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Jan/February 2000

Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

Are the scales tipping?

Health plan accountability Voice your opinion! New column:

Physician’s Soap Box

28

November/December 1999

MetroDoctors

The Bulletin of the Hennepin and Ramsey Medical Societies

Physician Advisor Thomas B. Dunkel, M.D. Physician Advisor Richard J. Morris, M.D. Editor Nancy K. Bauer Assistant Editor Doreen Hines HMS CEO Jack G. Davis RMS CEO Roger K. Johnson Managing Editor Sheila A. Hatcher Advertising Manager Dustin J. Rossow Cover Design by Susan Reed MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761.

To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of HMS or RMS. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. E-mail: nbauer@mnmed.org.

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

Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available.

CONTENTS VOLUME 2, NO. 1

2

JANUARY/FEBRUARY 2000

PHYSICIAN’S SOAP BOX

Seymour Handler, M.D.

4

COLLEAGUE INTERVIEW

Blanton Bessinger, M.D.

8

FEATURE: PATIENTS SUING HMOS

Two Different Views

12

Governor Sets Ambitious Goals for Improving Health

14

Medicare Geographic Disparity Lawsuit Update

15

Reforming Medicare Can Be Done

16

Physician Employment Contracts and Managed Care Contracts

19

METRODOCTORS.COM

Promoting www.metrodoctors.com

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Community Internship Program Provides Opportunity for Dialogue

22

AMA House of Delegates Acts on Four HMS/RMS Resolutions

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COMMUNITY SERVICE

Responding to Homeless Health Needs

RAMSEY MEDICAL SOCIETY

24 25 26 27

President’s Message RMS News Introducing the 2000 RMS Officers and New RMS Board Members RMS Alliance HENNEPIN MEDICAL SOCIETY

29 30 32

Chairman’s Report HMS News HMS Alliance

On the cover: There has been much discussion over whether or not patients should be allowed to sue their health plans. See page 8 for a point/counterpoint discussion.

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January/February 2000

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PHYSICIAN'S SOAP BOX

Physician’s Soap Box Have you ever just wanted to let the world know what you think about an issue but no forum existed for you to present your ideas and thoughts? MetroDoctors wants to fix that. We are starting a section called “Physician’s Soap Box.” We are inviting you to give us your ideas about any subject you feel strongly about. The idea is to start a dialogue among your peers, with thoughtful but spirited discussion about your ideas and opinions.

So if it’s a lack of operating rooms, new Medicare guidelines, or you just want to complain about our web page, you are welcome, just keep your comments to about 700 words.

Of course, there have to be some guidelines, but we will keep them as limited as possible. We want thoughtful discussions, not diatribes, and ideas that will stimulate discussion from your peers. The goal is ideas, not personalities, and light as much as heat. But we want a to and fro discussion as well, so controversy is welcome. Criticism, if it is insightful, is welcome. There are no sacred cows at “Physician’s Soap Box.” So, I invite you to step up and let us listen to your ideas. We are waiting.

Thomas Dunkel, M.D. Physician co-advisor

Great Expectations

A

AT A RECENT INSTITUTIONAL MEETING, it was pointed out that all aspects of health care are suffering, with a collision course occurring between providers and the public’s expectations. Physicians, hospitals, managed care organizations, etc., are all hurting financially, unable to balance the increased costs of care with reduced revenues or reimbursement. Despite the vigorous level of medical activity at hospitals, with high occupancy and activity levels, the bottom line on operations is in the red. If hospitals are to remain fiscally viable, revenues will have to be raised to balance the increase in costs. Various factors are incriminated, including the results of the Balanced Budget Act of 1997, whereby the federal government reduced Medicare reimbursement to providers as part of balancing the budget.

But is balancing the budget by the feds the total source of the problem, or even a significant part? I don’t think so. I believe health care problems stem from a crisis of expectations and this crisis stems

BY SEYMOUR HANDLER, M.D.

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January/February 2000

from factors in all of American society, not just health care. The people of this nation are blessed with a vibrant and successful economy, the reasons for which are multiple, but mostly relate to the vigor of the private sector and a relative lack of intrusion in business and industry by government. The American way is bigger, better and faster. We live in bigger houses, drive fancier cars, require three-car garages for multiple vehicles, eat out more at expensive restaurants, and spend more and more for recreational activities. Compounding the increases of these aspects of lifestyle is the desire of our young people to “have” everything early in their lives. Whereas in the olden days we senior citizens rented a small apartment early in our married lives, and accumulated money over a period of years to make a sizable down payment on a home, young people currently do not wait; they want the big house now, and mortgage themselves to the hilt accordingly. Young people eat out a lot, at considerably greater expense than preparing meals at home. Even though their plastic cards are overextended, paying 18-20 percent in interest each month, our young citizens do not forego a ski trip to Aspen or a winter vacation in Florida. Indeed, our society is afflicted with “great MetroDoctors

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expectations” (to quote Dickens’ Magwich and Pip) and these expectations extend to health care in very much the same way.

The notion that we have too much medical care, as compared to other nations of the Western world, is heretical and not acceptable to all. Every corner of our society vehemently supports unlimited availability of health care, apparently despite the costs. If you are sick, everyone agrees that you should go to the doctor. The notion of waiting a short time to see if the malady was self-limited and would pass away quickly without medical care is foreign. After all, the last time one had a cold and went to the doctor and was prescribed expensive antibiotics, the cold went away. What could be more convincing about the value of medical care. Or, if you had an acute back pain episode, and went to the doctor, and was prescribed antispasmodics, analgesics and physical therapy, the backache subsequently improved or went away. The fact that 80 percent of acute back strains go away spontaneously in a week or two is not given consideration; the medical care is credited with the good outcome. Or, when a patient has a bad cancer and receives chemotherapy or radiation therapy and improvement occurs, there is no doubt that the therapy was responsible for the good result. The fact that a significant number of clinical improvements occur without specific therapy is not appreciated; the credit always goes to the treater and the treatment. Perhaps the most exaggerated example of health care expenditures with little yield are the millions of dollars expended on taking care of an Antarctica expedition physician with a breast cancer. Getting diagnostic material to her and evacuating her was a formidable endeavor; the expense of that effort was never considered. She could have waited a few months for routine evacuation, but that is not the American way. What other nation would spend millions to treat or evacuate a patient in such a circumstance, rather than simply waiting a short time when the task would be routine?

Health care in the other Western democracies is equal in quality to ours. True, there are differences in ambiance and the busywork of preventive care. Despite our belief that medical care in the United States is superior to the rest of the world, the available data does not support that conclusion. Morbidity and mortality in Western Europe is pretty much the same as ours; the big difference is the cost. Historic comparisons during wartime support this contention.

In WWII when large numbers of physicians were drafted into the military, North Dakota had a large number of counties with nary a physician. The health of the people left at home, growing food for the war effort, was never better by most accepted standards. During WWII in England, when the majority of physicians were in the military, the health of the civilian population was never better.

Perhaps having less to eat improved the health of the people; surely the availability of physicians did not.

What can be done to change the widely accepted American ideas of how much medical care is needed? Not much, I fear. We are bombarded by the media constantly with claims of “major breakthroughs” in this or that disease. Despite the fact that the “breakMetroDoctors

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through” has occurred only in mice or rats and is years away from human clinical trials, the implication is incontrovertible; the disease will be cured in a short time and the cure rate will be 100 percent.

How on earth can we convince lay people that improvements in health care occur in tiny increments, take decades to institute, and the health of the individual is far more related to his/her inheritance and lifestyle decisions than doctors, hospitals, and drugs?

Not only do we have unrealistic expectations of what medical science offers in terms of morbidity and mortality, but we expend far too many resources treating the dying or aged patients. When patients achieve the ninth or tenth decades of life, when you treat or hopefully “cure” one condition, another potentially fatal disorder is just around the corner. One cannot successfully win against the “theory of competing risks.” Why are one-third of hospital care dollars spent on patients who do not survive six months longer; and those few months are rarely “quality time”? Medical realism unfortunately is not a popular concept in our society but who other than physicians can take the lead in these difficult decisions. Former Governor Lamm of Colorado did some years back; look what the voters did to him.

Unfortunately, much of the above diatribe is akin to tilting at windmills. Americans are reluctant to accept the notion that we have too much medical care or that there are serious limits to what modern care can accomplish in terms of morbidity and mortality.

Americans prefer the good life. Eating like pigs and smoking cigarettes is preferred to taking responsibility for one’s health.

Americans prefer to transfer health responsibilities to the doctor.

Further, can you imagine the consequences to health care providers, etc., if my heretical ideas about excessive medical care are accepted and put into action. Hospitals would close, physicians would suffer mass unemployment, medical schools would close or drastically reduce class size, and the federal budget would easily be balanced.

We might even eliminate the federal debt with the saved dollars. It may indeed be “the best of all possible worlds” (Pangless in Voltaire’s Candide). Not to worry. My ideas will not come to pass, at least not in the foreseeable future. Perhaps when health care expenditures exceed a certain level, perhaps 20 percent of GNP, will voices raise questioning the amount of medical care the nation expects or requires? Indeed, we have great expectations. ✦

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COLLEAGUE INTERVIEW

Blanton Bessinger, M.D.

