suburban Radiologic Consultants, Ltd. Richard R. Nelson, M.D. Northwestern University Medical School Cardiovascular Diseases Minneapolis Cardiology Assoc. Minneapolis Heart Institute Arthur L. Ney, M.D. University of Minnesota Medical School General Surgery Hennepin County Medical Center Carter J. Nichols, M.D. Medical College of Wisconsin Ophthalmology Edina Eye Physicians & Surgeons, P.A. Mark C. Oswood, M.D. Diagnostic Radiology Consulting Radiologists, Ltd.

David A. Levy, M.D. New York Medical College Internal Medicine Quello Clinic, Ltd.

Luis A. Pagan-Carlo, M.D. Temple University School of Medicine Cardiovascular Diseases Minneapolis Cardiology Assoc. Minneapolis Heart Institute

Joshua Alan Martini, M.D. University of Minnesota Medical School Anesthesiology Metropolitan Anesthesia Network

Thomas W. Peltola, M.D. Albany Medical College of Union University Diagnostic Radiology Minneapolis Radiology Associates, Ltd.

Thomas C. Matson, M.D. Medical College of Wisconsin Diagnostic Radiology Consulting Radiologists, Ltd.

John Perl II, M.D. University of North Carolina School of Medicine Diagnostic Radiology Consulting Radiologists, Ltd.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Amin F. Rahmatullah, M.D. Internal Medicine Metropolitan Cardiology Consultants, P.A. Jeffrey Lynn Raines, M.D. University of Missouri School of Medicine Obstetrics & Gynecology Columbia Park Med. Group/Brooklyn Park Clinic Basem M. Ratrout, M.D. Internal Medicine Fairview Southdale Hospital Alberto Ricart, M.D. Esuela de Medicina Universidad Nacional Pedro Henriguez Urena, Santo Domingo Internal Medicine Andover Park Clinic Daniel K. Ries, M.D. University of Minnesota Medical School Nephrology Kidney Specialists of MN, P.A. Stephen W. Robinson Jr., M.D. University of Minnesota Medical School Family Practice Andover Park Clinic (Continued on page 30)

Independent physicians partnering with patients.

MHN is an independent, physician owned and governed organization. We provide the following services: Contracting for the very best terms Care management to support you and your patients Group purchasing to lower your costs Data analysis to help you make informed decisions Business development to help you expand

Minnesota Healthcare Network, LLC 7900 International Dr., Suite 1080 Bloomington, MN 55425-1510 Phone (952) 883-3150 www.mhcn.com

March/April 2003

29

Hennepin Medical Society

Nissim Khabie, M.D. University of California School of Medicine Otolaryngology Ear, Nose & Throat SpecialtyCare of Minnesota, P.A.

Kari Lynn Mattson Ball, M.D. University of Minnesota Medical School Internal Medicine Park Nicollet Clinic - Brookdale

New Members (Continued from page 29)

Anton Rohan, M.D. University of Sri Lanka, Peradeniya Faculty of Medicine Anesthesiology Twin Cities Anesthesia Associates Leslie Rule, M.D. Medical College of Virginia Commonwealth School of Medicine Family Practice Northwest Family Physicians, P.A.-Crystal Christine M. Sarkinen, M.D. University of Minnesota Obstetrics & Gynecology Oakdale OB/GYN, P.A. Carol L. Sarpal, M.D. University of Saskatchewan College of Medicine, Saskatoon Family Practice Blaine Medical Center Multicare Assoc. of the T.C. Matthew S. Segedy, M.D. University of Pittsburgh School of Medicine Pediatrics Wayzata Children’s Clinic, P.A. Steven Sihai Shu, M.D. Shanghai Medical College, China Family Practice Northwest Family Physicians, P.A.-Crystal Samuel W. Spears, M.D. Medical College of Wisconsin Internal Medicine Consultants-Internal Medicine, P.A. John M Spielmann, M.D., Ph.D. University of Pittsburgh School of Medicine Anesthesiology White Oak Anesthesiologist Associates Trudie R. Sprenkle, M.D. University of Minnesota Medical School Pediatrics Partners in Pediatrics, Ltd. Jeffrey J. Stephens, M.D. University of North Dakota School of Medicine Ophthalmology Edina Eye Physicians & Surgeons, P.A.

