2005_January_February-optimized

Jan/February 2005

Seeking Pathways to Solutions

Governor Pawlenty's "Smart Buy" Alliance •

2005 Legislative Session Preview •

Pain Management – Part 2 •

Surgery Update

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Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

Physician Co-editor Y. Ralph Chu, M.D. 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 Photo by Naturfoto-Online Photographer Gerald Aschauer MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

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, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: bauerfamily@earthlink.net.

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CONTENTS VOLUME 7, NO. 1

2

JANUARY/FEBRUARY 2005

PHYSICIAN’S SOAP BOX

Valid Guidelines The Dark Side of a Smoking Ban

5

Health Care 2005 Legislative Session Preview

7

Governor Pawlenty Unveils “Smart Buy” Alliance

9

Index to Advertisers

11

The Appropriate Tools for Pain Management

15

What’s New in General Surgery

18

COLLEAGUE INTERVIEW

Roger G. Kathol, M.D., C.P.E.

22

Smart Card Applications for Health Care Begin to Emerge

RAMSEY MEDICAL SOCIETY

24 25 26 27

President’s Message 2005 RMS Election Results/RMS Board Meeting/In Memoriam RMS In Action Caring Hearts for Homeless People Supply Drive/Health Care Rationing/ RMS Annual Meeting HENNEPIN MEDICAL SOCIETY

28 29 32

Chair’s Report New Members In Memoriam

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.

On the cover: 2005 brings opportunities for innovative solutions in health care.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2005

1

PHYSICIAN'S SOAP BOX

Valid Guidelines

W

WE ALL AGREE THAT CLINICAL CARE GUIDELINES based on

evidence-based medicine offer the best approach for treating many medical conditions. Use of these guidelines may help both to ensure that the most scientific medical treatments are utilized and that avoidable disparities in treatment are decreased.

However, these guidelines should support the notion of shared decision-making, and shared responsibility between physicians and patients in managing medical conditions. There is really no flow chart or algorithm or dogmatic approach that is going to work for everybody. There is no average patient.

The guidelines need to be individualized to reflect patient’s values, circumstances and health history. The guidelines should acknowledge that the physician needs to use clinical judgment at times to weigh the benefits, safety and costs of different therapies. To attain the best possible medical care for the patient, there may need to be trade-offs in particular circumstances. After all, the practice of medicine is an art and a science. Strong definitive science may be lacking to address all possible treatment circumstances for a particular medical condition. Clinical care guidelines do have limitations.

The state mandated clinical care guidelines on diabetes, drawn up by the health care industry, unbelievably excluded all references to the basic, fundamental importance of patients initiating lifestyle behavior changes (weight loss, increase exercise) to control their blood sugars, cholesterol levels and blood pressures. The guidelines inaccurately emphasized drug therapy as the primary treatment of these conditions. Do these guidelines not give the wrong messages to our patients?

Using compliance to these guidelines as a basis to determine whether physicians are practicing evidence-based medicine is crucially limited by the fact that patient adherence to or noncompliance with these treatment guidelines is not measured or reflected in these guidelines. This fact results in the creation of misleading physician performance data that could unjustly affect a physician’s integrity (through report cards) and fair reimbursement. Physicians should not be held accountable for something almost always beyond their control — patient behavior.

Are clinical goals going to be harder to meet in low-income areas as compared to high-income areas? These guidelines are a state unfunded mandate. The exact treatment of medical conditions defined by the guidelines requires the use of prescriptive drugs. Our patients, especially the elderly, are least able to afford the myriad of drugs needed for them to meet the standards of these guidelines. Physicians are not being given one of the essential tools to fulfill, and therefore meet, these guidelines. Again, physicians are being held accountable for something beyond their control — health care system financing.

Will these government-mandated clinical guidelines increase physicians’ medical liability if they are not able to attain mandated treatment goals? Will physicians, to avoid failing report cards, have to use medications to meet the guidelines without allowing for such patient factors as advanced age, complex medical programs requiring the use of multiple medications, illness severity, response to past treatment and, most importantly, patient cultural values? Will this health care industry, micromanaging physicians through these guidelines, have any legal liability for their control?

Why was a pilot study not done before these guidelines were mandated to determine whether holding physicians accountable for these guidelines would lead to better clinical outcomes, increased patient and physician satisfaction, and decreased total medical costs?

Did we not just finish a statewide experiment involving managed care that was going to ensure quality care and cost control? It failed, unfortunately.

Physicians must not allow the health care industry to define the practice of medicine through clinical care guidelines that will simply not euthanize the complexity and cost out of the practice of medicine.

Physicians cannot allow any political agenda to unintentionally bring harm to their patients.

The practice of medicine is based on shared decision making, and shared responsibility in the physician-patient relationship. This essential reality must be contained in any valid clinical care guidelines that try to spell out how medicine is and should be practiced. ◆ Carl Burkland, M.D. is a family physician in New Prague.

BY CARL BURKLAND, M.D.

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January/February 2005

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

PHYSICIAN'S SOAP BOX

The Dark Side of a Smoking Ban

A

AS A PHYSICIAN, I AM POIGNANTLY AWARE of the ravages of

smoking. I have seen more cases of vascular disease and cancer as a result of smoking than I could ever count. Smoking is a filthy and unhealthy habit.

Although smoking is reprehensible, there is one thing worthy of even greater contempt. That is government that rejects the notion of private property rights and the freedom for us to choose for ourselves how we live our lives.

The American Revolution was the high water mark in the world’s recognition of rights in the original sense of the word. Rights were originally a principle defining and sanctioning human action in a social context. The solitary man on a desert island has no rights.

Rights are only relevant when living in society in the company of others. Rights define the freedom to act so long as one’s actions do not encroach upon the rights of others to do the same. For there to be an advantage to living in society as opposed to a solitary existence, humans must have rights.

John Locke helped inspire the American Revolution with his notion of individual sovereignty and the right to “Life, liberty and the pursuit of private property.” As sovereign beings, we owned our own lives. As owners of our own lives, we owned the fruits of our own labor and, therefore, were free to trade these fruits with others as we saw fit. Restated, we had properties rights to that which we created ourselves or that which others had voluntarily given us as a gift or through voluntary trade. The notion of property rights flows logically from the concept of self-ownership.

Rights originally merely meant liberty rights. They simply defined freedom of action. During the twentieth century the concept of rights has morphed into the concept of welfare rights. Rather than defining freedom of action, rights now define “goods and services.”

Such a distorted vision of rights evades the fact that such goods and services can only appear as a result of the coerced provision of these by others. The providers have their liberty rights annihilated by those who they are forced to provide for.

Freedom, as originally conceived, was limited to the field of politics. The term meant freedom from the coercion of others. It certainly was not a claim to the property of others. The claim that “A hungry man is not free” is absurd. It confuses the political concept of freedom with the biological fact that we all have needs for food and shelter. With freedom comes responsibility for our own lives. Freedom

BY LEE KURISKO, M.D.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

is not a claim on others to be responsible for us. Freedom is certainly not a valid claim on others to provide us with smoke-free restaurants, especially when we are free to not go there.

Freedom is the ability to make our own choices. There is no guarantee that we will make choices that ensure a successful path in life. Nor is there a guarantee that we will make choices of which others will approve. There also is no certainty that our choices may not have consequences just as the choice to smoke carries dire potential consequences.

America has strayed far from its original vision of rights defining freedom of action. We now demand universal health care, prescription drug benefits and smoke-free air in restaurants for which we have no responsibility for the mortgage.

As a newcomer to “the land of the free and the home of the brave,” I am astonished that government feels that it is within its ken to use its coercive force to decide how restauranteurs utilize their own private property. As owners of private property, it is for them to decide whether or not they allow smoking, not Hennepin County. It is also for the public to endorse or refute a restauranteur’s policy choice by voting with their patronage. Similarly, in a free market, workers can either negotiate their terms of employment or else offer their services elsewhere.

As thinking beings, humans have values. Values are entities that we seek to maintain or gain more of. Love, money, happiness or even the pleasures of smoking are values that an individual may hold. As sovereign individuals, we all have a hierarchy of values whether we explicitly realize it or not. As a physician, smoking is certainly not within my hierarchy of values. But not only am I a physician, I am also a sovereign member of society who wants my sovereignty respected. Therefore, I must respect the sovereignty of others and their right to formulate their own hierarchy of values. I may not like the choice of others to smoke or to not offer smoke-free restaurants, but it is not proper for sovereign individuals in a rights-based society to coerce one another. Such would be antithetical to the concept of political freedom. It is only proper to try and convince and persuade others of our viewpoint, not to ram it down their throat with the coercive force of government.

Those who feel it is moral to skip persuasion in favor of force may someday regret this choice when the values of others are forcefully imposed on them. The evasion of this logic is the reason why the United States of America is slowly but incrementally degenerating (Continued on page 4)

January/February 2005

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Smoking Ban (Continued from page 3)

from a bastion of freedom to a statist hell. The fact that the U.S. has a democratically elected representative government does not necessarily prevent this decay. America was envisioned by the founders as a rights-based republic designed to protect individual rights from the tyranny of the majority or big government. Democracy is a requirement for such a republic, but does not prevent its downfall if individual rights are not enshrined.

Invariably, there are those who claim it is legitimate to compel the behavior of others because society as a whole bears the cost of health care. Because taxpayers are compelled to pay for welfare state programs like Medicare and Medicaid, further compulsion is “justified” to strip people of their own choices. Compulsion begets further compulsion. Such is the downward spiral of socialism. People accept such compulsion because they have been sold a bill of goods that it is good for society. I have seen it all before. In my native land of Canada, private property rights are extremely limited in the sphere of health care and people docilely accept one and two year waits for basic health care because they have been indoctrinated that their universal health care system is good for society. But, after all, even the Soviet purges were supposedly for the greater good of society.

Although it is not proper for government to legislate against smoking on private property such as restaurants, it is completely just to do so for truly public places. Such places would be municipal buildings and courthouses because these places are truly public in that

they are owned by all and, therefore, the will of the majority should be manifest above the wishes of a minority.

As a patron of local restaurants, I would never return to one that does not provide me with a non-smoking section and would actually be more likely to go to a restaurant that is entirely smoke-free. The management of such a facility will be obligated to voluntarily comply with the wishes of a free market or suffer the consequences of going out of business. Adam Smith’s “invisible hand of the market” is already fulfilling this in that restaurants without a non-smoking section are very rare. Market forces are also at work increasing the number of completely smoke-free facilities.

Whether businesses are affected positively or negatively by a non-smoking ordinance is actually irrelevant to the issue. The real issue is whether or not Hennepin County truly believes in the concept of liberty and the right for us to make our own choices and to live by the consequences of our own choices. If liberty is to remain a value of American society, liberty cannot be violated when it seems convenient or expeditious to do so.

I came to the U.S. with my family to leave behind intrusive government and the resultant ramifications of such a social structure.

If government decides upon the usage of private property, is it really private property? The concept of private property is a cornerstone of the American Revolution. The essence of why I moved to the U.S. is embodied by the values of the American Revolution. Imagine my disappointment in Hennepin County. ◆ Lee Kurisko, M.D. is with Consulting Radiologists, Ltd.

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4

January/February 2005

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Health Care 2005 Legislative Session Preview

T

that could reach $1 billion and the fact that health care costs consumers at least 26 percent of the state’s budget, cuts in programs will be proposed and debated.

BY NORA STEWART, M.P.A.

Governor’s Health Care Cabinet At the time of writing, the Governor had not yet released the recommendations from the Health Care Cabinet. However, we know that certain items will be included in the recommendations.

• Streamlining regulatory reporting requirements. This initiative includes centralizing, consolidating and streamlining regulatory reporting requirements. The goal is to eliminate over one third of all reports required by health plans.

• Consolidate health insurance and health care delivery into one department — the Department of Commerce. In Minnesota, HMOs are regulated by the Department of Health, more traditional insurance is regulated by the Department of Commerce, and workers’ compensation is regulated by the Department of Labor and Industry. A proposal to move all regulation of health care delivery into the Department of Commerce is likely to emerge.

• A single source for credentialing providers. Legislation will be proposed that would authorize a single source for credentialing of providers. This includes all health plans, hospitals and clinic systems.

• Allow for-profit HMOs in Minnesota.

Minnesota is the only state that requires HMOs to be non-profits. There will be a proposal to repeal the prohibition of forprofit HMOs in the state.

• Require timely claims submission and payment. Statutory changes will be proposed so

THE 2005 LEGISLATURE will convene on

Tuesday, January 4, 2005, for what promises to be a very long and contentious session. The fact that the legislature failed to pass major legislation, including a bonding bill, during the 2004 session, combined with the realization that the 2005 legislative session is a budget year should make for a lot of fireworks. In addition, the makeup of the new 2005 legislature has changed dramatically with the House Republicans down 13 seats to a 68-66 slim majority, including the loss of key Republican committee chairs including the Health Care Committee Chair Lynda Boudreau (R-Fairbault). The Senate, not up for re-election until 2006 remains at 35 Democrats, 31 Republicans and one Independent. The slim majority in both bodies means both sides of the aisle will need to compromise or face a stalemate similar to the 2004 session.

Health care will be one of the top issues facing the legislature in 2005. The Governor convened a health care cabinet in February 2004 to assess the state’s health care purchasing systems, reduce health care costs and administrative burdens, and provide for regulatory reform within the state’s health system.

Along with the Governor’s health care initiative, there are many issues still unresolved from the 2004 legislative session. Medical malpractice reform, best practices, electronic medical records, worker compensation issues, the provider tax and use of the Health Care Access Fund are all pending issues the new legislature must address.

Additional issues likely to come up during the 2005 session include a tobacco tax (or “user” fee), a statewide smoking ban, and the health care budget. With a looming state deficit

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

that the time of payment and interest-only penalty are the same for all general health claim payers.

• Electronic Medical Records. A report is due to the legislature in December. The recommendations will include the appropriate role of the state in developing, financing, promoting, and implementing the system.

Medical Malpractice Reform Early in the 2004 session, Representative Fran Bradley (R-Rochester) unveiled a medical malpractice reform package. However, the reform was highly controversial and, as a result, the bill ultimately failed. The bill would have limited recovery of total damages for non-economic loss from a medical malpractice claim to $250,000 and prohibited disclosing this limit to the jury. The bill limited punitive damages in medical malpractice cases to $250,000 and required that the jury not be told of this limit.

There will be proposals during the 2005 session to limit the non-economic and punitive damages in medical malpractice awards and limit contingency fees that can be earned by attorneys in medical malpractice cases.

Workers’ Compensation Changes During the 2004 legislative session, providers worked overtime to kill a provision in the workers’ compensation bill that would have permitted a certified managed care plan to compensate providers for their services and care using “discounted fees” rather than the fees on the workers’ compensation fee scale.

Providers felt that this language would open the gate for managed care in the workers com(Continued on page 6)

January/February 2005

5

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January/February 2005

pensation system and injured workers would eventually have no choice but to accept the certified managed care roster for employers who contract exclusively with the certified plans. As providers who are unable to discount their fees drop out of the certified plan, injured workers would have fewer and fewer choices of providers. The proposal went right to the wire before being defeated in committee the last week of the session. The Department of Labor and Industry (DOLI) has issued proposed rule amendments that include the same language as the bill from the 2004 legislative session. In addition, the Workers’ Compensation Advisory Council likely will bring forth a similar bill in 2005.

Tobacco Tax Introduction of bills to increase the tobacco tax will likely be in the mix during the 2005 legislative session. The tax would add additional revenues to the state budget and it would hopefully curb smoking at the same time. While many Republicans have pledged not to increase taxes, the tobacco tax could be seen as a “user fee” and therefore may be more politically palatable.

We’ve been through 172,982.

LaMettry’s COLLISION

Legislative Preview (Continued from page 5)

Statewide Smoking Ban The time may be ripe for legislation that bans smoking in bars and restaurants statewide.