Editor’s Note: “Colleague Interview” provides HMS and RMS members with an opportunity to ask questions of their colleagues who are in unique roles. Dr. Bessinger was elected president-elect of the Minnesota Medical Association at the annual meeting of the House of Delegates in September. HMS and RMS delegates submitted questions for this interview.

Introduction Before trying to respond to several of the questions submitted by members of the Hennepin and Ramsey Medical Societies, I would like to express my appreciation to both societies for their support of my candidacy for president-elect at the MMA annual meeting. As I expressed at the meeting, my time spent as vice speaker and speaker of the house came about as the result of Ramsey Medical Society encouraging me to be involved in the state organization. My time spent in the last four years as an officer has been very enjoyable and I look forward to more opportunities to serve the physicians not only of Hennepin and Ramsey Medical Societies but of all the state. I welcome input from members of all the component societies as to how the state medical society can serve the needs of physicians and the patients that we care for.

Q

Why is there such a separation between the “local medical community” and the University of Minnesota medical school physicians and what can be done to increase medical school staff membership in the Minnesota Medical Association?

A

My career has spanned both sides of the “town-gown” communities. When I was full-time faculty in the pediatrics department at the University in the 1970s, I had very little knowledge of the private community and very little interaction. As a young academic physician, my goals seemed to be increasing my own knowledge base, performing teaching and education duties, and starting a research career. An overall goal was academic recognition at national meetings as well as advancement within the medical school. In the late 1970s, as I left the academic faculty and went into private practice in Minneapolis in pediatric cardiology, my goals changed.

Clearly, for basic survival, I had to get to know many other physicians in the private community. My goal was to build a practice, and serve pa4

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tients. The rewards were that of acceptance in the community and patient feedback. I don’t believe anyone in pediatric fields is ever really in it for the money, but certainly an adequate income was important in both the academic and private positions. I think many things contribute to the separation. A few academic physicians do still exhibit an arrogance that “the University way is the only way.” However, I believe the majority of academic physicians do not have that arrogance, but rather do not have the time to really interact outside of their own world. I believe many physicians in “private practice” are bent on showing that they can deliver just as good a care as their counterparts in academic medicine and so often may not call upon academic physicians, even when it may be beneficial. Simply the lack of daily interaction in the same hallways, in the same conferences, and the like contribute to this separation. Overall, I believe the basic reward system coupled with the goals of physicians in academic medicine compared to private practice contribute to the continued separation. I have personally not been involved in the recent Fairview/University experiment. We may be able to learn from that integration how to better achieve a larger coming together of local medical communities and the University medical school physicians. I truly believe it is important for members of the medical school physician community to be involved in the Minnesota Medical Association.

Again, my own experience 20 years ago suggested that we didn’t need anybody outside and we didn’t need organized medicine because all of our hopes and fears were tied up in the department that we were members of.

However, I believe that the interest of patients and the interest of physiMetroDoctors

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cians will be best served in our community by a coming together of physicians in all different types of “practices.” The Minnesota Medical Association has had regular dialogue with the dean and health sciences vice president’s office. We plan to continue that dialogue and to encourage them and other department heads in the medical school to support the involvement of their members in the local component societies and the Minnesota Medical Association.

What is your personal opinion regarding unification of dues?

This is one of the “hot” topics currently. I am keenly aware of the dissatisfaction on the part of some members of component medical societies that the state association appears at times to be insensitive to issues of the component societies and vice versa. I personally am in favor of physicians being members of both the component society and the state association and believe this is best accomplished by the unification of dues. My experience in dealing with legislative bodies, departments of health, and other policy making agencies, have led me to believe that coalitions are required to accomplish objectives. These coalitions are larger than any one group. I feel that individual component medical societies would not have the political clout in these areas that the larger state society can have. What we have to do is to get our visions and objectives more in sync. I will continue to be active in promoting dialogue between all of the component societies

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and the state organization. We can arrive at common purposes that serve the needs of our physician members and the needs of our patients.

What is your legislative agenda for 2001?

It may be somewhat premature to be thinking about the agenda for 2001, whereas we have not had the 2000 legislative session yet. Although this next session of the legislature will be shorter and is not expected to generate a lot of budget activity, one never knows what issues may arise and have to be addressed. However, in looking ahead to the new legislature in 2001, I believe that our organizations should continue to be involved in patient advocacy in many areas including patient rights, patient confidentiality, pharmacy issues, and quality of care. I believe we should be champions for access for all Minnesotans to appropriate health and medical care. I also believe we need to be champions for the appropriate reimbursement of physician and other healthcare services provided to our patients. I believe that we should support any activities that will lead toward medical and health care decisions being made between the patient and their caregivers, with support by the payer. In return for this decisionmaking ability, we have to provide clear-cut evidence of appropriate care, high quality care, and positive outcomes for the patient.

(Continued on page 6)

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shifting” by the pharmaceutical industry. Anyone that has traveled outside of the United States borders is aware that many of the same medications that we get here are available in other countries at a tenth of the price that is paid here. I do recognize that companies involved in research and development for future drugs have to have some markup to cover those R & D costs and make a reasonable profit. But I can’t believe that this leads to a factor of ten-fold difference in price, depending on which country you are in. I believe that the pharmaceutical industry itself has to participate in reasonable cost controls for pharmacological agents. In looking at Medicare, this cannot be a zero sum game, whereas any increased direction to pharmacy benefits would decrease reimbursement for physicians.

As most of you are aware, the Minnesota Medical Association has been actively involved for some time in trying to correct the geographic inequities of the current Medicare formulas for states. The MMA has thrown its support in with the Senior Federation in trying to address this issue. Medicare formulas must be made more equitable for states, such as Minnesota, which have already demonstrated excellent care and control of costs in many areas.

What are some concrete steps that physicians can do to change their image in this hostile medical environment?

(Continued from page 5)

Governor Ventura wants every child to have access to medical care and Minnesota minorities to receive equitable health care. How do you foresee the MMA will work with the Governor’s office to achieve these laudable goals?

These are laudable goals for our state. It is unbelievable that a state with the economic development and level of income that Minnesota enjoys still has 50,000 - 60,000 children without health insurance. It is also appalling that in several areas of health indices, (one example being infant mortality rate) minorities in Minnesota have some of the highest rates nationally, even though the overall state rate is quite low in comparison to other states. The MMA should take an active role in trying to approach the Governor’s office, primarily through the Health and Commerce Departments. I believe Commissioner Jan Malcolm is open to ideas for addressing the inequities and the lack of health insurance and access. We will try to increase our opportunities to interact with the staff of the health department in trying to achieve significant improvement in these areas.

We must come into this dialogue with a deep understanding of the problems and proposals for solutions that will benefit the patients.

How can the Minnesota Medical Association influence debate on pharmacy benefits for Medicare recipients, which might further erode payments to physicians?

The “hostile medical environment” seems to me to be more at a macro level. At the micro level, the individual patient-physician interaction in the office or at the hospital bedside, I believe is not a hostile one in the large majority of cases. The reason that this particular micro environment is not hostile is because that is truly where the physician is serving the patient, is trying to achieve the health and medical goal for the patient, and is listening to the patient. Only rarely is there a confrontation between the patient and the physician. I think most of us would agree that if there is, that does not lead to quality of care and should lead to a change of the relationship. In the macro environment, I believe that we as physicians can try to exhibit more of the same characteristics that we do at the micro environment interaction.

Namely, we can have concern for the overall health issues of the population at large; we can listen to possible solutions from different segments from our society; we can be positive with the “patient” in this macro arena; and we can bring positive solutions to the discussion and achieve the overall best solution for the “patient.” I believe we will be more effective using a style of positive attitude and positive persuasion than we will be with a negative, complaining, and confrontational style.

Conclusion Thank you again for the opportunity to serve as president-elect and then president next year of your state medical society. I look forward to working with all of you and urge you to be active in your component and your state societies. ✦

As I have read and heard about the pharmacy cost to our senior citizen patients as well as other patients, I am struck by what could be called “cost 6

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FEATURE STORY

Two Different Views on Whether or Not Patients

Patients Suing HMOs Should be Allowed to Sue Their Health Plans

Lori R. Swanson

A system of health plan

Editor’s Note: For this point/counterpoint look at whether or not patients should be allowed to sue their health plans, MetroDoctors asked Lori R. Swanson and Michael Scandrett to respond. Lori Swanson is a Deputy Attorney General in the Office of Minnesota Attorney General Mike Hatch.

Prior to joining the Attorney General’s Office, Ms. Swanson was an attorney in private practice, where she represented dozens of patients on a pro bono basis to secure coverage from health plans for care being recommended by treating physicians.

Michael Scandrett is the Executive Director of The Minnesota Council of Health Plans. Established in 1985, The Council is a St. Paul-based trade association representing Minnesota’s nonprofit HMOs, health plans and coordinated care systems.

accountability will still allow health plans to take steps to control costs, just not at a greater expense to the patient.

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S

Should patients be able to sue their health plans when a patient’s health is harmed by a health plan’s treatment decision? Why or why not?