Annelise Skor Swigert, M.D. Northwestern University Medical School Obstetrics & Gynecology Southdale OB/GYN Consultants

Christian M. Capitini Univ. of Rochester School of Medicine-Dentistry Pediatrics University of Minnesota

Ruth O. Szajner, M.D. Akademia Medyczna, Bialystock Family Practice North Memorial Clinic- Minnetonka Physicians

Stella Kurtz Evans, M.D. Ohio State University College of Medicine Pediatrics University of Minnesota Physicians

Amy J. Thorsen, M.D. Colon & Rectal Surgery Colon & Rectal Surg. Assoc., Ltd.

Bruce A. Evink, M.D. University of Minnesota Medical School Family Practice Creekside Family Physicians Clinic

Kathryn Tweedy, M.D. University of Minnesota Medical School Southdale OB/GYN Consultants

Abdullah Hamad, M.D. Transplantation Surgery Mayo Graduate School of Medicine

Marina Y. Usacheva, M.D. Kiev Medical Institute, Ukraine Family Practice Blaine Medical Center Multicare Assoc. of the T.C.

Yasmeen Khan, M.D. Anesthesiology, Pain Management

Andrew K. Vaaler, M.D. University of Minnesota Medical School Pulmonary Disease Respiratory Consultants Matthew Aaron Weinrich, M.D. University of Minnesota Medical School Obstetrics & Gynecology Western OB/GYN, Ltd.

March/April 2003

Judith L. Weisenberg, M.D. University of Minnesota Medical School Pediatrics University of Minnesota

Medical Student (University of Minnesota)

Kathleen Y. Whitley, M.D. University of Minnesota Medical School Internal Medicine Kidney Specialists of MN, P.A. David C. Zoschke, M.D., Ph.D. University of Wisconsin Medical School Rheumatology Arthritis & Rheumatology Consultants, P.A.

Residents Tiffany R. Beckman, M.D. University of Minnesota Medical School Internal Medicine Abbott Northwestern Hospital Stuart E. Cameron, M.D. University of Minnesota Medical School Pathology-Anatomic/Clinical

Suzanne K. Swan, M.D. Northeastern Ohio Univ. College of Medicine Nephrology Hennepin County Medical Center 30

Megan M. Reilly, M.D. University of Illinois College of Medicine Pediatrics Partners in Pediatrics, Ltd.

MetroDoctors

Adam Donald Ailabouni Corey Anderson Katherine K. Anderson Mary Leavitt Anderson Lisa M. Barroilhet Alok Bashuwar Shaquita L. Bell Robby Joseph Bershow Sanaya Darayus Bharucha Sarah Naomi Borge Joseph Aaron Browning Heather J. Buchholz Courtney M. Carraher Leslie Carranza Manish C. Champaneria An Church Erin Ann Collins Seth Alan Consoer Sameer Damle Suzanne Marie Darnell Julie Ann DeJong Suzanne DePaulo Brittany N.A. Dokter Stephen Jared Dunlop Annalisa Kay Eckman The Journal of the Hennepin and Ramsey Medical Societies

MetroDoctors

Joshua Rodney Rhein Karen Marie Rice Jennifer Joy Ringlien Erica Kristen Ross Glen Harry Rudolph Jack Robert Schleiffarth Sarah Elizabeth Schram Holly Lynn Schrupp Erin Elizabeth Seiberlich Erik Paul Severson Joshua C. Simonson Stephanie L. Smith Robert Reginald Snowden Mark William Steffen Karis Antonia Stenback Nicole Leigh Strand Alexander West Stricker, III Marnie Lynn Taylor Brian Robert Thompson Maharaj Alejandro Tomar David Aaron VanDyke Paul G. Wenner Rachel Anne Wenner Shannon Wesley Kristen Lee Williams Shruti P. Wilson Dirk Winter Robert James Woodruff ✦

In Memoriam ARTHUR B. JOHNSON, M.D., a physician and surgeon for 53 years, died January 26. He was 97. He graduated from the University of Minnesota Medical School. Dr. Johnson was a lifetime member of HMS. RICHARD H. OPHEIM, M.D., died December 29 at the age of 70. He graduated from the University of Minnesota Medical School and completed an internship at Southern Pacific Hospital in San Francisco. He served as a Captain and Medical Officer in the USAF. Dr. Opheim retired in 1994 after 32 years in family practice and a member of the staff of North Memorial Hospital. He joined HMS in 1962.