Last year the legislature balked at passing statewide legislation. Since then local units of government have stepped forward and bans will take effect in early 2005 in Hennepin County, Ramsey County, Bloomington and Minneapolis. Other states that have instituted a statewide ban include: New York, California, Utah, Florida, Connecticut and Maine.

Governor Pawlenty has stated publicly that he would sign a statewide smoking ban if it reaches his desk.

No-Fault Auto Medical Costs Proposals will be offered during the 2005 legislative session to allow a no-fault “managed care” system that is currently prohibited under state law. Additionally, proposals to adopt the workers compensation treatment parameters and fee schedule, with a conversion factor, are likely.

MetroDoctors

Provider Tax and the Health Care Access Fund A perennial issue at the state capitol is the provider tax. Each year legislation is introduced to either eliminate the provider tax or reduce it. However, these bills are rarely heard in committee and simply do not pass. Will this be the year that the tax is eliminated? The Health Care Access Fund has been raided to fill the budget gaps, and the 2005 session will bring proposals to leave the Health Care Access Fund untouched.

Budget The State of Minnesota operates on a two-year budget cycle. State fiscal years begin on July 1 and end the following June 30. The fiscal year is designated by the calendar year in which it ends. So, for example, we are currently in fiscal year 2005.

Each odd-numbered year the Governor proposes and the legislature ratifies the Operating Budget, often called the Biennial Budget, for the State of Minnesota. The budget is for a two-year period and includes expenditures for health care, education, roads and bridges, technology, public safety, housing, natural resources, agriculture, economic development, higher education, as well as state funding for agencies and local units of government. The legislature will debate and adopt the next twoyear budget in 2005. The Governor’s budget recommendations will be released in January next year. The legislature then must adopt a final budget by June 30, or face a government shutdown. Five key state budget numbers to watch include: • November Economic Forecast • Governor’s Budget Recommendations (January or February) • February Economic Forecast • Revised Governor’s Budget Recommendations (usually in March) • End of Session Estimates (usually in May or June) The 2005 session will be long and tough.

Physicians and other providers should strive to be active during the legislative session with a projected budget deficit of up to $1 billion, and as major health care reform and budget issues are debated and enacted. ◆ Nora Stewart, M.P.A, is with Lockridge Grindal Nauen P.L.L.P. The Journal of the Hennepin and Ramsey Medical Societies

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Respect, Integrity, Compassion… when a healthcare organization is committed to these

“Smart Buy” Alliance (Continued from page 7)

values, the whole community benefits. Allina Hospitals & Clinics is a group of 11 hospitals and 42 clinics in Minnesota and western Wisconsin.

We are proud of our values and of the difference we are able to make in the lives of many. If you share in these values…

Rewarding and Utilizing the Best Health Care Significant variations in cost and quality exist among health care providers. In many instances, health care providers with the highest quality of care and the best health care outcomes are also more efficient and economical, often by a large margin, than other providers. The Smart Buy Alliance has reached agreement on the following principles and expectations for their purchasing decisions and will encourage the use of high quality health care providers in a number of ways including: 1. Requiring or Rewarding “Best in Class” Certification.

Existing “best in class” certification programs verify that health care providers have achieved certain levels of expertise, experience, proficiency, quality of care and results. For example, the Health Value Partnership for Heart Care identifies and rewards “best in class” cardiac care centers in Minnesota. The Smart Buy Alliance will use certification programs as one measure of health care quality and certification will be one criterion in choosing providers and encouraging patients to use the best providers.

We have a place for you.

United Pain Center, in downtown St. Paul, MN, is a United Hospital-based outpatient clinic. We are accredited by the American Academy of Pain Management and are affiliated with Associated Anesthesiologists, PA and provide comprehensive services for individuals experiencing chronic pain. The clinic offers a variety of interventions including narcotic management, injection therapies, psychological assessment and support, acupuncture and biofeedback.

We are currently seeking a .75 to 1.0 Pain Managment Physician • Seeking experienced Internal Medicine, Occupational Medicine, Neurology, or Physical Medicine & Rehab. Experience and interest in pain management.

• The primary role of this opportunity is evaluation and management, this is not a procedural based position.

• Graduate of an approved medical school and approved specialty residency. Board certified in specialty area. Must be able to obtain a MN State Board of Medical Examiners license and DEA license.

• The center offers a variety of services including these major programs: inpatient stroke rehabilitation, inpatient spinal cord rehabilitation, brain injury program, outpatient chronic pain services, Language Care Centers, and sports injury clinics.

We offer a competitive salary, comprehensive benefits package and malpractice insurance.

Allina Physician Recruitment Services 8450 City Centre Drive Woodbury, MN 55125 Phone: 1-800-248-4921 Fax: 651-714-3311 E-mail: recruit@allina.com www.allina.com EOE

AD APPROVAL PUBLICATION:

METRO DOCTORSand Utilizing Uniform Measures 2. Adopting

and Results.

Traditionally, SIZE: 4.8125” X 4.625” purchasers have paid health care providers for performing procedures without EST. COST: much focus on quality of care or results. The WORKSHEET#: 1121866 Smart Buy Alliance will adopt uniform methAD #: 125493837 ods of measuring quality of care and results AE: SALLY and ALAR will purchase health care based upon those measurements. Where feasible, the alliance will AD FILE NAME: AL111904MPS purchase and reward improved clinical results OK AS IS: CHANGES: rather than just paying for procedures. To the APPROVED BY: extent procedures are used as a basis for paySIGNATURE: ment, procedures that have been demonstrated to by,yield best results will be featured and This material is developed and isthe the property of, Ludlow Advertising, Inc. and isrewarded. to be used only in connection with services rendered by Ludlow Advertising, Inc. It is not to be alliance will use value-based purchascopied, reproduced, published,The exhibited or otherwise used without the express written consent of Ludlow Advertising, Inc. ing tools — such as eValue8 (www.eValue8.org) sponsored by the National Business Coalition on Health (NBCH) — to guide such decisions. It provides uniform measures of quality and results. The alliance will also encourage and reward the use of “centers of excellence” ISSUE / DATE:

8

January/February 2005

MetroDoctors

of Quality JANUARY 2005

The Journal of the Hennepin and Ramsey Medical Societies

that demonstrate the best proficiency, quality and results for treating certain conditions.

Adjustments may need to be made to ensure continued geographic access to providers.

3. Empowering Consumers with Easy Access to Information.

Consumers and purchasers cannot make good health care decisions in the marketplace without access to standardized, easy-to-understand information about health care cost and quality. The Smart Buy Alliance will require health plans and providers to participate in efforts to make such information available. The Community Measurement Project initiated by the private sector and a new health information website (www.minnesotahealthinfo.org) sponsored by the Minnesota Department of Health are examples of the type of information to be made available.

4. Requiring the Use of Modern Technology in Health Care Administration.

While health care providers use cutting edge technology to treat patients, the health care industry is woefully behind in using the latest technology in the administration of health care.

This causes great inefficiencies and duplication of effort. For example, claims processing is fragmented, complex and inefficient.

Modern technology is often not used in the development and handling of medical records.

Prescriptions are still written by hand and the interaction between physician, pharmacy and patient is more difficult than it needs to be.

The Smart Buy Alliance will demand better use of technology in such areas as: providing patients with electronic readable insurance cards that will allow the consumer and provider to determine instant eligibility for benefits with a swipe of a card rather than hours of confusing phone calls; requiring that insurance claims be 100 percent electronic and that all providers use standardized claim forms such as the forms used by the Medicare system (forms CMC-92 and CMC-1500); and developing automated systems that track clinical outcomes, patient satisfaction, and speed up payments to providers.

“Until now, purchasers have bought what has been sold to them, not necessarily what they wanted to buy,” said Caroline Pare, chief executive officer of BHCAG. “What we’re sayMetroDoctors

ing today is that the public sector and private sector are going to work together in setting common expectations for what we buy. This alliance will create market changes that will allow consumers to make choices based on provider performance and value.”

Health Savings Accounts A new federal law encourages the use of Health Savings Accounts (HSAs). HSAs are similar to an Individual Retirement Account (IRA) except that the funds in an HSA are used for health care expenses, not retirement.

When using an HSA, individuals or employers obtain insurance with a high deductible (at least $1,000 for individual coverage, and at least $2,000 for family coverage), which is less expensive than comparable low deductible insurance.

Individuals and employers can contribute tax-deductible funds each year up to the amount of the health insurance policy’s annual deductible, subject to a cap, that must be used for their health care needs. HSA funds can be used to cover health care expenses such as the health insurance deductible and any co-payments for medical services, prescriptions, or medical devices. Like an IRA, individuals own their own HSA. Additionally, the HSA is portable and can be continued if an individual changes jobs.

Governor Pawlenty will recommend that the 2005 Legislature pass legislation requiring that Minnesota enact the state tax incentives that help to make HSAs an attractive option for consumers.

Regulatory Reform The Governor’s Health Cabinet extensively reviewed the regulatory burdens state government imposes on the health care delivery system in an effort to identify regulations that drive up costs, take time, and create bureaucratic burdens without adding much value to the system. As a result of this review, the Pawlenty Administration will pursue the following regulatory reforms: 1. Consolidate and Streamline Reporting Requirements.

Minnesota government requires hundreds of reports and vast amounts of information from

The Journal of the Hennepin and Ramsey Medical Societies

January/February Index to Advertisers Allina Health Systems ................................. 8 Allina Health Systems ............................... 12 Classified Ad ............................................... 9 Coldwell Banker Burnet— Bruce Birkeland............ Inside Back Cover Crutchfield Dermatology .......................... 21 HealthEast Vascular Center ....................... 13 HealthPartners Inst. for Medical Ed. ........... 4 LaMettry’s Collision, Inc. ............................ 6 MMIC ...................................................... 16 Minnesota Healthcare Network ................. 23 Regency Hospital of Minneapolis ............... 8 RCMS, Inc. ............................................... 16 Schwarz Williams Co., Inc. ...........................

Inside Front Cover U of M CME ............... Outside Back Cover U of M Medical School ............................. 14 Weber Law Office ....................................... 7 Whitesell Medical Locums, Ltd. ................ 12 Wirth Companies.............. Inside Back Cover

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(Continued on page 10)

January/February 2005

9

“Smart Buy” Alliance (Continued from page 9)

health care providers, insurers and health plans.

Some of those reports have become obsolete, outdated, and redundant or are not even used by regulators. The Health Cabinet has developed centralized, modern and streamlined reporting requirements that will reduce the number of reports that need to be submitted by approximately 33 percent.

2. Establish a Single Source for Health Care Provider Credentials.

In order to provide service to a health plan or hospital, physicians and health practitioners must demonstrate their credentials as part of a formal verification process. Often, the

same physician or practitioner seeks to be credentialed by several plans or hospitals. The process is time-consuming, expensive and largely duplicative. The State of Minnesota, in partnership with providers, will create a centralized third-party credentialing entity to create a one-stop credentialing process.

3. Use National Accreditation Standards.

To be eligible to provide services in programs sponsored by the Minnesota Departments of Health or Human Services, providers often must be “accredited.” Currently, the State operates its own accreditation process. Where appropriate, the State should be allowed to accept the accreditation given to providers by nationally recognized organizations such as the National Committee for Quality Assurance rather than requiring a parallel state process.

Mark Your Calendar

MMA Day at the Capitol 2005 Physicians Need to Show Their Presence at the Legislature

Hear political speakers, receive up-to-date information on the health care legislative issues being heard at the legislature, attend legislative hearings, and meet with your legislators.

Date: Thursday, February 17, 2005 Time: 11:00 a.m. – 4:00 p.m.

Place: Four Points Sheraton St. Paul-Capitol Hotel Save the date!!

You do not want to miss this exciting day.

10

January/February 2005

MetroDoctors

4. Require Timely Submission of Claims.

State law currently has several sets of different deadlines, types of information required, and different penalties surrounding when health claims must be made. The Governor will propose legislation that creates common standards for the timely submission and payment of health claims. Additionally, the state will eliminate the requirement that “zero balance” bills be mailed to consumers when a claim has been paid in full by the insurer. One payer estimated that this action will save more than $2.4 million a year.

5. Enhance Anti-fraud and Anti-kickback Enforcement.

Nationally, experts estimate that up to 3 percent of health care spending is for fraudulent activity. The state has consolidated anti-fraud units into the Department of Commerce and will continue to work to prevent this problem.

Governor Pawlenty’s Health Cabinet In February 2004, Governor Pawlenty formed the Health Cabinet to implement many of the health care reform ideas identified by a citizens’ panel on health care reform. The Health Cabinet, chaired by Commissioner of Employee Relations Cal Ludeman, consists of Commissioner of Health Dianne Mandernach, Commissioner of Human Services Kevin Goodno, Commissioner of Labor and Industry Scott Brener, Commissioner of Finance Peggy Ingison and Commissioner of Commerce Glenn Wilson. The group held a series of town meetings throughout Minnesota during the summer and fall, and will continue to implement and develop health care reform initiatives for the Pawlenty Administration.

The Governor concluded, “Today’s announcement is a start, but it’s just the beginning. I have asked the Health Cabinet to continue to work. This Administration will have much more to say on this topic in the coming weeks and months. Truly reforming and managing the costs surrounding health care is a long-term endeavor and we will continue to rise to the challenge.” ◆

The Journal of the Hennepin and Ramsey Medical Societies

The Appropriate Tools for Pain Management

A

A RECENT POLL by RESEARCH! America

stated that 57 percent of Americans have suffered chronic or recurring pain in the past year.

Ages 18 through 34 are only slightly less likely than older Americans to be in pain. One fifth of Americans have had a major lifestyle change in employment, residence or personal freedom and mobility as a result of chronic pain.

This article, the second of three, is intended to outline the necessary tools required to appropriately treat a patient suffering from chronic intractable pain. The definition of chronic pain is a pain state which is persistent and in which the cause of the pain cannot be removed or otherwise treated. Chronic pain may be associated with a long-term incurable or intractable medical condition or disease.

Pain, especially chronic pain, is a multifaceted process biologically, and thus a multifaceted experience for the patient.1 As a result, chronic pain responds best to a polymodal treatment approach, which may include medication, therapeutic exercise, psycho-social counseling, surgical intervention and, if necessary, chemical dependency treatment.

Medication therapy is the mainstay of chronic pain treatment and in many ways is the most difficult component of an integrated treatment plan to manage. Therefore, this article will concentrate on the overall clinical methodology appropriate for the use of a regimen based on drug therapy.

A good introduction to this topic is the World Health Organization’s “Stairstep” guidelines for recommended pharmacological approaches to treatment of chronic pain.

The WHO three-step ladder is described as follows:

BY A.V. ANDERSON, M.D., D.C., AND RICHARD L. AULD, Ph.D.

MetroDoctors

Step 1: Mild pain is treated with aspirin, acetaminophen, NSAIDs and adjuvants such as anti-epileptic medications, antidepressant medications, etc.

Step 2: Moderate pain is treated with the combination of medications of codeine, hydrocodone, oxycodone and dihydrocodeine.

Tramadol is included in this group. Continuation of the adjuvants would also be included in this category.

Step 3: Severe pain is treated with the added potency of morphine, hydromorphone, methadone, levorphanol, fentanyl and oxycodone.

Adjuvant medications remain integrated in the treatment plan.

The appropriate use of the medications is but one aspect of the care of the chronic pain patient. First and foremost, the physician must appropriately document the necessity of the treatment.2 The outcome of the treatment must be documented in the following visits.

Medical History and Physical Examination The authors recommend adherence to the evaluation and management guidelines set forth

by CMS (Center for Medicare and Medicaid Service). One could construct a template with which to guide the evaluation and documentation. This must document: • The nature and intensity of pain, the provocative factors (for example, position, activity, etc.).