SWANSON: Not too long ago doctors, not health insurers, controlled the practice of medicine. They examined their patients, made informed judgments about medical conditions and prescribed the appropriate treatment for their patients. And they weren’t second-guessed by bureaucrats at a health plan corporate office more interested in saving a few bucks than saving a life.

But that changed with the rising prominence of managed care, particularly in markets with little competition among health plans. “Cost containment” became the term of the day, and health plans accumulated staffs, and even designed computer programs, to make independent judgments about the medical necessity of treatment and, in some cases, overrule the best judgments of treating physicians.

If a health plan, in order to “contain costs,” is going to make medical decisions that affect the quality of the treatment provided to an enrollee, it only makes sense that the health plan be held accountable if it deviates from an appropriate level of care and a patient’s health is harmed as a result. If a doctor leaves a scalpel in a patient thereby committing negligence, the doctor can be held accountable in court. If a lawyer fails to sue out a case before the statute of limitations expires, the lawyer can be held accountable in court. And if an architect negligently designs a building that collapses causing injury to its occupants, the architect can be held accountable in court too. It makes no sense to allow health plans to operate with immunity.

A system of health plan accountability will still allow health plans to take steps to control costs, just not at a greater expense to the patient. In short, health plan liability will help level the playing field and disproportionate bargaining power between doctors and their patients, on the one hand, and health plans on the other.

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SCANDRETT: Patients should be able to take action to right a wrong; health plans should be held accountable. However, are lawsuits the best way to right a wrong? Physicians may want to ask themselves: Is expanding the existing broken tort system the best solution? Clearly, the current medical malpractice system needs reform. It allows medical cases to be decided by laypersons. Hired experts are paid to provide extreme views on a medical issue and then the case is turned over to a jury of laypersons to decide what is good medicine. This system does not work well in medical malpractice cases and should not be expanded to include health plans.

The real beneficiaries of expanding the tort system to health plans would be trial lawyers, not consumers. Research has shown that about half of the money in medical malpractice lawsuits goes to lawyers and legal expenses, and decisions come years after a patient can be helped. A better approach is to use alternative approaches that use neutral medical experts. During the last session of the Minnesota Legislature, state lawmakers opted in favor of external medical reviews of health plan decisions that are disputed, as opposed to expanded health plan tort liability. This solution is less costly and does not divert dollars away from health care services to trial attorneys and court costs. It is also a more timely solution that resolves disputes up front and enables patients to get the care they need when they need it. This new system might be a more appropriate approach to resolving medical malpractice suits as well.

Under what circumstances can a patient sue a health plan under existing law?

Michael Scandrett

The real beneficiaries of expanding the tort system to health plans would be trial lawyers, not consumers.

SWANSON: HMOs will sometimes claim that patients can already sue them and that, therefore, there is no reason to change the law. This only tells half the story, however. Under Minnesota law a patient can sue a health plan for the value of the covered service. In other words, if a health plan denies coverage for a medically necessary heart surgery, the patient can file a lawsuit to recover the cost of the surgery (if the patient goes ahead anyway) or for a declaratory judgment forcing the health plan to provide coverage for the surgery. Minnesota courts have not, however, recognized the right of a patient to recover for harm to his health if, for example, the health plan inappropriately overruled the treating doctor’s recommendations and judgment that the heart surgery was necessary and the patient was harmed as a result. The Fairness in Health Care Act proposed in Minnesota would change that by holding health plans legally accountable when they 1) make treatment decisions, 2) which deviate from an appropriate level of care, 3) and which affect the quality of care rendered to a patient, 4) when the patient’s health is harmed as a result.

(Continued on page 10)

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(Continued from page 9)

SCANDRETT: Currently, patients can sue a health plan under contract law for the cost of the medical services the patient feels should have been paid for by their health plan. They also can file an appeal with state regulators. Beginning in April 2000, patients can also obtain an external medical review that is binding on the health plan. Some Minnesota health plans have had an external review option in place even before the state law passed in 1999.

What intended or unintended consequences could result if health plans are held accountable in court?

SWANSON: Under current law, health plans have no financial incentive to approve treatment recommended by a patient’s treating physician. To the contrary, all the incentives run the other way. Health plans know that the worst that will happen to them if they inappropriately restrict care is that the patient can file a lawsuit to obtain coverage for the denied service. And all the while the health plan is holding onto money that should have been paid to fund the patient’s treatment.

Allowing health plans to be held accountable in court for harm to a patient’s health when they make negligent treatment decisions will help reverse this perversity. It will make health plans think twice before they “just say no” to a treatment being recommended by a treating physician. And this, of course, would free up time that doctors can spend treating patients rather than fighting the health care bureaucracy on behalf of their patients, saving health care dollars as a result.

SCANDRETT: One of the most significant unintended consequences of expanded tort liability is that health plans will have to manage physicians more tightly. Plans may also be forced to limit their provider networks or be more selective about their providers to lower the risk of potential litigation.

Another unintended consequence is that physicians may be dragged into court more often as a result of expanded health plan liability. It is much more enticing for a trial lawyer to bring a lawsuit against both the physician and the health plan because there are more dollars on the line. Under Minnesota’s current tort system, even if one party is found to have only a small measure of fault, that party could be held responsible for all damages. This rule can work against the physician as well as the health plan.

Liability will also lead to an increase in defensive decision-making on the part of health plans and physicians. In addition, even defensive decision-making may not keep physicians and health plans out of court. Under a bill offered by Minnesota Attorney General 10

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Hatch last session, health plans would have been held to a standard of “currently accepted” medical practice. Under this standard, the health plan could be sued even if it paid for the most effective medical treatment or for the latest technology, if current practice has not caught up with the latest developments. This creates a catch-22 that could result in liability regardless of whether the treatment was based on current practices or newly developed “best practices.” Even if the health plan tried to do the right thing and abided by a physician’s recommendation, both the health plan and the physician could be held liable.

Expanded tort liability would increase health care costs and lead to an increase in the number of uninsured. Supporters of expanded tort liability will claim that it will not increase costs. This is contrary both to research and to common sense. A single large lawsuit could result in noticeable increases in health care premiums. A study done by Barents Group (a leading economic and financial consulting firm) found that expanded tort liability would increase health care costs about 3-9 percent. Even more concerning is that, according to a recent survey, nearly three out of five small employers would likely stop offering health benefits if they became exposed to lawsuits. Expanded tort liability creates incentives to shortcircuit processes set up to resolve complaints and instead take them straight to court to try to collect punitive damages.

Another important issue related to expanded health plan tort liability is whether this should be addressed at the state or federal level. The federal government and not the state regulates employers that are self-insured, which provide health care coverage for about 40 percent of Minnesota’s population. Therefore, a state law expanding health plan tort liability would only apply to part of Minnesota’s health care market. This could have the unintended consequence of encouraging more employers to become self-insured and avoid state regulation altogether.

What effect would health plan liability have on doctors?

SWANSON: The Fairness in Health Care Act being debated in Minnesota in no way expands liability for doctors. Rather, it only deals with the liability of health plans. And it specifically makes it illegal for a health plan to pass on its liability to physicians by indemnification or otherwise. Its result, however, hopefully would be to help level the playing field between health plans and doctors and their patients. This, of course, would make it easier for doctors to be doctors.

SCANDRETT: As noted in the previous question, the effects on doctors of expanded health plan tort liability include: more oversight of physicians; defensive medicine; more lawsuits involving physiMetroDoctors

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cians; a chilling effect on medical advances; higher health care costs; and fewer people with health care coverage.

What is the law in other jurisdictions?

SWANSON: There has been a trend in other jurisdictions toward enacting health plan liability laws. Enactment of such laws has largely been credited to strong support by state medical association chapters. For instance, health plan liability laws have now been passed in Texas, California and Georgia. Sponsors of the laws in Texas and California indicated that passage would not have been possible without the strong support of physicians.

At the national level the U.S. House of Representatives, as of this writing, had passed a strong patient protection bill, with the support of the American Medical Association, which included health plan liability.

SCANDRETT: Most states have alternative remedies for patients with disputes with their health plans (such as external medical review) and have not opted for expanded tort liability. There are three states that currently have expanded tort liability for health plans. Georgia and California just recently passed their laws. Texas passed its law in 1997, but due to court challenges, the law did not actually become effective until March 1999. Due to the limited time these laws have been in place, it is inappropriate to draw conclusions based on their experience. In addition, both California and Texas had enacted broader tort reforms previously, which will likely reduce the impact of expanded health plan tort liability on health insurance premiums.

What effect will the right of patients to sue their health plans have on health care premiums? Why? What has been the experience in other states that allow these types of lawsuits?

SWANSON: Texas enacted a health plan liability law in 1997 similar to that contained in Minnesota’s proposed Fairness in Health Care Act. Yet, there have only been a handful of new lawsuits since that law was placed on the books, and health care costs have not increased. Similarly, Coopers & Lybrand examined the cost of health plans serving employees who have the right to sue under existing law and concluded that such liability costs a mere three to 13 cents per month per enrollee (or no more than .11 percent of premiums.)

And the Congressional Budget Office estimates that health plan liability would cost no more than 1.4 percent of premiums.