BYRON HARVEY ROBERTS, M.D., of Sanibel, FL (formerly of Edina), died January 25. He was 76. He graduated from the University of Minnesota Medical School and founded Minneapolis Anesthesia. Dr. Roberts was Chief of Anesthesia and a significant force in the growth of Fairview on the river from 1951until his retirement in 1986.He joined HMS in 1953. ✦

Shotwell Award Presented THE 2002 SHOTWELL AWARD, presented

by the Hennepin Medical Society, was given to Michael T. Osterholm, Ph.D., at Abbott Northwestern’s annual medical staff meeting on Jan. 7. Dr. Osterholm is the director of the Center for Infectious Disease Research and Policy at the University of Minnesota’s School of Public Health, and former state epidemiologist.

“Dr. Osterholm has continually demonstrated his visionary efforts of educating the public and health care community on the threat of bioterrorism and is preeminent in the field of epidemiology nationally,” said T. Michael Tedford, M.D., board chair of the Hennepin Medical Society.

The Shotwell Award is presented to individuals in the state of Minnesota who: have shown dedicated service to humankind; have had significant breakthroughs in some form of research; or have made a significant contribution to the field of medicine and improved the delivery of health care in the state.

The Journal of the Hennepin and Ramsey Medical Societies

Since the award had its start at Metropolitan-Mount Sinai Medical Center, a former Allina facility, Abbott Northwestern and its medical staff began to host the annual award ceremony this year. The Shotwell Award was established in 1971 in recognition of the financial support and dedication of Mr. and Mrs. James D. Shotwell towards Metropolitan Medical Center. ✦

Pictured with Dr. Osterholm (center) are William E. Petersen, M.D., 1996 Shotwell Award recipient and member of the selection committee (left), and T. Michael Tedford, M.D.

March/April 2003

31

Hennepin Medical Society

Catherine Anne Ehlen ELizabeth Joan Fallon Jonathan Andrew Faust Simon Nicholas Fenton Anthony R. Frattalone Ashley Elizabeth Fuller Celia Ann Garner Joseph Murphy Gleason Brooke R Glessing Sam R. Goblirsch Steven Todd Grandt Karla J. Hansen Joel David Harris Aaron James Hegg Paden Carl Hendrickson Tanya Kim Henke Marie Eleanore Hill Thuy An Thien Hoang Ryan David Horazdovsky Robert Christian Huebert Philip Bruce Imholte Alan Wellington Johnson Patrick K. Johnson Mollie Maureen Johnston Christine M Kalscheuer Michael John Kassing Melissa Anne Kath Joseph Charles Keenan Christina Tove Klug John Thomas Knapp Louis P Kohl Jeannette C. Lager Krista Lynn Larson Rhiana L. A. Lau Alisa B. Lee Francis Lee Hong Shing Lee Mayseng Lee Joseph Brent Lind Sabra Marie Lofgren Nancy Marie Luger Jeremy Macheel Jonathan Jay Melquist Kelly Marie Milkus Nicholas John Modjeski Brooke M. Moore Andrea Lynn Musel Orion William Nohr Tara Anne O’Connell Jacob Randall Oestreich Erin E. Olson Randy Lloyd Olson Nicole Marie Omann Kristina Marie O’Neill Christina R. Paulsen Beth A. Peter Hoai D. Pham Justine M. Pidcock Shawna E. Purcell Marcia Ann Radke

HMS ALLIANCE NEWS

Dinner with Dickens A Fundraiser

A

A “DICKENS” OF A GOOD TIME! On De-

cember 20, Gerald Charles Dickens, the greatgreat grandson of Charles Dickens, transported 180 people back to 1843. He dramatized A Christmas Story, using the voices and actions of the tale’s 26 characters.