• The quality of pain (aching, throbbing, stabbing, burning).

• Region of pain (focal, multifocal, generalized, deep or superficial).

• Severity (average, least, worst and current on a scale of 1-10).

The Journal of the Hennepin and Ramsey Medical Societies

• Temporal factors such as onset, duration and course. One must document the effect of the pain on the patient’s physical and psychological function.

Included in the history would be any documentation of substance abuse or history of legal implications of such. The pain history should also include reasonable etiologies, previous evaluations and diagnoses, and past treatments that have been attempted with success or failure.

The diagnosis should incorporate the etiology and appropriate syndromes as well as the appropriate coding numbers. Inferred pathophysiologies such as objective findings

by MRI scans, laboratory studies, etc. should be included. If there is nociceptive pain, neuropathic pain or psychogenic pain this should be included as a rationale for the use of medications to be prescribed. The examining physician should integrate the findings of physical and mental influences as well as psychiatric and psychosocial factors. The diagnosis should be clear as to the severity and nature of the disability associated with pain.

Evaluations and Consultations Assessing the patient for appropriate treatment, the physician should consider for consultation any issues involving complex pharmacotherapy, rehabilitative approaches, psychological assessment, surgery, neurostimulation and other invasive, procedure-based pain management techniques, as well as the wide array of complementary treatments and fundamental lifestyle changes.3 Treatment Objectives The four “A’s” of pain management are: Analgesia (pain relief), Activities of daily living (Continued on page 12)

January/February 2005

11

Respect, Integrity, Compassion… when a healthcare organization is committed to these

Pain Management (Continued from page 11)

values, the whole community benefits. Allina Hospitals & Clinics is a group of 11 hospitals and 42 clinics in Minnesota and western Wisconsin. We are proud of our values and of the difference we are able to make in the lives of many. If you share in these values…

(psychosocial functioning), Adverse effects (side effects) and Apparent drug-related behavior (addiction-related outcomes).3 The objectives should include an expected increase in function with the use of appropriate medications, including, if feasible, return to work.

This should be considered at the original job, a modified job or a change in the occupation consistent with the patient’s disability. The treating physician may have to adjust the therapy regimen to the individual needs of the patient if their activity has a substantial influence on the pain levels.

We have a place for you.

We are currently seeking a .5 Family Practice or Internal Medicine Chronic Pain Physician at Sister Kenny Institute.

• Join an established Chronic Pain Management team on the campus of Abbott Northwestern Hospital.

• Sister Kenny Rehabilitation Services are part of Abbott Northwestern Hospital in Minneapolis, a 612 bed facility, and the largest not-for-profit hospital in the Twin Cities. The ED is staffed 24 hours a day by ED staff.

• BE/BC FP or IM Provider experienced working in a multidisciplinary setting managing patients with acute, subacute and chronic pain.

Sister Kenny Institute’s Chronic Pain Program is dedicated to helping people manage their own chronic pain. As the most established residential program in the Midwest, our program has helped thousands of patients improve their lives. Join our team today!

We offer a competitive salary, comprehensive benefits package and malpractice insurance.

Allina Physician Recruitment Services 8450 City Centre Drive Woodbury, MN 55125 Phone: 1-800-248-4921 Fax: 651-714-3311 E-mail: recruit@allina.com www.allina.com EOE

Discussion of Risks and Benefits Risks and benefits should be discussed with the patient. The physician should carefully explain the difference between dependency and addiction, which have crucial distinctions. Physical dependence is common to many drugs, such as blood pressure medications, anti-seizure medications, insulin and opioids. It results in biochemical changes such that abruptly stopping these drugs will cause a withdrawal effect. Addiction, on the other hand, is a neurobehavioral syndrome with genetic influences that result in psychological dependence on the of aP substance A D useA P RforOtheirVpsychic A Leffects and is characterized by compulsive use despite harm.4 PUBLICATION: METRO DOCTORS Physical dependence and tolerance are normal ISSUE / DATE: JANUARY 2005 physiological consequences of extended opioid SIZE: 4.8125” X 4.625” therapy for pain and should not be considered EST. addiction.

COST: The patient must understand the raWe are a Minnesota based physician staffing service specializing tionale1122206 in prescribing the medication. The side WORKSHEET#: in Emergency Room, Clinic and Urgent Care coverage for effects, which are potential with every mediAD #: 1255473 Minnesota Health Care Facilities. cation and vary with each individual patient, AE: SALLY ALAR should be discussed before prescribing. The CLIENTS: Are you seeking quality staffing AD FILE NAME: AL113004KENNY patient should also be made specifically aware 1630 Anderson Avenue with physicians of the highest caliber who are OKof AS IS: CHANGES: Suite 100 the potential side effects of opiate medicareference verified and committed to completion Buffalo, MN 55313 tions, of an assignment?

APPROVED BY: particularly potential constipation and drowsiness. They should be made aware of the SIGNATURE: PHYSICIANS: Are you seeking competitive Metro: 763.682.5906 specific laws in the state in which you practice salary, variety of practice settings and malpractice This material is developed by, and is the property of, Ludlow Toll Free: 800.876.7171 coverage? regarding driving while taking medications that Advertising, Inc. and is to be used only in connection with Fax: 763.684.0243 services rendered Ludlow Advertising, Inc. It is nottime. to be couldbyinterfere with response Put our experience and resources to work for www.whitesellmedstaff.com copied, reproduced, published, exhibited or otherwise used you. Call us today!

without the express written consent of Ludlow Advertising, Inc.

Informed Consent Informed consent should be included in a prepared controlled substance prescription agreement document. This is an absolute requirement for the treatment of a patient who

16 YEARS OF DEMONSTRATED SUCCESS!

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January/February 2005

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

will be using opiate-type medications on an ongoing basis. This document should specifically outline the responsibility of the patient in managing his/her medication — specifically including that there will be no increase in dosage without approval. No other doctors are to be prescribing this medication without your knowledge. Regular visits are mandatory to fill the prescriptions. The determination of regularity should be at the comfort level of the physician, but these authors do not feel that there should be more than two to three months between evaluations. Thorough documentation must be done at each of these re-evaluations. Random bioassays should be considered as well, particularly if there are any risk factors involved such as a previous abuse history or if any aberrant behavior becomes evident as time goes along.4 An article in the Pain Medicine News, July/August 2003, stated that long-term use of opioids do not impair motor or cognitive function. Pain, on the other hand, is distracting, resulting in loss of focus and concentration. The article stated that patients who suffer 663-2789new B&W improved ad 9/24/03 from chronic painhoriz might have func-

tion when treated appropriately with opioid medication.

The patients must be made aware that states such as Minnesota have a zero tolerance policy for drivers taking or having scheduled medications evident in their blood or urine.

The treatment agreement should include that the prescriptions will be filled at the same pharmacy. The prescriptions should be filled during regular office hours to facilitate checking records before a prescription is called in.

Prescriptions should not be replaced or filled early, except under rare circumstances with a patient who is trustworthy. This should be understood at the onset of the treatment.4 The patient should be made aware that the physician must know all of the medications that are currently being taken, including over-the-counter medications and nutraceutical substances.

Periodic Reviews Periodic reviews are absolutely necessary to determine the function and capability of the patient. In this review JCAHO standards 3:41 PM Page 1 the visual or numerical recommend recording

pain scale on each visit. This may not be as important as the function of the patient. In other words, the patient can have a rather consistent pain scale rating, but if their performance and function are increasing, this is certainly justification and verification of goals that have been established previously. It should be noted that as human beings we do not have a good recollection of a pain, which occurred months before. If this were not true, there might only be one child in each family. It can be helpful to have significant others or family members write a note verifying change in the function of the patient since initiating treatment.

The periodic review should qualify for at least an intermediate examination as defined by the E&M (Evaluation and Management) guidelines. This should provide documentation as to the perceived pain levels, functioning capability, psychosocial factors, and potential adverse side effects related to the medications prescribed. Also included should be a review of systems, vital signs, general appearance, and a system-oriented physical examination as it (Continued on page 14)

“We’re here to guide your patients’ care and recovery.”

Arterial Disease Venous Disease Lymphatic Disease Wound Care

HealthEast

®

va s c u l a r c e n t e r To schedule a patient for a consultation or vascular study, call:

651/232-2550 St. Paul & Maplewood Offices www.healtheast.org

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2005

13

Pain Management (Continued from page 13)

relates to the chief complaint for which the patient is being treated.

It is our professional obligation to learn how to assess patients with pain and make reasonable decisions about a trial of opiate therapy. Prescribing principles should be adhered to, particularly in drug selection, dosing to optimize effects, treating side effects and managing the poorly responsive patient.5 The primary goal in treating the chronic intractable pain patient should be that of increasing function. If an increase in function is not documented, the use of opiate medications should be in question. The patient should be able to report that the pain is still there but does not have as much influence on their life as it had in the past.5 Management of Side Effects The management of constipation is an absolute necessity. Opioids typically cause slowing of the bowel function, which can result in severe constipation. Every patient receiving narcotics for pain must be put on a bowel program. This

program would include advising the patient regarding high fiber diets and appropriate fluid consumption. A stool softener or laxative should be prescribed with the first prescription of a narcotic medication.3 Drowsiness can occur with some patients during the first three to 10 days, but typically resolves with time due to tolerance.

Medications such as Provigil or Ritalin could be considered to relieve drowsiness during the initial phases of treatment and during titration. This would be considered off label use of these medications. Tolerance and physical dependence are natural biological reactions and are independent from addiction.

Conclusion It is not in the scope of this article to elaborate on the physiology of pain, other factors of the pain process or all the other modes of pain treatment. However, physicians undertaking the treatment of chronic pain should strive to gain knowledge on these topics.

Suffice it to say that there has been an explosion of information over the last 10 years that explains how and why patients

t-time AAssistant ssistant Dean (Ph duc Par art-time (Phyysician EEduc ducaator) Continuing Medic al EEduc duc Medical ducaation Univ ersit al School Medical Universit ersityy of Minnesota Medic The University of Minnesota Medical School is accepting applications for the Assistant Dean (Physician Educator) for the Continuing Medical Education (CME) Program. The selected candidate will be responsible for guiding the overall strategic direction of the Office of Continuing Medical Education. This is an annual renewable appointment at approximately 50% time.

Qualified candidates will possess an M.D. or D. O. degree; minimum of six yers faculty experience in a medical school, teaching hospital, or specialty society setting; experience to include involvement with CME as a course planner, speaker, etc.; familiarity with revenue sources for CME programs. Involvement with CME experience at both the local and national level, and a record of research in medical education is a plus.

Applications will be accepted until the position is filled.

Interested candidates should submit letter of interest and curriculum vitae to:

Richard L. Auld, Ph.D. has served as the assistant executive director at the Board of Medical Practice since 1985. He is primarily responsible for constituent outreach, policy and planning, educational development and legislative matters.

Reference List 1. Pappagallo M, Heinberg LJ. Ethical issues in the management of chronic nonmalignant pain. Semin Neurol. 1997:17(3):203-211.

2. Lister BJ. Dilemmas in the treatment of chronic pain.

Am J Med. 1996; 101(IA):28-58.

4. Federation of State Medical Boards. “Model Policy for Use of Controlled Substances for the Treatment of Pain” May 2004.

The University of Minnesota is an equal opportunity employer and educator.

January/February 2005

Alfred V. Anderson, M.D., D.C. is a pain management and manipulative medicine specialist and is also a licensed chiropractor. He operates the Pain Assessment & Rehabilitation Center, Ltd., in Edina. He is a Diplomat in Pain Management, the American Academy of Pain Management.

Dr. Anderson serves on the Board of Directors of the Minnesota Physician/Patient Alliance and on the Board of Medical Practice from the second congressional district.

3. Passik SD, Weinreb HJ. Managing chronic nonmalignant pain:overcoming obstacles to the use of opioids.

Adv Ther. 2000;17(2):70-83.

Kathleen V. Watson, M.D. Interim Senior Associate Dean for Education MMC 293 420 Delaware Street S.E. Minneapolis, Minnesota 55455 e-mail: drwatson@umn.edu

14

with intractable pain suffer as they do. Sufficient knowledge in these areas helps to give the prescribing physician insight into why treatment is necessary for this very complex disorder. It also helps the physician to convey the appropriate explanation to the patient as to why he/she is suffering this pain complex.

Consider that it has been a trend to attempt to treat chronic pain patients exclusively with anti-inflammatory medications. The New England Journal of Medicine, Nov. 23, 2000 states, “It has been estimated that more than 100,000 patients are hospitalized and 16,000 die each year in the United States as a result of NSAID-associated gastrointestinal events.”

It is probably prudent to consider the use of opioid medication for long-term pain therapy, since there is less potential for organ damage compared to NSAID medications.

The next article will deal with the type of medications that can be appropriately administered as well as the risks and benefits, including potential abuse and aberrant drugrelated behavior. ◆

MetroDoctors

5. Portenoy, R. K. Opioid Prescribing to Patient with and without Chemical Dependency. Presented at: International Conference on Pain and Chemical Dependency, June 6-8,2002: New York, New York.

The Journal of the Hennepin and Ramsey Medical Societies

What’s New in General Surgery

F

FEW DISCIPLINES in the field of medical practice have undergone such profound transformation in recent years as has general surgery.

The dictum “less is more” describes the current climate of surgical change, as the laparoscopic revolution has affected almost every aspect of surgical practice. New applications of laparoscopic surgery continue to be found, and it is clear that this trend is likely to last. Because the scope of general surgery is vast and beyond the purview of this short review, I will concentrate on major recent developments in several areas; other components of general surgery including trauma, thoracic and endocrine surgery will not be covered.

Breast Surgery The diagnosis of breast cancer is a devastating physical and emotional blow to patients, but several developments have improved the outlook for women with this disease. Most breast cancer is now detected at a curable stage, and smaller operations for breast cancer cause much less physical disfigurement and psychological trauma. Whereas previously it was common to find large tumors with nodal involvement at initial diagnosis, greater public awareness of breast cancer and consequent widespread screening by mammography, self-examination and physician examination has shifted the presentation to either in situ or Stage 1 lesions for most cancers. The initial biopsy is usually performed by one of a number of image-guided techniques rather than by open surgical incision, and truly minimal lesions are amenable to office-based vacuum extraction biopsy techniques.

The surgical intervention is also less traumatic. Lumpectomy with subsequent radiation therapy has been demonstrated to be

BY PETER WILTON, M.D.

MetroDoctors

as effective as mastectomy for tumors <4cm, which comprises the majority of presenting neoplasms. When mastectomy is indicated, skin-sparing techniques allow immediate reconstruction with improved cosmetic appearance. Axillary lymph node dissection, with its attendant morbidity of nerve injury and lymphedema, has been replaced by sentinel lymph node biopsy; formal node dissections are reserved for the small minority of cases with positive axillary nodes. Information from current trials should provide guidance in the future for selection of cancers that do not need any node sampling. Radiation therapy is also coming under closer scrutiny; a recent trial suggested that in women over 70 with early cancers, the risk of recurrence is sufficiently small to warrant observation rather than radiation if patients receive hormonal therapy.

Most heartening is the data that show that after decades of little change, the mortality from breast cancer is finally declining. It is anticipated that most of the future improvements in breast cancer therapy will occur in the fields of chemotherapy and hormonal manipulation rather than in changes in surgical techniques.

The Journal of the Hennepin and Ramsey Medical Societies

Hernia Hernia repair, the “bread-and-butter” procedure of most general surgical practices, has changed significantly in recent years and continues to evolve. Surgeons have come to accept the principle of tension-free repair.

Many studies have shown that tension-free hernia repairs involving mesh are superior to sutured repairs, and in the last few years mesh repairs (of which there are several types) have become the predominant operation.

Recently, laparoscopic approaches to hernia repair have been introduced, and both intra-and extra-peritoneal techniques have been described to repair inguinal, ventral and incisional hernias.