The knee-jerk reaction of many health plans is to claim the sky is falling whenever the government seeks to enact a law to restore a MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

little fairness to the health care financing system. For example, last year some health plans claimed that the enactment of a uniform definition of medical necessity for coverage purposes (to health plans from being able to define the term as “that which we [the health plan] determine is medically necessary based on our own judgment and discretion”) would have substantially increased premiums. Yet, when United Healthcare announced last October that it would stop reviewing physicians’ judgments about the medical necessity of particular treatments, it said it was doing so in part because it was spending over $100 million per year for such second-guessing and turning down very few requests.

SCANDRETT: No response submitted.

What legislative measures will be needed, if any, to prevent health plans from making decisions to restrict coverage for patients who have sued them?

SWANSON: The Fairness in Health Care Act contains a provision that prohibits a health plan from retaliating against a patient who has filed a lawsuit.

SCANDRETT: No response submitted.

What would a patient filing a suit against a health plan need to prove?

SWANSON: A patient seeking to hold a health plan accountable under the Fairness in Health Care Act being considered in Minnesota will need to meet a number of hurdles in order to establish a valid complaint.

First, a treating physician must have recommended a particular type of treatment.

Second, the health plan must have interfered with that decision by making its own health care treatment decision that affects the quality of treatment provided to the enrollee, such as that care is not medically necessary.

Third, in making its determination, the health plan must have acted negligently. In other words, it must have failed to exercise that degree of care that a health plan of ordinary prudence would have used.

Finally, the patient must have been harmed as a result of a health plan’s negligence.

SCANDRETT: No response submitted. ✦

January/February 2000

11

Governor Sets Ambitious Goals for Improving Health

I

tans. The decision to smoke is usually made before adulthood. Unfortunately, the use of tobacco products by adolescents is often accompanied by a host of other risky behaviors.

Minnesota’s new Tobacco Prevention and Local Public Health Endowment will build upon ongoing efforts to help young people make healthy choices. MDH, working together with community advisors, is developing a long term plan to address tobacco use and other high-risk behaviors.

The plan is based on the model recommended by the Centers for Disease Control and Prevention, which includes public awareness, community-based activities and school programs.

IN A STATE CONSISTENTLY RANKED one

of the healthiest in the nation, it may seem odd that we feel the need to establish new priorities for improving health. Our philosophy in the Ventura administration is to continuously set ambitious goals for ourselves so we can continue to be one of the best places in the country to live.

Governor Ventura’s Big Plan includes two key health initiatives: creating a health system for the next 50 years, and using the tobacco endowments to improve the health of Minnesotans. These two initiatives are also reflected in the new Minnesota Department of Health Strategic Directions for 2000-2001. These directions, summarized below, are designed to address current challenges and further improve the health of all Minnesotans.

1.

Eliminate disparities in health status. Even though Minnesota ranks high in overall health, our high marks drop when the data is examined more closely. Populations of color, children with special health needs, and foreign-born populations, among others, simply do not enjoy the same level of health as other Minnesotans.

Barriers to improved health often go beyond problems with access to care. Poverty, language, culture and other factors can make it harder for people to get appropriate information and treatment. MDH, together with Minnesota’s communities of color, local public health agencies and others, have begun employing a variety of approaches to eliminate disparities and make sure good health is attainable by all Minnesotans.

BY JAN MALCOLM Minnesota Commissioner of Health

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January/February 2000

4.

2.

Improve readiness to respond to emerging health threats. Despite the vast improvements in health over the past century, we continue to face serious public health threats. Drug-resistant infections, growth in the potential for food-borne illnesses, and bioterrorism all present new challenges. As governments struggle with limited resources, concern has grown about the ability of state and local public health agencies to respond quickly and effectively to such threats.

We will work to strengthen the state’s capacity to detect emerging health hazards, develop and introduce technologies to address them, and ensure a strong public health system.

3.

Reduce tobacco use and improve the health of Minnesota’s youth. Tobacco use continues to take a huge toll on Minneso-

Bring the community together on public health goals. No single agency—government or otherwise—can address all the social, economic and behavioral issues that affect health. Government can, however, act as the catalyst to engage the community in the search for solutions to health issues.

Minnesota did just that last year with the development of its Public Health Improvement Goals. These 18 goals were developed collaboratively with leaders from 26 public and private organizations. The goals cover many areas, including birth outcomes, violence prevention, workplace safety, childhood development, and the aging of our population.

To accomplish these goals, MDH will work with local public health partners to forge new and stronger connections with citizens, other government entities, health care providers, health plans, community organizations, and more. We all share the

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

benefits of—and therefore the responsibility for—a healthy society.

5.

Prepare Minnesota for the next wave of health reform. The rising tide of health care issues is leading us to the brink of another debate over health system reform. What are the issues? Too many Minnesotans still do not have insurance. Access to care is not equal for all. The systems that provide our care are complex and confusing. Costs are often shifted unfairly from one part of the system to another. Health care costs are continuing to rise. Too many health care dollars are spent on the results of unhealthy, personal behaviors.

Our health care system simply cannot sustain itself on this course. We must redesign the system to meet our needs for the next 50 years. MDH intends to provide leadership—to call the parties together, to obtain public input, and to find the right solutions.

We are confident that the strategic directions we have set for ourselves will go a long

way toward improving the health of Minnesotans. We realize, however, that we do not have all the answers and that we cannot do it all alone.

That’s why we need people like you—the medical professionals who serve our communities— to give us your ideas. We not only need to know what you think are the problems, but more im-

portantly, what you think are the solutions. To offer your comments and suggestions about Minnesota’s health system or our strategic directions, call our telephone comment line at (651) 215-1307 or log on to our Web site comment page at www.health.state.mn.us/ healthcare. ✦

Minnesota Poison Control Center Update As this issue of MetroDoctors goes to print, the Governor’s office has not yet made a decision about including the Minnesota Poison Control Center in the emergency funding bill to be presented to the 2000 legislature, according to Gayle Hallin, assistant commissioner of health. Three options for funding are being considered: 1) increasing the 911 tax; 2) utilizing the revenue in the General Fund; or 3) accessing the Health Care Access Fund as bridge funding for one year.

The Minnesota Medical Association has gone on record supporting the use of the General Fund for covering the shortfall. Physicians are encouraged to contact the Minnesota Department of Health, Commissioner Jan Malcolm, or your legislator to express support for continued funding of the Minnesota Poison Control Center through the General Fund. ✦

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Products and Services Offered to RMS Members by RCMS, Inc. For more information call 612-362-3704.

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2000

13

Medicare Geographic Disparity Lawsuit Update

I

IT’S OFFICIAL — a lawsuit against the United

States Government and Donna Shalala, the Secretary of Health and Human Services, was filed

by Attorney General Mike Hatch, on behalf of the State of Minnesota, the Minnesota Senior Federation, and a private citizen, Mary Sarno.

As featured in the September/October issue of MetroDoctors, seniors enrolled in Medicare residing in the state of Minnesota pay higher premiums, experience a significantly lower reimbursement for medical care, incur co-payments and no (or minimum) prescription drug coverage.

The lawsuit specifies the following claims: •

Constitutionally Protected Sovereignty — alleges that the State of Minnesota has suffered harm to its economy and has incurred significant increased costs in meeting the healthcare needs of its citizens, including senior citizens.

•

Mike Hatch, Attorney General

Equal Protection — the current reimbursement formula is based on traditional fee-for-service reimbursement rates. The

present formula does not bear a relationship to the cost of delivering managed care services in a given community.

•

AUTO LEASING

The purpose of the lawsuit is to have the present Medicare managed care reimbursement scheme declared unconstitutional and to have the court enjoin the federal government from continuing these unlawful payments.

For more information on the lawsuit or to review the complaint, feel free to access the Attorney General’s website at www.ag.state.mn.us✦

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Fair, competitive prices.

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Reminder… metrodoctors.com census sheet can be completed online.

Boulevard Leasing Nancy Kapps President 2817 Anthony Lane S., #104 St. Anthony, Minnesota 55418

(612) 781-8449

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January/February 2000

Right To Travel — the current reimbursement formula creates a Medicare managed care system that penalizes some seniors for exercising their right to travel.

Endorsed by Ramsey Medical Society

www.metrodoctors.com/census

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

Reforming Medicare Can Be Done

C

CONVENTIONAL WISDOM SAYS that

Medicare reform won’t happen in the year 2000 because big legislative changes don’t occur in election years. That’s particularly true with Medicare, which is just too valuable a weapon for one party to use against the other.

It’s time to tell conventional wisdom to shut up.

Medicare reform can indeed happen and it’s in the interests of both political parties to get it done. The key is whether or not members of Congress can put aside the short-term temptations of using Medicare as an object of 30second attack ads and instead achieve long-term reform that will benefit tens of millions of Americans.

Let’s look at the issue from both sides. President Clinton and his allies in Congress want a prescription drug benefit attached to the current Medicare program. They make a strong case that no senior citizen today should be denied access to the miracles being developed by pharmaceutical research. Science has given us the ability to help people lead longer, healthier, more active lives. Should that scientific progress be part of the Medicare program? Of course it should.