The evening performance was a “Christmas Feast” that included five staves separated by a three-course meal. As the story was enacted, Mr. Dickens creatively brought to life some of the characters through his spontaneous involvement of members of the audience. The Victorian setting of the Interlachen Country Club and the backdrop of fresh snow falling enhanced the story-like atmosphere of a dinner set in 1843.

Foremost, the entertaining evening event was also a fundraiser. Nearly $10,000 was raised

Gerald Charles Dickens began his seventh American Holiday Tour in mid-November of 2002. For 34 days, he crossed the United States, performing at libraries, Dickens’ festivals, historic hotels, theaters, churches and holiday galas. Back home in England, Dickens is an actor, producer, and director.

Dickens, his wife and three children live in the County of Kent, England.

Dr. Lee and Nancy Beecher with Mr. Dickens as he signs their book.

32

March/April 2003

for the Hennepin Medical Society Alliance (HMSA) preventive health education programs.

To quote HMSA member Jan Musich, “This event was a unique opportunity to share the seasonal message of generosity in this English classic, dramatized by Gerald Charles Dickens’ great-great grandson, presented with dinner in the holiday setting of the Interlachen Country Club.”

A Very Special Thank You to: Mr. Scrooge Sponsor (presenting sponsor) – Hennepin Medical Foundation Ghost of Christmas Past Sponsors – Pfizer Pharmaceutical & Guidant Corp.

Ghost of Christmas Present Sponsors – Dr. Bruce & Peggy Johnson Dr. James & Diane Gayes Ghost of Christmas Future Sponsors – Hennepin Medical Society Dr. Ann Lowry & Dr. John Overton Dr. Wendy Kiser/Nazarian Family Tiny Tim Sponsors – All who attended the evening event; Byerly’s Ridgedale for the turkey presented at the FEAST; Southdale Mini Print for the evening programs;

On January 8, 2003, Hennepin and Ramsey Medical Alliance members and the Medical Student Partners walked to raise more than $800 for the AMA Foundation. A few participants completed the circumference of the mall eight times (nearly five miles!)

MetroDoctors

Diane Gayes Co-President

Peggy Johnson Co-President

Hotel Sofitel for the day room for Mr. Dickens; Christos Sigakis for the poster artwork; Dianne Schottler for the scripted name tags; Mike Koski & Zach Jensen for assisting with the book sales; and Anthea & Carissa Johnson for event assistance.

In addition to the evening event, the HMSA sponsored an afternoon performance of A Christmas Story by Mr. Dickens at the Thrivent Financial (Lutheran Brotherhood) auditorium for their employees in appreciation for 20 years of their support of the HMSA Body Works program. Thrivent Financial donates the use of their auditorium for the annual five-day health education program. HMSA will celebrate the 20th anniversary of Body Works April 21-25, 2003.

Since 1983, Body Works has educated more than 40,000 Minneapolis Public School third-graders about their bodies and how to keep them healthy. ✦

The HMSA Holiday Tea/Silent Auction raised $1,800 for the Body Works program. Front row: Michelle Schroeder (HMSA member) & Jessica; Kim Schneider (2nd year medical student spouse) & Samuel; Dionne Meisterling (3rd year resident spouse) & Stephanie. Back row: Deena Anders (1st year Resident spouse) & Isabel; and Florence Jordan (4th year resident spouse) & Emily.

The Journal of the Hennepin and Ramsey Medical Societies

You DESERVE THE EXPERTISE of a

Proven Professional JOEL GREENWALD, MD CERTIFIED FINANCIAL PLANNERTM Professional Certified Employee Benefits Specialist

Named to the list of 150 Best Financial Advisors for Doctors by Medical Economics.

M e m b e r

N A S D / S I P C

4005 West 65th Street, Suite 112 Edina, MN 55435 952-922-0995 • 800-571-5771 Joel.Greenwald@Raymond.James.com

Joel specializes in helping doctors make smart investment choices about their personal finances so they can enjoy the financial success they deserve. For a private consultation, please contact him today.

2325 Prior Avenue North, Roseville, MN

(651) 636-6060

“THE FUSION OF DESIGN AND TECHNOLOGY”

2002 ESCALADE 345 HP — The most powerful SUV on the road today!

IT’S NOT YOUR DADDY’S CADDY ANYMORE! 2003 CTS

CONTACT STEVE ALLEN FOR DETAILS