Until recently, incisional hernia repairs have been plagued by high recurrence rates, despite mesh placement. This situation appears to be particularly suited to the laparoscopic approach with intra-abdominal mesh insertion to bridge the hernia defect (Figure 1), and results in shorter hospital stays and less recurrence than traditional repairs.

Repair of inguinal hernias is easily and rapidly accomplished via laparoscopic techniques. Not all patients are suitable candidates — obesity, large hernias, and previous

Figure 1. Intra-abdominal view of laparoscopic incisional hernia repair.

(Continued on page 17)

January/February 2005

15

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Membership Advantages for Physicians and their Practices Schwarz Williams Companies, Inc. offers RMS members individual and group benefits (medical, dental, life, disability) as well as human resource support services, executive benefits, retirement programs, COBRA/HIPAA/ERISA compliance, and benefit administration.

To find out more information, contact Jim Fries at (763) 591-5822 or visit their website at www.schwarzwilliams.com.

AmeriPride Apparel and Linen Services is a locally owned and

operated company offering rental and cleaning services of medical garments. Their organization is top notch with quality products and services. RMS members receive a discount. For a free price quote, contact Steve Severson from AmeriPride at 612-362-0334.

SafeAssure Consultants recently partnered with RMS to offer the required OSHA compliance training for our members and their staffs. Our members receive a 50-60% discount on services and training.

To meet or exceed the Minnesota OSHA and Federal OSHA requirements talk with SafeAssure at 1-800-920-SAFE or visit their website www.safeassuremedical.com for more information.

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Call RMS at 612-362-3704 for details.

16

January/February 2005

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The Journal of the Hennepin and Ramsey Medical Societies

General Surgery (Continued from page 15)

intra-abdominal or extraperitoneal pelvic surgery (such as prostatectomy) are contraindications to the laparoscopic approach. The primary advantages of laparoscopic repair in the inguinal location appear to be less postoperative discomfort and earlier return to work.

Which hernias should be repaired? The natural history of hernias is poorly understood, and the current practice is to repair all hernias to prevent possible catastrophic bowel incarceration and strangulation. Clearly, however, the risk in any single hernia is small, but at present we are unable to identify the small group of hernias at high risk for these complications. A current trial of operation vs. watchful waiting is in progress and the results are expected in early 2005. Hopefully these will enable surgeons to selectively repair hernias in the future.

Vascular Of all the fields in surgery, perhaps none are undergoing such rapid evolution — some would say revolution — as vascular surgery. Endovascular stenting of arteries, previously confined to the coronary and iliac vessels, is now being applied to the aorta, femoral and carotids. The indications for routine stenting in these locations are currently unclear, and intermediateterm data is only beginning to emerge.

The indication for operation on asymptomatic abdominal aortic aneurysms (AAA) has recently been clarified. The risk of rupture is directly related to size, and it was previously accepted that a 6 cm diameter AAA required operation, while those less than 4 cm did not.

The recent large United Kingdom and VA trials of operation vs. observation have demonstrated that it is safe to watch AAA up to 5.5 cm with repeated ultrasounds. Diligent follow-up of such patients with serial ultrasounds is necessary since the natural history of AAA is to progressively enlarge. The majority of patients observed on these trials ultimately underwent surgery, because their aneurysms grew to the critical diameter.

AAA have long been the province of the surgeon, but open repair carries significant mortality (approximately 5 percent nationwide) and morbidity. Endovascular stenting of asymptomatic AAA has become increasingly popular, and recent 10-year follow-up MetroDoctors

Figure 2. Endovascular AAA repair. CT demonstrating contrast within stent, excluding aneurysm sac.

data suggest that it can be done with lower mortality and morbidity than open repair (Figure 2). However, the failure rate of endovascular grafts appears to be continuous, so that with time the cumulative morbidity and mortality of endovascular procedures may well exceed that of open repair. For this reason, endovascular repair is best reserved at present for those patients who are not good candidates for open repair or whose life expectancy is limited. A very intriguing future possibility is that endovascular stenting may prove to be the procedure of choice for ruptured AAA. Early reports have been encouraging, but the grafts used are not widely available at this time.

Carotid endarterectomy has been the “gold standard” for treatment of severe internal carotid artery stenosis since the NASCET trial of 1991, with a stroke/mortality rate in experienced hands of about 3 percent. Carotid stenting has recently been introduced, and had an initial stroke rate several-fold that of endarterectomy. The stenting catheters have since been modified with protection devices to prevent intracranial emboli during stent deployment. Thus far, their therapeutic equivalence to open endarterectomy has not been proven, and stenting should be reserved for cases unsuitable for open repair. The recently published SAPPHIRE trial suggests that stenting with protective devices achieves equivalent results to endarterectomy in high-risk cases. There are several large randomized trials under way comparing stenting with endarterectomy in routine cases which should clarify the role of stenting in such cases in the near future.

Colon and Rectal The adoption of laparoscopic techniques has been slower in the field of colonic surgery than

The Journal of the Hennepin and Ramsey Medical Societies

elsewhere in abdominal surgery. There have been two main reasons for this. Firstly, colon and rectal surgeons have not had as extensive experience as general surgeons with advanced laparoscopic procedures. Secondly, initial reports suggested that laparoscopy was unsuitable for colon cancer due to implantation of malignant cells in laparoscopic port sites.

A major multi-institutional trial with almost five years of follow-up has recently dispelled these concerns, and it is anticipated that there will be a progressive increase in laparoscopic procedures for colon cancer in the near future.

Hand-access devices are now available which allow the surgeon to insert a hand into the abdomen to assist the laparoscopic operation while maintaining the pneumoperitoneum.

Such devices allow a convenient transition between wholly laparoscopic and entirely open procedures. Laparoscopic techniques have been employed with increasing frequency in benign colonic conditions such as diverticular disease and colostomy takedowns, and do appear to confer benefit in terms of length of stay and postoperative discomfort.

Other Abdominal Procedures There are few abdominal operations indeed that are not amenable to laparoscopic intervention. Laparoscopic procedures are now routinely used for cholecystectomy, bile duct exploration, abdominal exploration, splenectomies, adrenalectomies, anti-reflux procedures and even hepatic resections. One of the fastestgrowing areas of laparoscopic practice is that of bariatric surgery. The current plague of obesity, along with the recent acceptance by Medicare that obesity is a disease, has resulted in a huge increase in demand for bariatric procedures.

Laparoscopic techniques are used for gastric bypass as well as gastric restrictive procedures.

Their application to bariatric procedures is growing, although such operations have been plagued by higher complication rates than open procedures performed by experienced bariatric surgeons. In Europe, a laparoscopic adjustable banding procedure has been successful but this favorable experience has not been replicated in the United States. The direction of future practice is likely to be driven as much by patient preference and payer demand as by physician recommendation. ◆ Peter Wilton, M.D. is with St. Paul Surgeons, Ltd. January/February 2005

17

COLLEAGUE INTERVIEW

Roger G. Kathol, M.D., C.P.E.

Roger G. Kathol, M.D., C.P.E., president of Cartesian Solutions, Inc.™, is an innovative Certified Physician Executive with 30 years experience in the integration of general medical and behavioral health care. He has expertise in the development and operation of cross-disciplinary programs and services for clinics and hospitals; health plans; software vendors; case, disease, and disability management organizations; employee assistance programs; and employers.

Dr. Kathol is board certified in internal medicine, psychiatry, and medical management. He graduated from the University of Kansas School of Medicine. He completed his internship in internal medicine at Good Samaritan Hospital in Phoenix, Arizona, and residencies in psychiatry and internal medicine at the University of Iowa in Iowa City, and a year of endocrinology fellowship in Wellington, New Zealand.

He is currently adjunct professor of internal medicine and psychiatry at the University of Minnesota.

Q

Minnesota health plans and government agencies commonly outsource mental health/behavioral care to restricted provider networks which are separately funded and administered from general medical care (behavioral carve-outs). Often these organizations do utilization and network management (recruitment, fee negotiation), and they may contract with for-profit companies, for example Medica with United Health Group’s UBH. How do you recommend policy change given these segregated behavioral carve-outs?

A

Three points require clarification in order to understand my answer to this question: 1) Under our current “carve-out” system, more than 70 percent of those with mental health or substance abuse (behavioral health) problems receive no treatment for their psychiatric illness. Only a fifth of the 30 percent who do, get what would be considered evidence-based care.

2) Total health care costs for patients who use behavioral health services are double those who don’t with over 80 percent of service use for medical and pharmacy, not psychiatric care.

3) Independent managed behavioral health business practices prevent general medical and psychiatric service coordination.

In short, we are providing effective treatment to few of the patients 18

January/February 2005

who need it, are cost shifting service use from mental health to medical providers who have limited expertise in addressing behavioral issues and at great expense, and are doing these two things in a system that makes it impossible to improve the situation because of segregated business practices.

One could focus on independently managed behavioral health carveouts, such as United Behavioral Health (UBH) and Behavioral Health Care Providers (BHP) with whom Medica and PreferredOne contract, respectively, for their behavioral health care, as being the arbiters of the problem. The fact is that independent coding and billing, independent provider networks, independent claims adjudication, independent actuarial analyses, and independent payment pools, i.e. the business practices used to manage behavioral health, whether carved-out or owned by a medical care parent (carved-in), such as in the case of Blue Cross, is the problem. Quick fixes, such as paying primary care physicians to treat depression, parity reimbursement for behavioral health providers, etc., don’t and won’t work to change the poor outcomes documented in items #1 and #2 above because general medical and behavioral health managed care organizations have competing bottom lines. Each benefits from limiting service use in their own sector and transferring it to the other. Their profit comes from limiting access and use.

Improved behavioral health outcomes and, with them, reduced health care costs will only occur in Minnesota when independent management of behavioral health (carved-out or carved-in) is replaced by a system in which mental health and substance abuse treatment becomes an integral part of general medical care. This can only happen with infrastructure change, which includes: • Purchasers demand no financial distinction between reimbursement for medical and behavioral health services for their constituents or employees.

• Health plans write purchaser contracts in which: 1) mental health and substance abuse services are included without differentiation MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

from other medical services; 2) general medical and behavioral health claims adjudication occurs in the same computer system using the same rules; 3) general medical provider networks include psychiatrists (and other mental health professionals); and 4) actuarial projections are based on the total health care dollar spent for those covered rather than independent spends for general medical and behavioral health service use in the same patients. Finally, provider contracts must include language that reimburses behavioral health fairly and encourages behavioral health treatment in the primary and specialty medical settings, where the majority of mental illness is seen.

• Hospitals and clinics do away with general medical and mental health geographic and functional service segregation practices (largely the result of current reimbursement practices). Mental health and non-mental health clinicians work together as they jointly accept accountability for the total health care outcomes of their patients.

Many PCPs want direct access to psychiatrists for their patients in the same way they want access to and collaboration with other specialists. How can this be achieved?

The first problem, of course, is that there is a shortage of psychiatrists, especially child psychiatrists, and mental health service settings in Minnesota in which psychiatrists are available. Expanding their number, and thus access, will only occur when psychiatric practice opportunities attract medical students to the field in increasing numbers or psychiatrists trained in other states move to Minnesota to enjoy a better practice environment.

Since the number of psychiatrists is unlikely to increase in the near future, interim improvement in access could occur if there was better support for psychiatric practice, and thus geographic availability, in the medical setting. Data demonstrates that mental health treatment by PCPs in collaboration with mental health assistance in the primary care setting, usually under the supervision of a psychiatrist, leads to improved outcomes and ultimately lower health care costs. This can only occur, however, if reimbursement practices encourage care collaboration in which both medical and mental health professionals become accountable for the total clinical outcomes of the patients treated. This cannot be accomplished when medical and behavioral health services are managed separately.

The second problem has to do with directly accessing psychiatrists who do work in Minnesota. As long as independent general medical and behavioral health networks and reimbursement processes exist, limited direct access to psychiatrists will continue. Since the PCP’s patients may have mental health benefits through a variety of behavioral health networks in the state, it forces PCPs to encourage the patient to call a 1-800 number rather than providing them with a direct referral. Since mental health and substance abuse problems often require personal communication and a personal touch to even get them to show up for help, referral to a telephone number has a demonstrated poor compliance rate.

Is the widespread prescribing of antidepressants by family practitioners a good practice? If not, why?

Yes. There are far too many patients with depression to expect that even a small percentage could access treatment through a psychiatrist.

Now we just have to get non-psychiatrist physicians to prescribe antidepressants to those who are likely to benefit and in ways that lead to better patient outcomes. Data demonstrate that while antidepressant prescribing is up in the past 10 years, particularly in the primary care setting, unless support for medication treatment is provided by nurse managers or mental health professionals, patients do not improve any more than those who receive no treatment.

Treatment of depression requires education about the illness, individual support, close follow-up to ensure adherence and avoid side effects or drug interactions, and personal attention during the treatment process. While all of these could be considered integral parts of general medical practice, time and reimbursement constraints in the typical PCP practice and a lack of appreciation for the importance of education and follow-up both likely contribute to poor treatment outcomes when general medical physicians try to tackle treatment of depression alone.

This is where mental health support staff in the medical clinic contribute to the changing outcomes.

Do you think that Minnesota payers should beef up payments for psychiatrists who do psychotherapy and medications rather than preferential funding for split treatment arrangements, i.e., the doctor writes prescriptions and non-physicians do the talking treatment?

This is an unanswerable question. There are clearly some patients who improve more rapidly and to a greater degree when they receive their total care from a skilled and empathic psychiatrist with whom they have rapport. If increased reimbursement for this is necessary to get a psychiatrist to assume the responsibility to give this type of treatment to the patients most likely to benefit, then it should be a reimbursement option.

On the other hand, there are far too few psychiatrists available to just assist with medical management to encourage them to uniformly take on formal psychotherapy responsibilities along with medication management through better reimbursement. This would further limit access to an already scarce resource. If you compare the total number of patients that can be treated annually using cognitive behavioral therapy, a psychotherapy with evidence of efficacy for depression and anxiety (7 sessions/day X 5 days/week X 48 weeks a year with at least 8 sessions needed per patient = 210/year) with the number that can be treated annually with medication (21 medication management appointments/day X 5 days/week X 48 weeks with at least 6 appointments per patient for acute phase treatment = 840/year), the number of patients that can be helped by a psychiatrist is increased fourfold.

This does not imply that crisis-oriented and/or supportive psychotherapy should not take place during a 20 minute medication check or that the addition of formal psychotherapy either by the psychiatrist or (Continued on page 20)

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January/February 2005

19

Colleague Interview (Continued from page 19)

a mental health colleague should not be included, especially when a patient is not responding well to medication. Making these judgment calls is a part of the clinical practice of psychiatry and for that matter all of clinical medicine. Nor am I implying that reimbursement for the services rendered, such as the combination of medication management and psychotherapy, should not be fairly compensated. The reimbursement system should recognize the value that psychiatrists bring to the system and reimburse them fairly without substantially penalizing them for implementing value adds such as concurrent medication management and psychotherapy in appropriate cases. At the same time, the reimbursement system needs to acknowledge that there are other mental health professionals with psychotherapeutic skills that could assume the therapist role in coordination with the already too busy psychiatrists.

With increasing emphasis on consumer choice and cost sharing, for example with health savings accounts (HSAs), how can and should potential patients find and evaluate a “mental health provider” or physician who might be of help to them? What role could organized medicine play to educate the public about proper expectations for evaluations and treatments?

It is even difficult for physicians to evaluate which of their colleagues are good providers and for what, based on the information available in today’s health care environment about individual clinicians. To expect patients to be able to do this with anything other than rudimentary sophistication is unrealistic. Furthermore, it is not just the quality of the physician that needs review. Clinic or hospital organization, health plan reimbursement practices, and the benefit provisions of the patient’s health care contract also influence health care outcomes.