The idea that a drug benefit should be grafted onto the current Medicare program, however, is ill-considered. Medicare is a program with a shaky foundation and insolvency waiting just 15 years down the road. No home builder would erect a fancy penthouse suite on top of a poorly-built house, and no lawmaker should place a massive pharmaceutical benefit on top of a Medicare program whose very foundation needs rebuilding.

BY TIM PENNEY Former Congressman, S e n i o r F e l l o w, H u m p h r e y I n s t i t u t e

MetroDoctors

The answer lies on the other side of the Medicare debate, with those who want comprehensive reform of the program.

Medicare needs bigtime fixing. Today, we have a program that has a precarious financial future, a set of benefits that are inadequate compared to most employee health plans and 75 million baby boomers waiting in the wings whose collective demands could sink the proFormer Congressman Tim Penney and Hennepin Medical Society Senior Physician’s Association President E. Duane gram as it exists today.

Engstrom, M.D. Today’s Medicare — with its government-dictated, one-size-fits-all benefit plan — doesn’t cut it, then you would see health plans engaged in vigfor current beneficiaries or future ones. To make orous competition to offer the latest, most efthe program work in the 21st century, we need fective treatments and medications at the lowto trust consumers — Medicare beneficiaries — est feasible cost. to use their power of choice to make the proThree Senators — Democrats John Breaux gram more effective and efficient. and Bob Kerrey and Republican Bill Frist — What if we shifted much of Medicare derecently announced publicly that they are decision-making away from Washington bureauveloping such a plan for Medicare. The fact that crats and into the hands of the program’s benthis proposal will be bipartisan is encouraging. eficiaries? Today, Washington decides what benIt gives us hope that, even in an election year, efits Medicare beneficiaries will and will not reMedicare reform is a real possibility. ceive. Washington issues over 135,000 pages of It also demonstrates that we can achieve rules, regulations and guidelines to govern the two goals: The President and his allies can claim program. And the fact that Medicare can’t victory of achieving access to prescription drugs change until Congress and federal officials defor more seniors. Those who want comprehencide it can change — a slow, cumbersome prosive Medicare reform can reach their goals and cess — means that Medicare can’t respond create a stronger program that can better meet quickly when new lifesaving drugs and medical the needs of today’s beneficiaries and give us devices become available to consumers. realistic hope of coping with the increased deIf, however, each Medicare beneficiary mands of tomorrow’s. ✦ could choose from a variety of health plans and benefit packages, and choose the option that offered the most desired services at the best value,

The Journal of the Hennepin and Ramsey Medical Societies

January/February 2000

15

Physician Employment Contracts and Managed Care Contracts Why They’re Important From the Physician’s Perspective

M

MEDICAL SCHOOL CURRICULA typically

place very little or no emphasis on the business/ legal aspects of medical practice. Even Governor Jesse Ventura knows of a friend who “is one of the best trained hand surgeons in Minnesota, but wouldn’t have a clue as to how to bill for his services.” With the increased number of physician-employees and the ubiquity of managed care contracts, physicians need to know something about these contracts.

In my 14 years of practice I have had to negotiate many employment contracts with and without an attorney. I will share some common scenarios and pitfalls below.

An attorney’s analysis of such contracts accompanied by an accountant’s financial advice can go a long way toward protecting your and your patients’ interests. Nevertheless, you as the physician, the one charged for the ultimate legal responsibility for caring for your patients, are the only one who can finally say how elements of your contract will affect your ability to provide patient care.

Employment Contracts Usually if the physician is employed by a group of physicians, or by a large health system, a “boiler plate” employment contract will be presented to the physician by the system or group, specifying major areas of the employment relationship.

It’s important to note that the State of Minnesota is an “employment at will” state, which means that any employee without an employment contract can be terminated “at will” usually “without cause.”

The legal definition of an employment B Y J E F F L A R S O N , M.D., M.B.A. CERT.

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January/February 2000

contract: A contract establishes “a legal relationship consisting of the rights and duties of the contracting parties and promises constituting an agreement between the parties that gives each a legal duty to the other and also the right to seek a remedy for the breach of those duties.”

Unless the agreement clearly stipulates the responsibilities and rights/benefits accruing to each party, the document may not be valid.

Note: the contract should be balanced in terms of these rights and responsibilities. If it is not, it may be desirable or necessary to re-negotiate or re-write it.

Points to consider in the Employment Contract: 1. The Parties: This establishes specifically who the parties to the contract are. In the case of a contract with a large system, this may be important because the party listed may be another corporate entity owned by the system, different from the system corporate entity.

2.

Duties: This establishes the responsibilities of the employee(physician), and whether or not the M.D. is permitted to engage in outside employment activities or not. It is extremely important to clarify the physician’s duties under the contract, because this establishes up front just what those duties are. Without this, interpretations may vary at a later time, if disputes arise. Note that phrases such as “duties that may from time to time be assigned to him/ her by employer” and “other M.D.s may be hired to perform the same or similar services” could dilute the physician-employer relationship and basically allow the

MetroDoctors

employer a “blank check” to later change the duties or hire other M.D.s in the physician-employee’s place!

3.

Term and Termination: This is also one of the most important aspects. This section states for what term(calendar dates)the contract is valid and the conditions under which the physician may be terminated by the employing party.

Note that this aspect of the contract protects the physician-employee from arbitrary termination. The wording is crucial. Typical reasons for termination for cause in contracts include “conviction for moral turpitude” (conviction for sexual assault in the office) and loss of medical license, which are among the few valid reasons for the employer to terminate a contract.

Other phrases to watch out for include termination “with or without cause” — this in effect may give the employer the right to terminate without a reason.

Phrases such as “for cause, but not limited to,” could give the employer a “blank check” to terminate for any reason, and would probably best be re-negotiated or deleted.

Both parties should have a chance to get out of the contract, if necessary. Nonperformance, for example, would be a legitimate reason. However, one must be

The Journal of the Hennepin and Ramsey Medical Societies

careful that the rights of both parties are balanced and not one-sided.

4.

5.

6.

7.

Benefits: It’s important to spell out exactly what the employee’s benefits are. This should include salary, vacation, cme, health, disability, and sick time, and may include 401K or other profit-sharing plans.

Disability benefits should be looked at carefully. Again, phrases such as “compensation that shall be determined from time to time” may be a blank check to change the stipulations of the contract unilaterally and should be avoided.

Malpractice Insurance: Generally, the employer pays for malpractice insurance.

However, since the market for “occurrence” malpractice is limited, one must be careful with contracts that make the physician responsible for paying the tail insurance, or significant portions of the tail insurance.

Non-Compete Agreements: Physicians need to be aware that in Minnesota, noncompete agreements can, if written properly and not too restrictively, be upheld by Minnesota courts. Unreasonable non-competes will probably not be upheld. You may be restricted from practicing in an area where you have established your professional reputation if you leave an organization having signed one of these agreements.

Even more problematic, you may be denied the right to join another plan or group because language in a previous contract forbids it. Non-competes can restrict physicians from growing a legitimate practice, but it is almost always possible to negotiate these.

It’s important to remember that physicians have the right to negotiate an employment contract and have it reviewed by an attorney and/ or CPA. Too many physicians give up this right by not taking the time to review the contract. If not satisfied, re-negotiate it. In fact, some employers may rely on the fact that most physicians will sign the contract without review in order for the M.D. to obtain a patient base.

Some physicians will not risk the conflict inevitable in a re-negotiation. If a successful relationship between the employer and physician-employee is to develop, then, negotiation, and even re-negotiation should be part of the deal. If a potential employer is unwilling to negotiate important parts of the employment contract, then the relationship may become too one-sided, and the potential physician-employee may want to look elsewhere.

The Managed Care Contract Managed care contracts are generally between an individual physician or physician group and a contracting entity, such as a large health plan or insurance plan. Most of the above observa-

tions will apply to these contracts as well, with the addition of some other caveats.

In general, some suggestions: Research the Managed Care Organization (MCO). You will want to know as much as you can. Who owns the organization? Who administers it? What is their background and do their business and patient care policies make you comfortable in placing your patients and your financial future in their hands? Do they have other business ventures and can you determine how their business objectives might affect your practice?

Some Managed Care Plans have taken a “take it or leave it” approach with physicians, but some are becoming less rigid, due to pending congressional legislation, medical society review of contracts, etc. Don’t assume in any case, that they will be totally unwilling to negotiate!

(Continued on page 18)

Dispute Resolution: It is always a good idea to consider how disputes about the contract will be resolved. Many employment contracts make no provision for dispute resolution. However, because no contract is perfect, disagreements are likely to occur. One alternative to litigation is to include a section on arbitration. The American Arbitration Association, an impartial group which will hear contract disputes, has an office in Minneapolis.

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The Journal of the Hennepin and Ramsey Medical Societies

January/February 2000

17

may include language that limits the physician’s ability to give patients the type of informed consent discussion required both by the profession and the law. Such clauses should be removed.