Consistent with this bias, there are two roles that organized medicine can play. First, it can actively participate in the development of strategies in which physicians, the hospitals and clinics in which they work, health plan’s clinical reimbursement support procedures, and employer health care contract provisions can be assessed for outcome changing value brought to patients. Currently, clinician practices and clinic and hospital operations are at the center of patient outcome assessments.

This should be expanded to include health plans and purchasers of care.

Results of these outcome analyses should be used to identify opportunities to improve rather than to institute punitive measures.

The second role for organized medicine is to become educated about health plan based case and disease management. Case and disease management nurses are trained to be impartial patient advocates and educators as they help patients navigate a complicated health care system.

Unlike the utilization managers of old, whose job it was to approve or deny care, case and disease managers educate patients, encourage active participation in their provider’s interventions, often follow-up to assure compliance, assist in identifying community resources, etc. Since they have access to the total clinical service use and medication picture of the patient through the health plan claims database, they can often uncover 20

January/February 2005

missed clinical opportunities, poor compliance, transportation problems, etc. before a crisis necessitating an emergency room visit or hospitalization occurs. While these professionals do not replace appropriate staffing needs in clinics, they can go a long way to helping patients adhere to good treatment programs, add outcome augmenting activities, and identify additional clinical options when improvement is not progressing.

How important is continuity of relationship and continuity of care in the treatment of chronic mental disorders?

How would you assess how much or little the present insurance system values, enhances, or discourages continuity of professional relationships and care?

Relationships between patients and the clinicians who care for them play a large role in the degrees to which patients, regardless of the branch of medicine in which they are treated, follow the directions of the treating provider. Presuming that the treatment being given can be expected to improve the patient’s condition, then every effort should be made to maintain patient–provider continuity.

There is tremendous variability among health plans regarding the consistency and longevity of their provider networks. In general terms, however, decisions about the inclusion and exclusion of providers has more to do with regulatory requirements, provider cost, and purchaser requests for certain providers than interest in the patient-clinician relationship or the continuity of care. This is particularly true in behavioral health where there can be large discrepancies in the providers participating on various health plan local or regional panels because of the health plan’s intervention biases, e.g. some have few options for electroconvulsive therapy, or interest in containing health care dollars, e.g. some have few psychiatrists on their provider panel to encourage the use of lower cost providers. I know of no way for patients to assess a health plan’s commitment to this important component of care.

Can you comment on the issue of lack of integration of the mental health disciplines in providing comprehensive and individualized mental health evaluations prior to a decision or a course of treatment, especially in relation to child evaluations?

Few would argue that pertinent information regardless of the source should be brought into a comprehensive evaluation so that the best diagnosis can be made and the best treatment given. Implied in this is the need to include any discipline, mental health or otherwise, into the assessment process. For instance, in a child evaluation, the assessment team may be composed of a child psychiatrist, social worker, teachers, school psychologist, pediatrician, and/or juvenile detention authority.

Depending on the situation, one of the members of the assessment team would assume responsibility for synthesizing the information and developing a plan. While this is the ideal, it often does not happen, in part, because of limited reimbursement for the assessment process.

Another problem plays into this important question. An attempt was made to force the completion of a comprehensive evaluation by the

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

creation of a rule that treatment for a mental health condition could not be initiated without first completing a comprehensive assessment. This has led to a number of patients receiving no treatment because there were no mental health professionals available to complete the comprehensive evaluation in a timely fashion.

This is an area in which balance is necessary. Reasonable comprehensive evaluations should be encouraged and adequately reimbursed, but waiting for them to be completed should not prevent interim treatment from being given.

Employers and government policymakers sometimes justify cutting mental health by claiming a lack of evidence for treatment effectiveness. Are they right? If not, how can they be educated? Give us some resources.

based treatments or to use them in a way that they will change clinical and ultimately economic outcomes. Therapists need to use cognitive behavioral treatment, interpersonal psychotherapy, or one of the other psychotherapies with evidence of efficacy for depression, anxiety, and a variety of other conditions in preference to therapies without evidence of efficacy. Like pills, psychotherapies are not equally effective. The same can be said of medication prescribing in the primary care setting. If the prescription alone doesn’t change outcomes, as the literature suggests, then the other factors shown to influence outcome need to be added when treatment is provided in the primary care setting.

Finally, members from different mental health disciplines, such as psychiatry and psychology, need to stop bickering and giving mixed messages. Both have much to offer patients with mental illness and should draw on their special areas of expertise, such as psychotherapy for psychologists, systems and social support for social workers, and biopsychosocial factors for psychiatrists, as they come together to foster more appropriate care of patients with mental illness and substance abuse.

Frankly, there are more patients that need treatment with a variety of modalities than there are treatment providers.

If mental health professionals can get their act together, they have the potential of saving the health system and employers lots of money by doing what they got into the profession to do, i.e. effectively treat patients with mental illness. ◆

The data related to the effective treatment of many mental illnesses, such as depression, anxiety, schizophrenia, bipolar illness, and increasingly, substance abuse is no longer subtle. Furthermore, understanding of this fact by audiences who are willing to listen has increased dramatically in the last decade. While there have been many reports and national agendas that have contributed to this, one of the most influential was the Surgeon General’s Report on Mental Health.

Rather than going into a list of references documenting this fact, I prefer to suggest that it is no longer ineffective treatment that is at issue. There are three other major barriers that now retard advances in the treatment of patients with mental health and substance abuse problems. The first is the managed behavioral health sinkhole. We are so administratively entrenched in a separate general medical and behavioral health system, despite its terrible record of patient “Remarkable patient satisfaction from quality, treatment and the documented high cost asservice, convenience and excellent results” sociated with it, that we are unwilling to take the necessary steps to change. Like tobacco “Exceptional care for company cover-ups in the old days, manall skin problems” aged behavioral health organizations know that their approach to behavioral health care Charles E. retards effective treatment, especially in the Crutchfield III, M.D. medical setting where the majority of mental Board Certified Dermatologist health patients are seen, yet administering Psoriasis & Acne Specialist it is a “cash cow” which they are loath to give up. Even the medical managed care companies now recognize that independent 1185 Town Centre Drive behavioral health management is bad for Suite 101 the health of their members, however, the Eagan, MN 55123 Your Patients will effort and cost associated with integrating it with the rest of medicine awaits actionLook Good & Feel Great able demand by public consensus and their Appointments with Beautiful Skin purchasers.

651-209-3600 The second barrier has to do with the www.CrutchfieldDermatology.com Prompt Appointments via reluctance of many mental health or other Physician Requests professionals involved in the treatment of behavioral disorders either to use evidence-

Crutchfield Dermatology

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The Journal of the Hennepin and Ramsey Medical Societies

January/February 2005

21

Smart Card Applications for Health Care Begin to Emerge Editor’s Note: K. James Ehlen, M.D. is a familiar name to many in the Twin Cities medical community. A physician who specialized in endocrinology, Dr. Ehlen has, for the last 16 years, occupied a series of executive roles in health care, both locally and nationally. In 1988 he became chairman and chief executive officer of Physicians Health Plan, the organization that subsequently evolved into Medica.

In 1994, Dr. Ehlen oversaw Medica’s merger with HealthSpan, creating the Twin Cities’ based system, Allina. In 2001, Dr. Ehlen was appointed chief medical officer of Humana, a role he held until last year when he returned to Minnesota to become chairman of Halleland Health Consulting. With a career-long interest in improving the health care system, and a growing appreciation for technology’s ability to effect positive change, Dr. Ehlen accepted an offer early this year to join the board of Minneapolis-based Cardtronic Technology, a leader in health care specific smart cards.

MetroDoctors invited Dr. Ehlen to respond to questions on this advancing technology.

T

THE TERM “SMART CARD” is the generic

name for something that looks very much like a credit card. It’s made “smart” by a small computer chip embedded in its left section.

This chip allows the card to store, retrieve and display information and to perform tasks much like a small computer. Long used by the U.S. government for security purposes, and especially in Europe and Asia for its varied capabilities, it is only recently that smart card applications specific to health care have begun to emerge.

Smart cards seem to have changed a lot in the last decade or so. How have these changes impacted their ability to improve health care delivery?

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January/February 2005

How does the whole process work?

It’s very true that smart cards have changed.

Not only is the hardware involved with cards and readers far less costly than before, the capabilities have also increased tremendously.

But that’s how a technologist looks at things. I look at things as a doctor — one whose primary goal is to find systems that make the physician’s life easier and the patient experience better. For me, these are the real drivers and they are the reasons I’m excited about what today’s smart cards can do.

What type of information is being placed on the cards today?

The cards are capable of holding — or retrieving — a wide range of data that can be displayed on an office PC screen. The initial smart card deployment here in Minnesota will focus mainly on two things: Real-time verification of a patient’s health plan eligibility and enabling payment from health-related financial accounts such as employer-based flexible spending accounts. In the future, smart cards will very likely be used to obtain and track a patient’s prescription drugs, their immunization history or other health care information to support various care and disease management programs.

MetroDoctors

Let me give you a simple scenario as an example. It begins with the health plan that replaces its current member ID card with smart cards. The readers and desktop software are provided free of charge to health care providers.

These readers are small devices — about the size of a computer mouse — and they fit easily on the desks of clinic staff. When the patient arrives with the smart card — obvious by its visible computer chip, the card is placed in the reader, which then fires up an application on the computer. In the presence of Internet connectivity (increasingly common in physicians’ offices today) the card contacts the database at the patient’s health plan. This allows the provider to get real-time eligibility verification and details about the patient’s benefit coverage. The result, of course, is that the provider’s staff no longer has to spend time calling the health plan prior to a visit in order to check eligibility and benefit coverage. It’s also more convenient for the patient, and lowers costs for the payers.

What about payment capabilities? It would seem this is a natural function for the smart card.

Yes, smart cards can certainly execute payments right in the office at the time of the visit, and can directly debit one or more financial accounts. The cards that the Minnesota provider community will be seeing soon are designed to link up with a patient’s flexible spending account or health savings account. This is one of those capabilities that help everyone.

The patient has the convenience of deducting health care payments directly from their tax-free health care account, which minimizes

The Journal of the Hennepin and Ramsey Medical Societies

the need for complicated paperwork. The provider is paid at the point of service, and the employer gains a better incentive to offer employees when it comes time to sign up for these pre-tax accounts.

How easy will it be to set these readers up in provider offices?

The readers being deployed in Minnesota in the coming months are extremely easy both to install and to use. Easier than installing a printer — basically they just need to get plugged into a computer with their installation CD and the software walks you through a simple process. Some registration steps are required in order to ensure that the reader is attached to a legitimate health care provider. But after that, the application quietly waits until a card is placed in the reader. Then the program springs to life on the computer screen. And again, these readers are free to the providers.

What do you believe is the single biggest benefit the smart card offers to providers?

There are probably two benefits I would characterize as extremely significant. The first is the time saved for provider office staff who will be able to get instant, real-time membership and eligibility status just by placing a patient’s ID card into a reader. The second is the ease of payment. Patients with health care spending accounts, whether employer-based FSA or the new HSA, will find it much more convenient to use those funds with a smart card that debits the account directly, while simultaneously creating an audit trail, which validates that the payment was for eligible expenses.

What do you see as the single greatest challenge to the widespread acceptance of smart cards within the provider community?

I think we all have a natural resistance to change even when the change promises many

positive benefits. A lot of us, for example, resisted bringing PCs into our offices. Why did we need a computer when we had typewriters?

But today, most of us barely remember that transition and I don’t know anyone who would trade the PC on his or her office desktop for a typewriter. There is no comparison between these tools. A typewriter generates documents in real time — that’s all it does. A computer can do that along with countless other important tasks. So today, we realize that the comparison is silly. I guess I believe that one day, in the not too distant future, we’ll look at smart cards in much the same way as we view computers today. We’ll appreciate them as multi-functional tools that not only save time and money, but that also increase patient safety, help us comply with HIPAA regulations, and a whole host of other things. I see them as a great aid to the important goals of simplifying and standardizing our work in health care. ◆

What about integration with existing practice management and electronic medical records systems?

I think the operative phrase, at least for me, is “standardize and simplify.” That’s what the smart card revolution is all about. The technology we’re using will allow us to connect effectively to most of the more commonly used practice management and EMR systems. The smart cards from Cardtronic are being developed as open system platforms specifically so that users can expand their utility in the future. As we all become more accustomed to smart cards, and as more and more patients have them, we’ll see more applications take advantage of the cards’ capabilities. And they will link up with more and more of the things we do — both clinically and administratively.

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�������������������������������������� How well do the smart cards comply with HIPAA regulations?

I can only speak for Cardtronic’s smart card which I know complies with all HIPAA requirements regarding the secure holding and transmitting of patient data, and the maintaining of patient privacy.

MetroDoctors

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The Journal of the Hennepin and Ramsey Medical Societies

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23

PRESIDENT’S MESSAGE PETER J. DALY, M.D.

A Year of Accomplishments

RMS-Officers

President Charles G. Terzian, M.D. President-Elect James J. Jordan, M.D. Past President Peter J. Daly, M.D. Secretary Gretchen S. Crary, M.D. Treasurer Charles E. Crutchfield III, MMB, M.D. RMS-Board Members

Todd D. Brandt, M.D., At-Large Director Victor S. Cox, M.D., Specialty Director Laura A. Dean, M.D., Specialty Director Jeremy Carlson, Medical Student Andrew S. Fink, M.D., At-Large Director Ronnell A. Hansen, M.D., Specialty Director James J. Jordan, M.D., Specialty Director Bradley C. Linden, M.D., Resident Physician Thomas J. Losasso, M.D., At-Large 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 Jacques P. Stassart, M.D., At-Large Director David C. Thorson, M.D., Specialty Director Peter B. Wilton, M.D., At-Large Director RMS-Ex-Officio Board Members & Council Chairs

Blanton Bessinger, M.D., AMA Alternate Delegate Victor S. Cox, M.D., Communications Council Chair Kenneth W. Crabb, M.D., AMA Delegate Robert W. Geist, M.D., Ethics & Professionalism Council Chair Frank J. Indihar, M.D., AMA Delegate Neal R. Holtan, M.D., Community Health Council Chair Mark Kleinschmidt, Clinic Administrator Anthony Orecchia, M.D. Education Resource Council Chair Stephanie D. Stanton, Vice Speaker, AMA Medical Student Section Lyle J. Swenson, M.D., Public Policy Council Chair Wayne H. Thalhuber, M.D., Sr. Physicians Association President RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive Officer Katie Anderson, Executive Assistant Doreen M. Hines, Membership & Web Site Coordinator

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MY YEAR AS RAMSEY Medical Society president has flown by! As I write my last column, I extend my gratitude to Roger Johnson (CEO), Doreen Hines and Katie Anderson of the RMS staff, for their hard work and professionalism.

Our work simply could not be done without their support and attention to detail. I am also grateful for the scores of physicians who have given their time and energy to our RMS efforts to maintain the patient and his/her interests at the center of our activities. These efforts have culminated in several accomplishments.

MN Health Plan Contracting Act On May 29, 2004, culminating three years of work by the Minnesota Fair Health Plan Contracting Coalition, led by RMS and HMS, Governor Pawlenty signed into law the basic rights of providers as they enter into contractual relationships with health plans. These rights include full disclosure of contract terms, elimination of unilateral terms, interest payment on delayed reimbursements, notification of coding changes, prohibition of shadow contracting, and efficient notification of preauthorization. These rights give providers more equal footing in advocating for patient concerns.

Smoke free ordinances in St. Paul and Ramsey County RMS physicians and staff worked diligently, along with other members of the Ramsey Tobacco Coalition, to lobby for a St. Paul smoke free ordinance. When our efforts were thwarted

by Mayor Kelly, at least the Ramsey County Board of Commissioners adopted a smoke free ordinance on September 14, which covers only restaurants in Ramsey County. Further efforts continue to strengthen the Ramsey Smoke Free ordinance to include bars.

Provider Tax/Minnesota Health Access Fund Efforts to understand the complexities of the provider tax and its relation to the state’s budget were assisted by discussions with Phil Riveness, a former state legislator and current legislative policy advisor to the Minnesota Medical Group Managers Association. We learned disturbingly that provider tax revenues have already been MetroDoctors

committed by the state legislature (through previous budget appropriations) for several non-health care related purposes through fiscal year 2007. With a $700 million forecasted state budget deficit up for discussion in the 2005 state legislature, it is politically naïve to think that our state will reverse the trend of raiding the Minnesota Health Access Fund for use in the General Fund ($425 million was reallocated to the General Fund by the 2003 legislature). Proposed solutions include first pushing for alternative tax sources, such as a $1 per pack cigarette increase.

Second, demand that revenues in the Health Access Fund be used only for the purpose for which it was created—to provide health care to low income Minnesotans. Implementation of a “blinking” feature on the provider tax revenues would allow the tax to “blink off” when raised monies exceeded the forecasted needs of the MinnesotaCare program. This feature would ensure that the provider tax rate mirror the financial requirements of MinnesotaCare. A broad coalition of provider groups and frequent contact with our legislators is required to support these needed changes. We owe it to our patients to reverse the reality of this unjust tax.

Ambulatory Health Care Access RMS and other provider organizations successfully opposed the MN Hospital Association’s attempt to limit the access and use of non hospital-based ambulatory surgery centers and outpatient imaging centers. The MHA proposed bill would have established an onerous certificate of need on these services and substantially increase their costs by forcing them through the higher cost inpatient facilities. Data and testimony was provided to the state legislature by RMS, HMS and MMA physicians emphasizing that cost savings, high patient satisfaction, low complication rates, and improved access to care were all strong features of maintaining these services to our patients. The bill was successfully modified to a form that maintains non hospital-based services at this high level of care for our patients.

(Continued on page 25)

The Journal of the Hennepin and Ramsey Medical Societies

RMS President’s Message (Continued from page 24)

Congratulations to the elected RMS leaders

PRESIDENT Charles G. Terzian, M.D. Internal Medicine (Hospitalist) United Hospital

PRESIDENT-ELECT James J. Jordan, M.D. Psychiatry Hamm Memorial Psychiatric Clinic

SECRETARY Gretchen S. Crary, M.D. Anatomic Pathology Hennepin Faculty Associates

DIRECTOR-AT-LARGE Andrew S. Fink, M.D. Vascular Surgery Radiation Oncology

DIRECTOR-AT-LARGE Thomas J. Losasso, M.D. Anesthesiology Valley Anesthesiology

DIRECTOR-AT-LARGE Jacques P. Stassart, M.D. Reproductive Endocrinology Reproductive Medicine & Infertility Associates MMA HOUSE OF DELEGATES Blanton Bessinger, M.D. Amy L. Gilbert, M.D. J. Michael GonzalezCampoy, M.D., Ph.D. Frank J. Indihar, M.D. Lyle J. Swenson, M.D.

HOSPITAL BASED SPECIALTY DIRECTOR Ronnell A. Hansen, M.D. Diagnostic Radiology St. Paul Radiology, P.A.

INTERNAL MEDICINE SPECIALTY DIRECTOR Jane C. Pederson, M.D., M.S. Internal Medicine (Geriatrics) Stratis Health

In Memoriam LOWELL L. KVAM, M.D. died October 19, 2004 at the age of 71. Dr. Kvam graduated from the University of Minnesota in 1960 and was a general practitioner on the east side of St. Paul for five years before returning to train in pathology. He later became the director of pathology at St. Joseph’s Hospital, St. John’s Hospital and HealthEast Hospitals. While at St. Joseph’s, he was director of the St. Joseph Hospital Medical Technology School. He was active in the American Red Cross and the Blood Bank Program. Dr. Kvam practiced in St. Paul until retiring to Florida in 1997.

He joined RMS in 1963. ◆

MetroDoctors

RMS Board Updated on MMA Task Force on Health Care Reform RMS Board Members met on Wednesday, December 1 at Bethesda Hospital. Dr. Judith F. Shank, M.D., Task Force Chairperson, provided a presentation on the preliminary findings of the MMA Task Force on Health Care Reform. Dr. Shank stressed the importance in understanding that this presentation is in no way final and there will be ongoing changes as they fine-tune their report. The final report will be submitted to the MMA Board of Trustees on January 22, 2005. ◆

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2005

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Ramsey Medical Society

Health Care Reform Governor Pawlenty recently announced (November 29, 2004) his plan to slow health care costs and improve quality. Although all parties agree that cost containment is needed, and continuous quality improvement is good, the governor’s plan currently emphasizes business interests, rather than focusing on patients. Several RMS physicians are serving on the MMA’s Task Force for Health Care Reform, and will soon outline their proposals for change. RMS members Drs. Robert Geist and J. Michael Gonzalez-Campoy (our MMA president) have been emphasizing the need for physicians to guard quality and expose the dangers of “pay for performance” or contingency payments to physicians. Although well intentioned, payments contingent on disease management will likely create another layer of bureaucracy, fragment care, and reduce clinic productivity with compliance demands. We physicians have to remain vigilant and engaged in defining quality in health care. To leave quality and its continuous improvement up to the governor, or consumers, or business interests is to abandon our patients. We must keep the patient’s interests at the center of health care reform.

As the next legislative session begins, let us make our first 2005 new year’s resolution be that of serving our patients in the health care arena and in the halls of government. I encourage your participation in the activities of the RMS Council on Public Policy and at the MMA Day at the Capitol on February 17, 2005. I urge you to respond to Legislative Alerts during the 2005 session and to make an effort to meet and know your legislators.

2004 has been a good year. Let’s keep working! ◆

2005 Ramsey Medical Society Election Results

RMS IN ACTION ROGER K. JOHNSON, RMS CEO

The Ramsey Tobacco Coalition met on June 7 to continue strategic planning for the City Council and County Commissioners. Roger Johnson spoke at a Ramsey Tobacco Coalition news conference on June 9 urging adoption of a Saint Paul smoke free ordinance. Meetings with Ramsey County Commissioners Reinhardt, McDonough, Ortega and Haigh were conducted June 14-16 to urge them to support a smoke free ordinance to include bars and restaurants. Dr. Blanton Bessinger spoke on behalf of RMS and the Ramsey Tobacco Coalition advocating for a smoke free ordinance at City Hall on June 24 and was quoted in the June 25 Pioneer Press. Dr. Susan Crutchfield spoke for RMS and the Ramsey Tobacco Coalition advocating for a smoke free ordinance on Lucille’s Kitchen on KMOJ radio on July 13.

On August 25 Dr. Amy Gilbert testified at the Saint Paul City Council meeting in support of the smoke free ordinance. Dr. Peter Daly, RMS president, and Dr. Amy Gilbert accompanied Roger Johnson to meetings with Saint Paul Councilman David Thune, the author of the smoke free ordinance, to talk strategy, and with Mayor Randy Kelly to urge him to sign the ordinance. The Saint Paul City Council approved a smoke free ordinance on September 1 for Saint Paul. Dr. Daly signed a letter from the RMS president to Mayor Kelly again urging him to sign the smoke free ordinance. Dr. Blanton Bessinger testified at the smoke free ordinance hearing before the Ramsey County Board of Commissioners on September 7. Dr. Bessinger told the Commissioners that “the smoking ban is a health issue.”

Mayor Kelly vetoed the Saint Paul smoke free ordinance on September 13 and the Ramsey County Board of Commissioners adopted a smoke free ordinance on September 14 which essentially covers only restaurants. A meeting of the Ramsey Tobacco Coalition was held on October 5. Jeanne Weigum of the Association of Non-smokers and Roger Johnson met with Ramsey County Commissioner Tony Bennett on October 14 to discuss the future likelihood of strengthening the Ramsey Smoke Free ordinance to include bars.

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Advocacy work during the month of June included Roger Johnson meeting with Representative Jim Abeler in the offices of Lockridge, Grindal, and Nauen. Mr. Johnson represented RMS at the Governor’s Health Care Cabinet meeting June 23. Phil Riveness, Minnesota Medical Group Managers Association (MMGMA), and Roger Johnson met July 13 with Katie Cavanaugh of the Minnesota Senate legal staff and representatives of the Minnesota Department of Finance to discuss the Minnesota Health Access Fund which is the fund that receives the provider tax revenue. The disturbing fact we learned was that provider tax revenue was committed by the Minnesota Legislature to the Health Care Access Fund and several other purposes including the General Fund through Fiscal Year 2007.

The RMS Board of Directors met on June 30.

A tradition of RMS continued on August 10 with the Annual RMS Board Family Night at the Saint Paul Saints at Midway Stadium. The RMS Board of Directors met on September 15 where Commissioner Cal Ludeman was a guest speaker, and on December 1 where Dr. Judith Shank, chairperson of the MMA Task Force on Health Care Reform, made a presentation, and to plan for 2005.

The Council on Education Resources, chaired by Dr. Tony Orecchia, met on July 6 to plan for the 2005 Winter Medical Conference and to continue working toward the implementation of a clinic CME program. Their next meeting on August 3 reviewed progress on the RMS CME program and approved faculty for the 2005 Winter Medical Conference. They again met on October 26 to discuss the CME program. Roger Johnson and Doreen Hines of the RMS staff attended the MMA Conference for CME Planners on October 29.

At their July 7 meeting the Ramsey Medical Society Foundation Board of Directors approved its first grant which was awarded to the Hmong Refugee Health project headed by Dr. Kathleen Culhane-Pera. Dr. Robert Moravec, president of the RMS Foundation, and Roger Johnson met with Dr. Kathleen Culhane-Pera MetroDoctors

on September 17 to present the Foundation check. Their next meetings were held on September 8 and November 10.

The RMS Executive Committee met August 11 to take up several issues related to positions at the MMA Annual Meeting, to discuss advocacy issues, and to talk about identifying physician leaders to nominate for RMS offices.

The RMS Executive Committee then met on October 13 to review the actions of the MMA House of Delegates. On November 10 they met to learn about the health care reform proposals and discuss the upcoming legislative session.

Roger Johnson hosted a breakfast in September for clinic administrators to inform them about Portico’s Healthnet program for the uninsured.

The 27 delegates from RMS to the MMA House of Delegates met on June 8 and June 29 to review draft resolutions and to adopt resolutions for consideration by the House in September. The Minnesota Medical Association Annual Meeting was held in Duluth September 29, 30, and October 1. The 27 delegates from RMS carried 14 resolutions to the MMA House of Delegates. Two were adopted, four were adopted as amended, one was referred to the MMA Board, and seven were not adopted.

Roger Johnson and Jack Davis of the Hennepin Medical Society met with Dr. Kent Wilson and the leadership of the Minnesota Ambulatory Health Care Consortium on October 13. They continue to meet monthly.

The MMA Board of Trustees met on November 6 to hear a preliminary report from the MMA Task Force on Health Care Reform.

Drs. Michael Gonzalez-Campoy, MMA president, and Lyle Swenson, MMA vice president, attended as did Roger Johnson.

Roger Johnson was invited to the briefing on the launching of the Minnesota Community Measurement Project Web site (Continued on page 27)

The Journal of the Hennepin and Ramsey Medical Societies

Caring Hearts for Homeless People Supply Drive

Health Care for the Homeless — A medical team that provides care for nine shelters and drop-in locations each week.

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

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

Call the RMS office at 612-362-3705 for more information or to let us know that your clinic is interested in participating in this drive.

Arrangements will be made for all donations to be picked up at your clinic and delivered to the drop-off location at St. Joseph’s Hospital. ◆

Special Opportunity In addition to collecting supplies, we are also looking for cash donations. The Ramsey Medical Society Foundation plans to provide a grant for the rent of a room at Mary Hall for the year. These rooms are used to house a homeless person who is ill. The rent is $400 per month. The Health Care for the Homeless currently rents two rooms.

Checks can be made payable to Ramsey Medical Society Foundation and sent to P.O. Box 131690, St. Paul, MN 55113.

Please indicate in the memo that it is for the Mary Hall Room Rental.

RMS In Action (Continued from page 26)

mnhealthcare.org on November 12. The Minnesota Senate Commerce Committee held a hearing on no fault auto insurance legislation on November 15 and RMS President Dr. Peter Daly provided excellent testimony on the complexities that no fault auto cases present to treating physicians.

The RMS Council on Community Health, chaired by Dr. Neal Holtan, met on November 23. The Council discussed a number of public health issues, including the pertussis surveillance grant and smoke-free state legislation.

Dr. Charles Terzian, RMS president elect and Roger Johnson attended the AMA Interim Meeting in Atlanta along with AMA Delegates Drs. Frank Indihar and Kenneth Crabb and

AMA Alternate Delegate Dr. Blanton Bessinger, and other members of the Minnesota delegation December 4-7.

Roger Johnson attended a meeting with Commerce Commissioner Scott Brener, Representative Fran Bradley, and Senator Sheila Kiscaden hosted by Lockridge, Grindal on December 10. Other meetings in December included a Minnesota Provider Coalition (the successor organization of the Contracting Coalition) meeting on December 15; and a HealthEast Report to the Community on December 10.

The Year 2004 ended with the looming of the 2005 Session of the Minnesota Legislature in January. ◆

Save the Date:

RMS Annual Meeting

January 29, 2005 6:00 p.m.

Oak Marsh Golf Club, Oakdale Installation of Charles G. Terzian, M.D., RMS President MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

What’s Wrong with Rationing Health Care?

On Friday, November 19, Dr. Peter Ubel, director of the Program for Improving Health Care Decisions at the VAMC and University of Michigan, Ann Arbor, spoke on: “What’s Wrong with Rationing Health Care?” at the United Hospital Heart and Lung Center Conference Hall. The occasion was a special meeting of the Ramsey Medical Society (RMS) Council on Professionalism and Ethics and co-hosted with the HealthEast Medical Staff and the United Hospital Medical Staff. The presentation addressed an important segment of the council’s agenda this season: “Universal Health Insurance (UHI): Health Care Rationing, Equity, and Affordability.”

United Hospital videotaped Dr. Ubel’s presentation and it is available for you to borrow for viewing. Please call Marge Avioles, United Hospital, Physician Services Dept., at (651) 241-8548. ◆ January/February 2005

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Ramsey Medical Society

Hygiene supplies, over-the-counter medications, cotton socks and mittens are just a few items that homeless people have a great need for. We are asking you and your clinic employees to participate in collecting these much-needed supplies from February 1 through February 28. Some of the urgent suppplies needed are ibuprofen, Aleve, cough syrup, deodorant, razors and chapstick.

We will supply you with promotional materials to post within your clinic. Collected items and money will be distributed to the homeless through the following three programs:

CHAIR’S REPORT MICHAEL B. BELZER, M.D.

The Uninsured—Who Are They and Who Cares?