(Continued from page 17)

Points to consider in the Managed Care Contract: 1. Look at language that defines how the doctor-patient relationship may be established or terminated. Most physicians don’t want to see long-standing patients assigned to someone else and want to know when new patients choose or are assigned to their practice. When an emergency arises and the physician must provide care for someone he’s never seen, a potential liability for the physician and a disservice to the patient may result. Also assignments or withdrawal of patients should not inconvenience or threaten patients’ health. If the contract is terminated, patients need to be provided with appropriate alternatives to their current care. The contract should stipulate that the MCO will continue to pay the physician at an agreed upon rate during the transition.

2.

3.

4.

Capitation is a common part of these agreements, but the physician needs to know how these may affect the quality of service by reducing the level of care or restricting referral options. It’s important from a financial viewpoint to consider the capitation rate and whether such rates are adequate to provide an appropriate level of care.

Are you comfortable with the level of services or skills required by the contract? If you are a primary care physician, determine if the wording requires you to perform procedures or provide services which you believe should not be performed in an office setting or for which you are inadequately trained.

You may want to eliminate language that enforces a “production” quota, requiring you to see X patients an hour or perform a certain number of procedures per month.

A court in California recently ruled in favor of a Kaiser physician who was required to see 11-12 patients per hour.

5.

Although Minnesota and most states now prohibit gag clauses, some contracts still

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January/February 2000

6.

Watch for “hold harmless,” “indemnity,” or indemnification” language. This means that the MCO may hold the physician responsible for harm occurring to any party because of its own actions/policies. Assuming the legal liabilities of others makes no sense whatsoever.

7.

“Negligent referral” is an allegation that can be used against referring doctors when a patient suffers a poor outcome and feels that the specialist was incompetent. Review all referral language and make sure that if you are expected to accept referrals or to refer out, that the MCO informs you of these doctor’s names, training, and specialties.

8.

Formularies: determine if the MCO restricts you from prescribing outside the formulary for good cause, i.e., allergies or serious side effects. Will the MCO pay the standard amount toward the non-formulary drug if the patient is willing to pay additional charges?

9.

Utilization Review Procedures: The MCO should provide a comprehensive explanation of its UR procedures, including appeals processes and the physician’s rights in working with UR representatives.

10. Quality Assurance Guidelines/Practice Parameters: The MCO should provide a copy of these, and any other protocols that may affect, limit, or influence the way patients are treated. Determine how these guidelines were developed. Some managed care entities refer to quality requirements without providing copies of them. By agreeing to follow guidelines you have not seen, you may be placing yourself and your patients at risk.

11. Dispute Resolution: Dispute resolution processes for denial of patient care should be included for analysis along with the con-

MetroDoctors

tract. Actually, many states now require MCOs to disclose their appeals and dispute resolution rules.

Before signing the contract, ask the plan to provide additional materials. These include: QA Guidelines, UR requirements, Practice Guidelines, marketing materials, appeals procedures panel information, samples of materials provided to patients, and any other documents/rules referenced in the contract. When you evaluate a managed care plan, contact state medical societies, and the state department of insurance to inquire about complaints, legal guidelines for complying with contractual agreements, and any suggestions these bodies may offer. The Ramsey and Hennepin Medical Societies have been reviewing specific managed care contracts in Minnesota and are developing resources to do this. Watch out for contracts that want to redesign your practice; the number of patients you see; the way you discipline staff; the scope of services you provide; your right to determine, with the patient, when referral is necessary; and any other changes that might place a burden on your ability to provide quality care.

This is by no means an entire list of considerations in reviewing a Managed Care Contract. Again, an attorney’s analysis along with that of a CPA regarding the financial issues, can go a long way in protecting your interests. Be assured that the managed care entity will have attorneys of its own looking after its interests.

Above all else, READ THE CONTRACT! ✦

The author is Jeff Larson, M.D. M.B.A.cert., an occupational health physician who has learned the hard way about medical contracts. He may be reached for comment at belarson@mn.uswest.net * Parts of the Managed Care Contracts section were excerpted and reprinted, with permission, from The Medical Protective Company, ©1998.

This article is a general discussion of contracts and is not intended to be legal advice. MetroDoctors publishes this article for informational purposes only.

The Journal of the Hennepin and Ramsey Medical Societies

Please take a few moments to visit our web site and check your listing. If you haven’t yet expanded your listing, go to www.metrodoctors.com/census and complete your personal mini web page. If you would like to view an example, select through the “Find a Doctor” button Dr. Jon V. Thomas. If you would like to change your previously expanded page, simply e-mail your changes to the webmaster.

There is no charge for having your personal mini webpage on www.metrodoctors.com — it is a benefit of your membership in RMS and HMS. If you are unable to access a computer to fill out the census form, call 612-362-3704 and we will mail or fax one to you. ✦

...........................➤

Sample of a portion of the Census Form

➤ A service offered by Hennepin and Ramsey Medical Societies

Are You Listed Correctly?

Looking for a physician?

The Ramsey and Hennepin Medical Societies have initiated the promotional campaign of metrodoctors.com to the public. The strategy is to position metrodoctors.com as the premier electronic physician directory in the Twin Cities. The ad on the right appeard in the January 2000 “Top Doctor” issue of Minneapolis/St. Paul Magazine.

www.metrodoctors.com

Promoting www.metrodoctors.com

The premier on-line consumer health care directory

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The Journal of the Hennepin and Ramsey Medical Societies

January/February 2000

19

Community Internship Program Provides Opportunity for Dialogue

O

On November 9 and 10, HMS and RMS hosted 12 business and community leaders in a jointly sponsored Community Internship Program.

The program provides a rare opportunity for physicians to communicate in a formal setting with those outside the medical community who

don’t always understand a physician’s perspective, but who may judge or influence the way health care is purchased or provided. Each participant spends two days in four different specialties, observing physicians and other health care professionals in action. Thirty-nine HMS/

RMS physicians participated as faculty, sharing their knowledge, skill and concerns about the issues affecting the practice of medicine today.

Evaluation of the program by the “interns” is most always positive and appreciative of the experience. Follow-up comments received included: • “I’m amazed at the pace decisions and diagnoses are made”; • “Now I have even more questions about managed care”; • “The concern that doctors have for their patients was more intense than I had imagined”; • “I understand better the fun of practicing medicine as well as the frustrations”; • “The experience of technology is absolutely wondrous.”

HMS and RMS sponsor several Community Internship Programs throughout the year.

Please contact Nancy Bauer (612) 623-2893, www.nbauer@mnmed.org; or Doreen Hines (612) 362-3705, www.dhines@mnmed.org to participate! ✦

Interns participating included: Susan Castellano, Rosemary Goff, John Hart, David Allen, Kathleen Anderson, Glen Howatt, Steve Wilson, Michael Huber, Kathy Oldyn, Okokon Udo, Brenda Holden, and (not pictured) David Aafedt.

Participants in the Community Internship Program David M. Aafedt, assistant attorney general, Minnesota Attorney General’s Office; David W. Allen, Jr., chief executive officer, Minnesota Specialty Physicians, Inc.; Kathleen Anderson, district director, Congressman Martin Sabo’s office; Susan Castellano, Dept. of Maternal/Child Health, Dept. of Human Services; Rosemary Goff, director majority research, G-13 Captiol; John Hart, vice president Ovations, Ovations United Health Group; Brenda J. Holden, executive director, Health Technology Advisory Committee; Glen Howatt, health care reporter, Minneapolis Star Tribune; Michael R. Huber, director, consumer assessment, Blue Cross/Blue Shield; Kathy Oldyn, assistant vice president—risk management, St. Paul Medical Services (The St. Paul Co’s.)

Okokon Udo, executive director, Center for Cross-Cultural Health; and Steve Wilson, research consultant, House Republican Caucus.

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January/February 2000

MetroDoctors

Glen Howatt with Dr. Alyson Emory at Green Central Clinic.

The Journal of the Hennepin and Ramsey Medical Societies

Thank you to the following physicians for participating in the Community Internship Program.

Susan Castellano with Dr. Benjamin Boardman and Kathy Huntington, PA at Bloomington Lake Clinic.

Dr. Kenneth Crabb and Kathy Oldyn.

Dr. Peter Kelly and Brenda Holden.

James Amsterdam, M.D. Steve Atwater, M.D. Bradley Bart, M.D. Benjamin Boardman, M.D. Peter Bornstein, M.D. Graeme Browne, M.D. Raul Cifuentes, M.D. Kenneth Crabb, M.D. Daniel Dunn, M.D. Thomas Dunkel, M.D. Alyson Emery, M.D. Susan Ferron, M.D. Allan Fuller, M.D. John Gates, M.D. John Graber, M.D. Kevin Graham, M.D. Louis Jacques, M.D. Peter Kelly, M.D. Patrick Lilja, M.D. Sajad Mir, M.D. Eugene Ollila, M.D. William Omlie, M.D. Brian Patty, M.D. John Paulson, M.D. Pamela Paulsen, M.D. Thomas Raih, M.D. Jody Rowland, M.D. Milagros Santiago, M.D. Eric Schenk, M.D. Steven Siegel, M.D. Steven Sterner, M.D. Lyle Swenson, M.D. Mark Tanz, M.D. Charles Terzian, M.D. David Thompson, M.D. Audrey Traub, M.D. Gordon Welke, M.D. Peter Wilton, M.D. Robert Zeleznikar, M.D.