HMS-Officers

Chair Michael B. Belzer, M.D. President James A. Rohde, M.D. President-elect Paul A. Kettler, M.D. Secretary Edward P. Ehlinger, M.D. Treasurer Anne M. Murray, M.D. Immediate Past Chair Michael B. Ainslie, M.D. HMS-Board Members

Mary Anderson, Co-Presiding Chair, HMS Alliance Abdhish R. Bhavsar, M.D. Carl E. Burkland, M.D. Eric G. Christianson, M.D. Peter J. Dehnel, M.D. Marlene Ellis, Co-Presiding Chair, HMS Alliance Lisa McGinnis, Medical Student Ronald D. Osborn, D.O. Frank S. Rhame, M.D. David F. Ruebeck, M.D. Richard D. Schmidt, M.D. Jan H. Strathy, M.D. Thomas C. Tunberg, M.D. Valerie K. Ulstad, M.D. Peter A. Wallskog, M.D. HMS-Ex-Officio Board Members

Lee H. Beecher, M.D., MMA-Trustee Karen K. Dickson, M.D., MMA-Trustee David L. Estrin, M.D., AMA Alternate Delegate Kenneth B. Heithoff, M.D., MMA-Trustee Donald M. Jacobs, M.D., MMA-Trustee Karin M. Tansek, M.D., MMA-Trustee Benjamin H. Whitten, M.D., AMA Alternate Delegate Barbara Daiker, MMGMA Rep. HMS-Executive Staff

Jack G. Davis, Chief Executive Officer Kathy R. Dittmer, Executive Assistant Sue Schettle, Director, Marketing & Member Services

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AS YOU ARE UNDOUBTEDLY aware, health care has shifted from its traditional role as a social issue to become a political issue. Why has this transformation occurred? In no small part it has to do with the ever-increasing cost of health care and the growing legion of the rolls of the uninsured in our country.

On any single day one can pick up any newspaper and read numerous articles that outline the plight of the 45 million (15.2 percent) uninsured in America in 2004. Unfortunately, 8.5 million of these uninsured are children.

Almost one in five adults ages 18-64 was uninsured in 2002. Nearly 85 million Americans (30 percent) lacked coverage at some point between January 1996 and December 31, 1999.

In Minnesota we have fewer uninsured than the national average (8 percent) but estimates are that 350,000 Minnesotans presently have no health insurance.

Just who are the uninsured and what difference does their lack of health insurance make?

This is an important question when we all think we know that the uninsured can surely receive their needed medical care through the safety net of community clinics and public safety net hospitals like Hennepin County Medical Center.

The Alliance for Health Reform, The Robert Wood Johnson Foundation, The Kaiser Family Trust and the Institute of Medicine have all studied the uninsured. They have challenged common myths about the uninsured and have come to some very uncomfortable conclusions about the consequences of being uninsured. Let me cite some of their recent work and examine five myths regarding the uninsured.

Myth #1. People without insurance do not work. Fact: Eight out of 10 people who are uninsured are in working families.

Myth #2. Recent immigration has been the source of the high number of uninsured.

Fact: Over 80 percent of the net increase in the uninsured occurred in U.S. citizens.

Myth #3. Most uninsured people in the U.S. are minorities. Fact: Non-Hispanic whites make up three fourths of the uninsured.

Myth #4. Most people without health insurance are poor. Fact: Almost 29 million of MetroDoctors

the uninsured in 2002 had incomes of $25,000 or more compared to 14.8 million in households earning less.

Clearly the myth that the uninsured are irresponsible, choose not to work, are poor, likely to be immigrants or minorities is not true.

Let’s examine the health consequences of being uninsured.

Myth #5. The uninsured receive the medical care that they need. Fact: Absolutely Not True!!

This is the most disturbing fact regarding the plight of the uninsured. Many studies have revealed that the uninsured do not receive the care they need and as a result, they have a worse health status, live sicker and die younger than the insured.

Goal: Provide to every U.S. resident insurance that is universal, continuous, affordable and provides effective preventive and acute coverage.

Problem: The greatest clinical, medical and academic minds have worked on this issue for decades and the problem clearly is worsening. No proposed “politically acceptable” effective solution appears on the radar screen. We spend way more on health care per individual than any other country and still have 45 million uncovered.

While politicians and their policymakers propose incremental changes and marketplace reform, medical savings accounts and competition based solutions, we need to have a better understanding of the identity and, more importantly, the health consequences of being uninsured. In this author’s opinion, only radical, bold and total system reform is likely to solve this $1.7 trillion problem (2003). The currently proposed mainstream solutions the public will accept are merely “tinkering around the edges,” done while millions of U.S. residents continue to suffer the serious symptoms and die from the effects of the newly defined and fatal disease called uninsurance. ◆

The Journal of the Hennepin and Ramsey Medical Societies

HMS NEWS

Laura Lynn Bultman, M.D. HCMC Emergency & Level 1 Trauma Center Emergency Medicine Scott R. Bundlie, M.D. HCMC Neurology Clinic Neurology

New Members HMS welcomes these new members to the Society.

Janet E. Andrews, M.D. HCMC Acute Psychiatric Service Psychiatry Jennifer Jo Arnhold, M.D. Obstetrics, Gynecology & Infertility, P.A. Obstetrics & Gynecology Richard W. Asinger, M.D. HCMC Cardiology Clinic Cardiology Woubeshet Ayenew, M.D. Hennepin Faculty Associates Cardiology Fouad Bachour, M.D. HCMC Cardiology Clinic Cardiovascular Diseases Emmanuel G. Balcos, M.D. HCMC Surgery Clinic Colon & Rectal Surgery Ricardo Hilarion Bardales, M.D. HCMC Pathology Lab Anatomic Pathology Dana R. Barr, M.D. Hennepin Care South Family Medicine Bradley A. Bart, M.D. HCMC Cardiology Clinic Cardiology Robert O. Berkseth, M.D. HCMC Bone & Mineral Metabolism Clinic Nephrology Debra L. Betow, M.D. HCMC Acute Psychiatric Service Psychiatry Gail M. Brottman, M.D. HFA Pediatrics Clinic Pediatrics Alan Buchbinder, M.D. HCMC OB/GYN Clinic Obstetrics & Gynecology

MetroDoctors

Ellen M. Coffey, M.D. HCMC Medicine Clinic Internal Medicine Allan J. Collins, M.D. HFA Research Labs Nephrology Heidi Marie Coplin, M.D. HCMC Medicine Clinic Internal Medicine Laura L. Coultrip, M.D. HCMC OB/GYN Clinic Maternal & Fetal Medicine David Leon Councilman, M.D. Hennepin Family Medical Center Family Medicine Robin Michelle Councilman, M.D. Hennepin Family Medical Center Family Medicine Michel Armand CramerBornemann, M.D. HFA Multispecialty Clinic Neurology Eileen Crespo, M.D. HFA Pediatrics Clinic Pediatrics John K. Cumming, M.D. HCMC Surgery Clinic General Surgery Lori Angeline Cunningham, M.D. HCMC Anesthesiology Anesthesiology Diana Becker Cutts, M.D. HCMC Newborn Nursery Pediatrics David C. Dahl, M.D. HCMC Transplant Clinic Nephrology Sloan W. Dâ&#x20AC;&#x2122;Autremont, M.D. HFA Pediatrics Clinic Pediatrics William S. David, M.D., Ph.D. HFA Multispecialty Clinic Neurology

The Journal of the Hennepin and Ramsey Medical Societies

Evan GrifďŹ ths, M.D. Paul Larson OB/GYN Clinic, P.A. Obstetrics & Gynecology

Laura J. Dexter, M.D. Metropolitan Anesthesia Network Anesthesiology

Richard H. Grimm, M.D. HFA Internal Medicine Clinic Internal Medicine

Carmen N. Divertie, M.D. HCMC Medicine Clinic Internal Medicine

Marco A. Guerrero, M.D. HCMC Cardiology Clinic Cardiovascular Diseases

Connie Leona Emerson, M.D. HCMC Radiology Diagnostic Radiology

Teresa K. Gurin, M.D. Minnesota Orthopaedic Specialists, P.A. Phys. Medicine & Rehabilitation

Mark Edward Engelstad, D.D.S., M.D. HCMC Dental & Oral Surgery Clinic Oral and Maxillofacial Surgery

Jonathan Christopher Haas, M.D. HCMC Orthopedic Specialty Center Orthopaedic Surgery

Dallas D. Erdmann, M.D. HFA Psychiatry Clinic Psychiatry

Guilford G. Hartley, M.D. HCMC Diabetes & Metabolism Clinic Internal Medicine

Paul F. Erickson, M.D. Hennepin Family Medical Center Family Medicine

William G. Heegaard, M.D. HCMC Emergency & Level 1 Trauma Center Emergency Medicine

Kambiz Farbakhsh, M.D. HFA Multispecialty Clinic Nephrology David E. Fisher, M.D. HCMC Newborn Intensive Care Unit Neonatal-Perinatal Medicine Robert N. Foley, M.D. HFA Research Labs Research Martin L. Freeman, M.D. HFA Multispecialty Clinic Gastroenterology Jerry Walter Froelich, M.D. LifeDiagnostic Imaging Center Nuclear Radiology Padma Gadela, M.D. Allina Medical Clinic Nicollet Mall Internal Medicine John James Garcia, M.D. HFA Pediatrics Clinic Pediatrics George S. Goding, M.D. HFA Multispecialty Clinic Otolaryngology Laxmana M. Godishala, M.D. HFA Internal Medicine Clinic Internal Medicine Richard Jay Granger, M.D. HCMC Medicine Clinic Internal Medicine Richard Oren Gray, M.D. HCMC Emergency & Level 1 Trauma Center Emergency Medicine

Masha A. Hemmati, M.D. Hennepin Family Medical Center Family Medicine William Keith Henry, M.D. HCMC Medicine Clinic Infectious Diseases Nemesio Manalo Herrera, M.D. HCMC Physicial Medicine and Clinic Phys. Medicine & Rehabilitation John W. Hildebrandt, M.D. HCMC Radiology Radiology David Richard Hilden, M.D. HFA Internal Medicine Clinic Internal Medicine Steven D. Hillson, M.D. HCMC Medicine Clinic Internal Medicine Jeffrey D. Ho, M.D. HCMC Emergency & Level 1 Trauma Center Emergency Medicine Marjorie J. Hogan, M.D. HCMC Newborn Nursery Pediatrics Jeremy J. Hollerman, M.D. HCMC Radiology Diagnostic Radiology Jeremy Holtzman, M.D. HCMC Medicine Clinic Internal Medicine (Continued on page 30)

January/February 2005

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Hennepin Medical Society

Active

Raul F. Cifuentes, M.D. HCMC Newborn Intensive Care Unit Pediatrics

Morris M. Davidman, M.D. HFA Multispecialty Clinic Nephrology

New Members (Continued from page 29) David B. Hom, M.D. HFA Multispecialty Clinic Otolaryngology Back Ki Hong, M.D. HCMC Anesthesiology Anesthesiology Kea-Kyung Hong, M.D. HCMC Anesthesiology Anesthesiology Conrad Iber, M.D. HCMC Pulmonary Clinic Pulmonary Disease Tutu Ion, M.D. Metropolitan Anesthesia Network Anesthesiology Peter Erik Jensen, M.D. HCMC Cardiology Clinic Thoracic Surgery Michelle F. Johnson, M.D. HFA Internal Medicine Clinic Internal Medicine Paul E. Johnson, M.D. HCMC Medicine Clinic Internal Medicine Sidney A. Jones, M.D. HCMC Center for Diabetes Obesity Endocrinology Julia P. Joseph-Di Caprio, M.D., MPH HCMC P7 Pediatric Clinic Pediatrics Michelle Lynn Karsten, M.D. Hennepin Family Medical Center Family Medicine Bertram L. Kasiske, M.D. HCMC Transplant Clinic Nephrology Mary Holman Kathol, M.D. Consulting Radiologists, Ltd. Musculoskeletal Radiology Lawrence Jay Kerzner, M.D. HFA Hennepin Senior Care Center Geriatric Medicine Helen G. Kim, M.D. HFA Psychiatry Clinic Psychiatry Andrew Waititu Kiragu, M.D. HCMC P7 Pediatric Clinic Pediatrics Natalia Y. Kramarevsky, M.D. HCMC Ophthalmology Clinic Ophthalmology

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Virginia L. Kubic, M.D. HCMC Pathology Lab Hematology Pathology

William A. Marinelli, M.D. HCMC Pulmonary Clinic Pulmonary Disease

Paul H. Kuneck, M.D. Center for Reproductive Medicine Reproductive Endocrinology

Stacene R. Maroushek, M.D., Ph.D. HCMC P7 Pediatric Clinic Pediatrics

Rebecca Wing See Lai, M.D. HCMC Medicine Clinic Gastroenterology

Marc Leo Martel, M.D. HCMC Emergency & Level 1 Trauma Center Emergency Medicine

Kevin Lee Larsen, M.D. HCMC Medicine Clinic Internal Medicine James W. Leatherman, M.D. HCMC Pulmonary Clinic Pulmonary Disease Howard Mitchell Lederer, M.D. HCMC Surgery Clinic General Surgery Rachel Elizabeth Lerner, M.D. HFA Oncology Clinic Internal Medicine Sanaz A. Loftus, M.D. HFA Eye Clinic Ophthalmology Rueben N. Lubka, M.D. Columbia Park Medical Group, P.A. Columbia Park Clinic Internal Medicine Gregory L. Lucas-Silvis, M.D. HCMC Medicine Clinic Internal Medicine Kipton J.V. Lundquist, M.D. HFA Multispecialty Clinic Plastic Surgery Stephen MacLeod, D.D.S., MS, FRCS HCMC Dental & Oral Surgery Clinic Oral and Maxillofacial Surgery Lourdes Maglaya-Pira, M.D. Hennepin Family Medical Center Family Medicine Robert H. Maisel, M.D. HCMC Ear, Nose & Throat Clinic Otolaryngology Mobin Ahmed Malik, M.D. HCMC Medicine Clinic Internal Medicine James S. Mallery, M.D. HFA Multispecialty Clinic Gastroenterology Richard L. Manka, M.D. HCMC Ophthalmology Clinic Ophthalmology Karen L. Margolis, M.D. HCMC Medicine Clinic Internal Medicine

Dawn L. Martin, M.D. HCMC Newborn Nursery Pediatrics M. Kathryn McCulloch, M.D. HFA Internal Medicine Clinic Internal Medicine Martha L. McCusker, M.D. HFA Hennepin Senior Care Center Geriatric Medicine John W. McGill, M.D. HCMC Emergency & Level 1 Trauma Center Emergency Medicine

Gary L. Oftedahl, M.D. Internal Medicine Kathleen M. Ogle, M.D. HFA Oncology Clinic Medical Oncology Eileen Ann Oâ&#x20AC;&#x2122;Shaughnessy, M.D. HFA Multispecialty Clinic Nephrology Kara Louise Parker, M.D. Hennepin Care South Family Medicine Barbara Kaye Patrick, M.D. HCMC Neurology Clinic Neurology Charles E. Pearson, M.D. HFA Psychiatry Clinic Psychiatry Craig J. Peine, M.D. HFA Multispecialty Clinic Gastroenterology Paul R. Pentel, M.D. HCMC Medicine Clinic Toxicology

Alexander McKinney, M.D. HCMC Radiology Radiology

Anne Gamble Pereira, M.D. HCMC Medicine Clinic Internal Medicine

Kenneth E. Miles, M.D. HCMC Urgent Care Center Family Medicine

Phillip K. Peterson, M.D. HCMC Infectious Diseases Clinic Infectious Diseases

Robert P. Miller, M.D. HCMC Radiology Radiology

Gina M. Petrungaro, M.D. HCMC Anesthesiology Anesthesiology

James Nelson Mohn, M.D. HCMC Cardiology Clinic Cardiology

David W. Plummer, M.D. HCMC Emergency & Level 1 Trauma Center Emergency Medicine

Jeffrey John Morken, M.D. HCMC Surgery Clinic General Surgery Anne Mary Murray, M.D. HFA Hennepin Senior Care Center Geriatric Medicine Nancy K. Newman, M.D. Hennepin Family Medical Center Family Medicine Arthur L. Ney, M.D. HCMC Surgery Clinic Critical Care Surgery Tsewang Ngodup, M.D. Hennepin Family Medical Center Family Medicine Rick M. Odland, M.D., Ph.D. HCMC Ear, Nose & Throat Clinic Otolaryngology