Dr. Lyle Swenson and John Hart.

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The Journal of the Hennepin and Ramsey Medical Societies

January/February 2000

21

AMA House of Delegates Acts on Four HMS/RMS Resolutions

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THE AMA HOUSE OF DELEGATES 1999 In-

terim Meeting was held in San Diego, December 5-8. Minnesota was represented by seven delegates and seven alternate delegates which are elected by the MMA House of Delegates. Members of the delegation from the metro area included: Hennepin Medical Society members Robert Christensen, M.D., A. Stuart Hanson, M.D., Carolyn McKay, M.D., and Andrew J.K. Smith, M.D.; and Ramsey Medical Society members Frank Indihar, M.D. and Kenneth Crabb, M.D. A. Stuart Hanson, M.D., completed an 18year term in the AMA House of Delegates at the December meeting. On several occasions Dr. Hanson was recognized for his excellent

work on public health issues, most notably as a champion of tobacco cessation and violence prevention initiatives. Ben Owens, M.D., Range Medical Society, also retired from the delegation, having served 18 years.

Four resolutions that were sponsored by either the Hennepin Medical Society (HMS) or the Ramsey Medical Society (RMS) at the MMA House of Delegates in September were carried by the Minnesota delegation to the AMA House of Delegates Interim Meeting in San Diego.

• Resolution 123, Pharmaceutical Costs, calls on the AMA to study the various aspects of increasing pharmaceutical costs. The intent of Resolution 123 was carried out in the

“Professional Projects for the Professional” • Clinics • Professional Buildings • Hospitals •

Morcon Construction, Inc. 5905 Golden Valley Road Golden Valley, MN 55442 Phone: 612-546-6066 Bill Jundt Medical Construction Specialist Member MMGMA/Gold Sponsor

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January/February 2000

morcon@isd.net

MetroDoctors

A. Stuart Hanson, M.D.

adoption of Substitute Resolution 123.

• Resolution 416, Health Care Standards in U.S. Correctional Facilities, was adopted as amended.

• Resolution 516, FDA Regulation of Dietary Supplements and Herbal Remedies was incorporated into AMA Policy H-150.954 along with other amendments to that policy.

• Resolution 518, Ethnic Data Reporting for Clinical Trials, was not adopted as the AMA Minority Consortium is studying the matter and will be issuing a report.

The AMA House also considered two additional issues raised by the MMA House of Delegates. The MMA Resolution 204 sponsored

by HMS and RMS on Medical Savings Accounts (MSAs) was not carried to the AMA, however, the AMA Council on Medical Service Report 10 expands AMA policy on MSAs. The AMA Council on Scientific Affairs Report 9 includes many of the issues identified in the RMS/HMS joint resolution 411, Consensus Statement of Physician Leadership on National Drug Policy. HMS, RMS, and Minnesota Psychiatric Society members should refer to this report for further information.

In addition, the MMA sponsored Resolution 117, Medicare History and Pre-Operative Physical Examinations, which was referred to the AMA Board of Trustees. This resolution asks the AMA to pursue changes in the Social Security Act that would specifically authorize coverage for preoperative examinations. The testimony was mixed on the need for adoption of the resolution which resulted in the referral to the AMA Board.

A copy of the reference committee reports and actions taken by the AMA House of Delegates can be obtained through the Center for Physician Advocacy at the MMA or downloaded off the AMA home page at www.ama-assn.org.✦ The Journal of the Hennepin and Ramsey Medical Societies

COMMUNITY SERVICE

Responding to Homeless Health Needs

F

FOR THE PAST SEVEN YEARS HealthEast,

Ramsey Medical Society, and the Ramsey Medical Society Alliance have taken a leadership role in educating the community on the needs of homeless people from a medical perspective.

These groups have coordinated efforts to secure

needed medical and hygiene supplies for the homeless in Ramsey County by holding an annual drive in February.

The Eighth Annual “Caring Hearts for Homeless People” supply drive will kick-off on Sunday, February 13, 2000 and conclude on Sunday, February 27, 2000.

The goal of the campaign is to collect over $30,000 worth of supplies for the Health Care for the Homeless Clinics and Listening House.

Please agree to help the homeless by participating in one of these three different ways: 1. Committing your clinic to participate. All we ask is that you designate a “Caring Hearts for Homeless People” coordinator for your clinic.

Have this person call Doreen at 612-362-3705. We will

Many volunteers help sort items collected at a previous “Caring Hearts for Homeless People” supply drive.

Shopping List (Non-Alcoholic) (Trial/Travel Sizes)

Medications • Multicomplex Vitamins (Adult and Children’s) • Robitussin, Triaminic, Cough drops • Tylenol (Adult, Children’s), Ibuprofen • Antibiotic ointments • Hydrocortisone ointments

Hygiene • Diapers - all sizes • Sanitary pads/tampons • Toothbrushes & Toothpaste • Soap for sensitive skin, Shampoos, and Lotions • Combs, Brushes, Deodorant & Razors

Other • Foot & Hand Care (e.g. Corn pads, anti-fungal powder and cream, nail clippers, white socks) • Carmex & Vaseline lip balm • Similac with iron, Juice packs & boxes

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The Journal of the Hennepin and Ramsey Medical Societies

Sponsored By:

Alliance

then send you posters and a shopping list for you to post within your clinic. We suggest you designate a collection point within your facility. During the campaign, collect as many supplies on the shopping list as possible. On Monday, February 28 or Tuesday, February 29, volunteers from the Ramsey Medical Society Alliance will pick up the supplies from your clinic and deliver them to the collection site where they will be sorted and prepared for distribution. All participating clinics will be listed in the Ramsey Medical Society journal, MetroDoctors.

2. Encourage your local place of worship to participate. We would again need a designated coordinator to call us. The total time commitment to the project is approximately 4-5 hours. This is a great opportunity for youth to participate in a service project. Call Jodie at Health Care for the Homeless (651-290-6814) or Julie at Listening House (651-227-5911) to learn more about the drive and people who benefit from it.

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

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

Please call the RMS office at 612-362-3705 if you have any questions. ✦ January/February 2000

23

PRESIDENT’S MESSAGE LY L E J . S W E N S O N , M . D .

RMS-Officers

President Lyle J. Swenson, M.D. President-Elect John R. Gates, M.D. Past President Thomas B. Dunkel, M.D. Secretary Robert C. Moravec, M.D. Treasurer Peter H. Kelly, M.D. RMS-Board Members

Kimberly A. Anderson, M.D. John R. Balfanz, M.D. James A. Brockberg, M.D. Charles E. Crutchfield, M.D. Peter J. Daly, M.D. Aimee George, Medical Student Michael Gonzalez-Campoy, M.D. James J. Jordan, M.D. F. Donald Kapps, M.D. Charlene E. McEvoy, M.D. Joseph L. Rigatuso, M.D. Thomas E. Rolewicz, M.D. Jamie D. Santilli, M.D. Paul M. Spilseth, M.D. Jon V. Thomas, M.D. Randy S. Twito, M.D. Russell C. Welch, M.D. Phua Xiong, M.D., Resident Physician RMS-Ex-Officio Board Members

Blanton Bessinger, M.D., MMA President-Elect Chad Boult, M.D., Council on Professionalsim & Ethics Chair Kenneth W. Crabb, M.D., AMA Alternate Delegate Duchess Harris, Alliance Co-President Neal R. Holtan, M.D., Community Health Council Chair Nicki Hyser, Alliance Co-President Frank J. Indihar, M.D., AMA Delegate William Jacott, M.D., U of MN Representative C. Randall Nelms, M.D., AMA Specialty Delegate Robert W. Reif, M.D., Sr. Physicians Assoc. President William M. Rupp, M.D., Joint Contract Review Program Chair Melanie Sullivan, Clinic Administrator Kent S. Wilson, M.D., MMA Past President RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive Officer Doreen Hines, Assistant Director

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January/February 2000

A

AS THE NEW YEAR APPROACHES, I’ve been

thinking about what the practice of medicine will be like, and how our professional lives will change. There is no doubt that medical care and the practice of medicine will change, but will those changes be for the better? As physicians, we will have opportunities to foresee how medicine will evolve, and make changes that improve health care, our profession, and our society. But, as we look towards the future, some troubling and difficult questions arise.

Will society and the physicians of tomorrow continue to regard the relationship between patient and physician as sacred, governed by a covenant based on trust, with the well-being and interests of the patient taking precedence over all other interests?

Will we as physicians be able to safeguard the essential aspects of our profession? How will we respond to the many inevitable challenges that threaten our professional ideals?

We have all witnessed how a market-based approach to medicine and governmental regulation have encroached upon the practice of medicine. Despite a booming economy, many physicians are experiencing decreasing reimbursement. Large health care businesses have become very powerful, dictating how health care is delivered and controlling the conditions of employment and reimbursement of physicians.

It is not surprising that many physicians have felt powerless in confronting these challenges, and in some cases have given up on efforts to rectify developments that seem unjust and unfair.

One of the reasons why some physicians feel powerless to confront challenges to our profession is that we do not have a mechanism to speak as one unified, powerful voice to business interests, government, and to the public. Physicians are a very diverse group. We are men and women, young and old, conservative and liberal, academic and non-academic, employed and independent, primary care and specialist. We have different needs and look to many different organizations for support and for our professional identity.