MetroDoctors

Michael K. Popkin, M.D. HCMC Psychiatry Psychiatry Arthur James Puff, M.D. United Hospital, Inc. Emergency Medicine Craig N. Qualey, M.D. HFA Psychiatry Clinic Psychiatry Robert Reid Quickel, M.D. HCMC Surgery Clinic Critical Care Surgery Lotfollah Raissi, M.D. HCMC Urgent Care Center Family Medicine Lakshmi Raman, M.D. HCMC P7 Pediatric Clinic Pediatrics

The Journal of the Hennepin and Ramsey Medical Societies

Udayalakshmi Rao, M.D. HCMC Anesthesiology Anesthesiology

Stephen Sems, M.D. HCMC Orthopedic Specialty Center Orthopaedic Surgery

David M. Thompson, M.D. HCMC P7 Pediatric Clinic Pediatrics

Douglas J. Rausch, M.D. HFA Oncology Clinic Hematology

Robert S. Shapiro, M.D. HCMC Pulmonary Clinic Pulmonary Disease

Linda R. Thompson, M.D. HFA Pediatrics Clinic Pediatrics

Robert F. Reardon, M.D. HCMC Emergency & Level 1 Trauma Center Emergency Medicine

Gilbert J. Shin, M.D. HCMC Anesthesiology Anesthesiology

Albert Kang Tsai, M.D. HCMC Emergency & Level 1 Trauma Center Pediatric Emergency Medicine

Teresa J. Reid, M.D. HFA Pediatrics Clinic Pediatrics

Richard C. Reut, D.O. HCMC Orthopedic Specialty Center Sports Medicine David J. Rhude, M.D. HCMC Medicine Clinic Rheumatology

Joseph M. Sierra, M.D. Hennepin Family Medical Center Family Medicine John R. Silkensen, M.D. HCMC Transplant Clinic Nephrology Charles Lee Smith, M.D. HFA Multispecialty Clinic Nephrology

Joan M. Van Camp, M.D. HCMC Surgery Clinic General Surgery Thomas F. Varecka, M.D. HCMC Orthopedic Specialty Center Orthopaedic Surgery Richard S. Velders, M.D. HCMC P7 Pediatric Clinic Pediatrics Teresa Vrabel, M.D. HCMC Medicine Clinic Internal Medicine

Christopher David Robert, D.O. HCMC Anesthesiology Anesthesiology

Stephen W. Smith, M.D. HCMC Emergency & Level 1 Trauma Center Emergency Medicine

Sarah B. Rockswold, M.D. HCMC Surgery Clinic Phys. Medicine & Rehabilitation

Mark Douglas Sprenkle, M.D. HCMC Pulmonary Clinic Internal Medicine

Peter F. Weissmann, M.D. HCMC Medicine Clinic Internal Medicine

Diane M. Ruhr, M.D. HFA Multispecialty Clinic Obstetrics & Gynecology

Selma L. Sroka, M.D. Hennepin Family Medical Center Family Medicine

Joseph A. Wels, M.D. HCMC Anesthesiology Anesthesiology

Meena Sahadevan, M.D. HCMC Transplant Clinic Nephrology

Warren R. StanchďŹ eld, M.D. HCMC Radiology Diagnostic Radiology

Robert Werner, M.D. HFA Psychiatry Clinic Psychiatry

Prateek Sahgal, M.D. HCMC Radiology Radiology

Constantin N. Starchook, M.D. HCMC Anesthesiology Anesthesiology

Kathleen M. Wesa, M.D. HFA Addiction Medicine Clinic Internal Medicine

Carl K. Sakamoto, M.D. HCMC Anesthesiology Anesthesiology

Martin Jeffrey Stillman, M.D., JD HCMC Medicine Clinic Internal Medicine

Michelle M. Wiersgalla, M.D. HFA Psychiatry Clinic Psychiatry

Elizabeth Sawinski, M.D. HFA Psychiatry Clinic Psychiatry

David D. Stuart, M.D. HCMC Center for Diabetes Obesity Endocrinology

David I. Wigren, M.D. HCMC OB/GYN Clinic Obstetrics & Gynecology

Michelle A. Schabert, M.D. Hennepin Family Medical Center Family Medicine

Suzanne K. Swan, M.D. HFA Multispecialty Clinic Nephrology

Laurel Margaret Wills, M.D. HCMC P7 Pediatric Clinic Pediatrics

Peter A. Schlesinger, M.D. HFA Multispecialty Clinic Rheumatology

Philip M. Sweetser, M.D. HFA Multispecialty Clinic Urology

Margaret R. Winters, M.D. HCMC Comprehensive Cancer Ctr. Radiation Oncology

Patricia A. Schuster, M.D. HCMC Surgery Clinic General Surgery

David C. Templeman, M.D. HCMC Orthopedic Specialty Center Orthopaedic Surgery

Mark A. Wolters, M.D. HFA Internal Medicine Clinic Internal Medicine

Ronald L. Schut, M.D. HCMC Infectious Diseases Clinic Infectious Diseases

Jeanette M. Thomas, M.D. HFA Multispecialty Clinic Obstetrics & Gynecology

Patrick Yoon, M.D. HCMC Orthopedic Specialty Center Orthopaedic Surgery

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Jeffrey S. Warshaw, M.D. HCMC OB/GYN Clinic Obstetrics & Gynecology

Michael D. Hobbs, M.D. Pediatric Services, P.A. Pediatrics

Resident Physicians Fouzia Anwar Aftab, M.D. Himanshu Agrawal, M.D. Shabeer Ahmed, M.D. Aakash Mohan Ahuja, M.D. Sanjeev Kumar Akkina, M.D. Sharmin Alam, M.D., M.P.H. Mark Ryan Alexander, M.D. Casandra Ann Anderson, M.D. Michael Herman Anikeev, M.D. Zurya Shakeel Anjum, M.D. Rebecca Ansari, M.D. William F. Auffermann, M.D. Harpreet Singh Bajaj, M.D. Amanda Marie Baker, M.D. Cristina Ann Baker, M.D. Alisa Maria Bardo, M.D. Christopher R. Becker, M.D. Negar Schmidt Beheshti, M.D. Rimon Nagy Bengiamin, M.D. Heather Maria Berg-Patel, M.D. Moeen Ahmad Bhatti, M.D. Nadeem Bhatti, M.D. Laura Bland, M.D. Nancy Marie Blonigen, M.D. Paul Jerome Bock, M.D. Kristen Kathleen Boebel, M.D. Edwin Ndemo Bogonko, M.D. Lisa Marie Bolin, M.D. Anne-Marie Boller, M.D. Shulamith Carr Bonham, M.D. Mary Frances Braun, M.D. Cynthia Kay Brenden, M.D. Kenneth Marshall Bricker, M.D. Aaron Francis Brosam, M.D. Amy Lou Brown, M.D. Samatha Judith Brown, M.D. Gavin Budhram, M.D. Daniel Tyra Cabot, D.O. Sharon Sweeney Carmody, M.D. Nicole Chaisson, M.D. Harpreet Singh Chhokar, M.D. Maribeth Aguilar Ching, M.D. Bradley Daniel Chmielewski, M.D. Steven Chow, M.D. Derrick Hua Chu, M.D. Gary Bernard Collins, M.D. Peter Thomas Currie, M.D. Mark Steven Danahy, M.D. Frank Ojo Dania, M.D. Suzanne Marie Darnell, M.D. Scott Patrick Davarn, M.D. (Continued on page 32)

January/February 2005

31

Hennepin Medical Society

Christopher Reif, M.D., MPH Hennepin Family Medical Center Family Medicine

Ashajyothi Siddappa, M.D. HCMC Newborn Intensive Care Unit Pediatric Critical Care

1st Year in Practice

New Members (Continued from page 31) Nilima Nalinbhai Desai, M.D. Jeffrey Edwin Eichten, M.D. Katherine G. Esse, M.D. Erin Elizabeth Eyberg, M.D. Michael Eliot Farber, M.D. Dion Duval Farrell, M.D. Kathryn Lynn Fischer, M.D. Kathleen Ann Fisher, M.D. Andrew Gardner Florence, M.D. Christina H. Frazel, M.D. Ethan Michael Fruechte, M.D. Michael Robert Galle, M.D. Mamta Goyal, M.D. Inder Raj Grewal, M.D. Julia Vitaly Grigoriev, M.D. Juneko Elaine Grilley, M.D. Danqing Guo, M.D. Jessica Maria Gutierrez, M.D. Katherine Ann Hadden, M.D. Brita M. Hansen, M.D. Tracy RuthElin Hartmann, M.D. Kathleen Mary Heaney, M.D. Kimberly Faye Heller, M.D. Eric Moore Hernandez, M.D. Matthew Edward Herold, M.D. Mark John Hill, M.D. Darren Lee Huber, M.D. Jorge L. Infante, M.D. Heidi Jo Iwanski, M.D. Mohamad Jafferany, M.D. Bharathi Dasan Jagadeesan, M.D. Sadia Ali Jama, M.D. Joseph Jimenez, M.D. Jairaj Suresh Joglekar, M.D. Anne M. Johnson, M.D. Mark Emerson Jones, M.D. Gary Michael Jonson, M.D. Jeremy Scott Juern, M.D. Milind Yashwant Junghare, M.D. Chitradevi Kandaswamy, M.D. Henry Maranga Kerandi, M.D. Sarah Margaret Kesler, M.D. Shravan Kethireddy, M.D. Siddiq Ahmed Khan, M.D. Manasi V. Kolpe, M.D. Eric Maison Kraska, M.D. David Aaron Ladmer, M.D. Anne Louise Lapine, M.D. Lucas Maxwell Lathrop, M.D. Daniel James Lewis, M.D. Juan Ricardo Lewis, M.D. Kjell Norwood Lindgren, M.D. Sara Ann Lindquist, M.D. Yi Liu, M.D. Kelley R. Lockhart, M.D. Renee Lohse, M.D. Jose Luis Luna, M.D.

32

January/February 2005

Hongbao Ma, M.D. Matthew Thomas Malone, M.D. Arjuna Prasad Mannam, M.D. Adnan Masood, M.D. Carolyn Anne McClain, M.D. Donald Spencer Mehr, M.D. Roman Melamed, M.D. Melody Anne Mendiola, M.D. Kari G. Messner, M.D. Wendy Jean Miller, M.D. William John Miner, M.D. Farah Naz Momen, M.D. Ayham Moty, M.D. Tonia Mowbray-Donahue, M.D. Arshi Jan Muhammad, M.D. Subho Mullick, M.D. Malini Anil Nair, M.D. Margaret Ann Ness, M.D. Ashley Marie Newberry, M.D. Brent Eric Nykamp, M.D. James A.W. Orr, M.D. Gillian D. O’Shaughnessy, M.D. Al Dinesh Patel, M.D. Reba Denise Peoples, M.D. Trey Pham, M.D. Charles Pogemiller, M.D. Lori Poitra, M.D. Matthew Gerald Pollema, M.D. Megan M. Popp, M.D. Scott Paul Prawer, M.D. Bernadette Kim Quadling, M.D. Omer Qureishy, M.D. Matthew T. Raddue, M.D. Mohammed Abdul Aziz Rafiq, M.D. Afanta Bellamkonda Rao, M.D. Ida Rachel Rosebrock Rapacz, M.D. Ganga Reddy, M.D. Charles Paul Reznikoff, M.D. Ramiro Saavedra Romero, M.D. Susan Renee Ross, M.D. Lydia Yang-Lei Sahara, M.D. Angelo Noel Santos, M.D. Olga Konstantinovna Sarnov, M.D. Alexander Joseph Schad, M.D. Gregory Carl Schmieder, M.D. Eric Steven Schneider, M.D. Brian Toby Schroeder, M.D. Bryan Joseph Schwieters, M.D. Eric Christopher Scott, M.D. Sonal Arvind Shah, M.D. Gautam Rohit Shroff, M.D. Mengistu Alemayehu Simegn, M.D. Kevin Walter Sirmons, M.D. Lisa Dawn Skinner, M.D. James Edward Slattery, M.D. Jennings Ryan Staley, M.D. Ann Patricia Sterzinger, M.D. Kathleen Ruth Stirling, M.D. Angelique Quinn Stobl, M.D.

Leslie Winter Surbeck, M.D. Daniel Susanto, M.D. Li Ping Tan, M.D. Jodie H. Taylor, M.D. Oanh Constance Thai, M.D. Bhavik Vadilal Thakkar, M.D. Linda Kay Thompson, M.D. Andrew Allen Thoreson, M.D. Amitabh Arun Tipnis, M.D. John David Tomlin, M.D. Camilo Torres, M.D. Arleigh Rosann Trainor, M.D. Huy Tran Trieu, M.D. Eduardo Dumlao Trinidad, M.D. Kai A. Tuominen, M.D. Chinelo Stella Ude, M.D. Martin Chizoba Umeh, M.D.

Nathan Paul Unkefer, M.D. Patricia Angeline Valusek, M.D. Glen David Varns, M.D. Natalya Andreyvna Verbinskaya, M.D. Anne Louise Viestenz, M.D. Meghan Mary Walsh, M.D. Alison Marie Warford, M.D. Charles Kahn Weisman, M.D. Suzanne Eve Weiss, M.D. James Jesse Wheeler, M.D. Melissa E. White, M.D. Helen J. Wood, M.D. Wenying Yan, M.D. Vivian Mae Yu, M.D. Weimin Xu, M.D. Rebecca Jeanne Zadroga, M.D. ◆

In Memoriam ROBERT BREITENBUCHER, M.D., died October 3 at the age of 82. He graduated from the University of Minnesota Medical School.

Dr. Breitenbucher specialized in internal medicine. He was on the faculty at HCMC, and served as an associate professor of medicine at the University of Minnesota. He joined HMS in 1949.

RICHARD ORMOND LEAVENWORTH, JR., M.D., 80, died October 31 as a result of injuries from a car accident on September 14. He graduated from the University of Minnesota Medical School. Dr. Leavenworth was an ophthalmologist at Park Nicollet Medical Center for 31 years. He joined HMS in 1955.

THOMAS K. RUCKER, M.D., a retired ophthalmologist, died October 25 at the age of 74. He graduated from the University of Minnesota Medical School. Dr. Rucker joined HMS in 1960.

HOWARD A. SHAW, M.D. died October 17. He was 91. He graduated from the University of Minnesota Medical School. After serving in the U.S. Army Air Force, he completed a residency in ophthalmology, which he practiced MetroDoctors

for 35 years until retirement. For more than a decade, he served as the Chief of Ophthalmology at the Hennepin County Medical Center.

Dr. Shaw joined HMS in 1941.

LEONARD A. TITRUD, M.D., died on October 18 at the age of 93.

He graduated from the University of Minnesota Medical School with degrees of M.D., B.S. and M.B. Following completion of medical internships at the U.S. Marine Hospital in New York City, the United States Public Health Service Hospital in Lexington, Kentucky and the University Hospital in Minneapolis, he was awarded and completed a National Cancer Fellowship and Fellowships in Surgery and Neurological Surgery, all at the University Hospital in Minneapolis. Following WWII, Dr. Titrud returned to the University of Minnesota Medical School and in 1946 was awarded an M.S. in Surgery and a Ph.D. in Neurological Surgery.

BENEDICT B. TRACH, M.D. of San Francisco, formerly of St. Louis Park, died October 11. He was 91. Dr. Trach graduated from the University of Minnesota Medical School. His specialty was family medicine. ◆

The Journal of the Hennepin and Ramsey Medical Societies

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Primary Care Urology March 18, 2005

Cardiac Arrhythmias: An Update for Internal Medicine, Family Practice and Pediatrics April 1, 2005

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Reducing Tobacco Use in Minnesota: Research Into Action February 28, 2005

Endourology & Urologic Laparoscopy April 21-23, 2004

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Advances in Gastrointestinal and GI Laparoscopic Surgery (69th Annual Surgery Course) June 15-18, 2005

Workshops in Clinical Hypnosis June 2-4, 2005

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