MetroDoctors

There is a real possibility that our diversity and lack of unanimity will prevent us from being able to have a say in how health care delivery and financing evolves in this country. We know from past experience that when dialogue with other participants in health care reveals that physicians are divided, the dialogue and outcome are directed by the non-physician participants, sometimes to the detriment of health care and physicians.

Certain other trends are disturbing, and may have profound effects on our future. Membership in local, state, and national medical societies is declining. Without these broadly inclusive organizations working on behalf of physicians, we will lose power to affect health care as a profession.

More and more physicians are becoming employees of large health insurance companies.

Although employment is not inherently detrimental to the profession of medicine, employed physicians are less apt to participate in local, state, and national medical societies; they tend to identify with their employer rather than other physicians, and they have an inherent conflict between their employers’ best interests and their patients’.

Finally, the media portrayal of physicians comes almost exclusively from non-physicians.

No matter what the goals, they are generally not those of physicians, and frequently the media portrayal is negative.

If the profession of medicine is to remain rewarding in the future, and continue to attract the best and the brightest of society, physicians must be vigilant and responsive to the continuing challenges to our profession. We must be unbending in our efforts to preserve the sanctity of the physician-patient relationship. We must always hold the interests of our patients (Continued on page 27)

The Journal of the Hennepin and Ramsey Medical Societies

RMS NEWS

Applicants for Membership We welcome these new applicants for membership to the Ramsey Medical Society.

Politics Begins at the Grassroots A Successful Senate District 56 Reception

reception sponsored by the RMS Public Policy Council at their home on Thursday, November 18 near Stillwater. Twenty-three physicians and spouses discussed important health care issues with Senator Gary Laidig (Sen. Dist. 56) and Representative Mark Holsten (Dist. 56A). RMS President Dr. Lyle Swenson said, “We will con-

tinue these very successful legislative receptions to give physicians the opportunity to meet their legislators and provide the legislators with the physicians’ views on the issues. We know the legislators appreciate hearing from the physicians in their districts because that is what they tell us when we meet with them.” ✦

Ramsey Medical Society

DR. MARK AND MARILYN WIEST hosted a

Active Sheryl L. Breiholz, M.D. University of Minnesota Family Practice HealthEast Cottage Grove Clinic David E. Burnham, M.D. University of Alabama Pediatrics HealthEast Pediatricians for Health Todd J. Morris, M.D. University of Minnesota General Surgery Regions Hospital Anthonia A. Olajide-Kuku, M.D. Semmelweis Med. U, Budapest, Hungary Pediatrics Multicare Associates Jeffery M. Rank, M.D. University of Minnesota Internal Medicine/Gastroenterology Minnesota Gastroenterology, P.A.

Senator Gary Laidig (Sen. Dist. 56), RMS President Dr. Lyle Swenson, Representative Mark Holsten (House Dist. 56A), and hosts Marilyn and Dr. Mark Wiest.

Your Gift to the RMS Foundation THE RMS FOUNDATION welcomes your tax deductible gifts. Your gift will ensure that the RMS Foundation will continue to support the Alliance Health Fair, Caring Hearts for Homeless, and many other worthy community resources.

If you have a question about making a bequest to the RMS Foundation in your will or contributing gifts other than cash, please call the RMS office at 612-362-3704. Your check should be payable to the RMS Foundation and mailed to the Ramsey Medical Society, P.O. Box 131690, St. Paul, MN 55113-0015.✦ MetroDoctors

Gregory M. Vercellotti, M.D. University of Illinois Internal Medicine/Hematology Fairview-University Medical Center

In Memoriam

Student

ANATOLE RABCEVICH, M.D, 75, died

Brian J. Allen Darren A. Manthey Joshua W. Quaas Rufino R. Rodriguez

November 16 of a heart attack. As an immigrant from Eastern Europe, he later treated many immigrants as a family physician in St. Paul. He completed his degree at the University of Minnesota Medical School. He retired in 1989.

CHARLES GORDON VAUGHN, M.D,

died September 17 at Health-East Hospice St. Joseph Hospital. He was 73. He graduated from the University of Minnesota Medical School. Dr. Vaughn practiced dermatology in St. Paul until 1995. ✦

The Journal of the Hennepin and Ramsey Medical Societies

(from the University of Minnesota)

Transfer into RMS —Active Kenneth R. Britton, D.O. University of Osteopathic Medicine & Health Science Physical Medicine & Rehabilitation/Geriatrics Geriatric & Rehabilitation Consultants ✦

January/February 2000

25

Introducing the 2000 RMS Officers and New RMS Board Members Thank you to each RMS member who cast their ballot in the recent election for RMS officers and Board members. You have elected an excellent team to lead RMS into the new millenium. âœŚ

President John R. Gates, M.D.

26

President-elect Robert C. Moravec, M.D.

Past president Lyle J. Swenson, M.D.

Secretary Jamie D. Santilli, M.D.

Treasurer Peter H. Kelly, M.D.

Director at Large Charles E. Crutchfield, III, M.D.

Director at Large Russell C. Welch, M.D.

Specialty Director Mark E. Wiest, M.D.

Specialty Director James J. Jordan, M.D.

Specialty Director Thomas F. Rolewicz, M.D.

Specialty Director Ragnvald Mjanger, M.D.

January/February 2000

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

RMS ALLIANCE NEWS DUCHESS HARRIS, Ph.D.

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Swenson shares my enthusiasm for political awareness. This November the Ramsey Medical Society and its Alliance were busy meeting legislators and potential candidates. On November 3, I attended a reception for a physician who is seeking the Democratic endorsement to run for the United States Senate; and on November 18, I went to a session with a Republican state senator and representative who both have held office for several years. Pen and paper in hand, I was ready to become informed.

…we take the legislative process for granted when our needs are being met…

What I learned was that some people knew about health care, and not legislation—others knew about legislation, but not health care.

What if we could find a candidate or an incumbent that was knowledgeable about both! I don’t mean to sound smug, but as a voter I do have standards. For instance, if you are a geriatric internist and a colleague asks you what role insurance companies should play in the health care delivery system, it’s not a trick question.

Honest, no one is trying to confuse you. If an infectious disease specialist takes the time to go to your web page and sees that you are for universal health care, but not socialized medicine, it’s fair for him or her to want to know what that means. See it works like this, you invite us to ask you questions because you want us to vote for you.

So what’s my solution to this dilemma? We should run for office ourselves! I got my idea from an event the Alliance had on November 17 called “Dust off your Dreams.” This was a

The Journal of the Hennepin and Ramsey Medical Societies

program that was geared toward women who were in “middlessence” looking for a second career. There were six women on the panel, who had all made mid-life career choices — one had even become the mayor of a small town in Ramsey County. It was after hearing these women tell their stories that I realized that if members of the Alliance want their family’s concerns about the future of health care addressed in the local or national arena, we need at least one informed person to come forward ready to “Venture” into the ring. If the dream that you want to dust off has nothing to do with running for office, help the Alliance Legislative Committee in any way that you can; for instance, we could organize a day at the State Capitol. Whatever you do, don’t “Skip” the opportunity because it seems to be the “Norm.”

Just remember, it only takes one Body, or one Mind to decide that “Politics do matter.” ✦

President’s Message (Continued from page 24)

above our own self-interest, and above the interests of any employer or business entity. We must in some way give back to the profession and be involved in our profession. Whether that means writing or calling your elected representative when an issue demands it, providing charity care, being active in your community, or serving in some capacity with your local, state, or national medical society, every physician needs to be involved.

In a few years, when my children are a little older, it would not surprise me if they asked, “Should I be a physician?”. I hope I can say, “Yes, being a physician is wonderful.” ✦ January/February 2000

27

Ramsey Medical Society

N

NOVEMBER IS ONE OF MY favorite months.

I enjoy the fervor of elections and the flock to the polls. In November of 1998 I attended the American Medical Association Alliance Leadership Confluence in Chicago. I was able to participate in several sessions, but the one that was closest to my heart was the one on the legislative process. As a political science professor, I often encounter cynicism about government and hear claims that participatory democracy does not work. When I try to get people involved, the usual response is that “Politics don’t matter.” When I returned from the Chicago Confluence I was excited to spearhead two initiatives: 1) Have an Alliance member team up with a medical society lobbyist; and 2) Have an Alliance member participate in the AMA Campaign School on Capitol Hill. When I delivered my report at the next Alliance meeting, I was dismayed to find that we had faltering interests in the Legislative Committee.

Shortly after realizing that our organization had this void to fill, I found myself being asked what I thought of the new GovernorElect. Some were terrified at the prospect of being able to buy their child an action figure of the highest ranking elected official in the state, while others were excited by the novelty of it all. (A year later the novelty has worn off.) Regardless of their stance, I took the opportunity to ask them why they were so interested—why after all, “Politics don’t matter.”

The message that I was trying to get across was that we take the legislative process for granted when our needs are being met, and last November’s election proves that apathy can lead to being pinned to the mat, as opposed to residing on Summit Avenue. Although the members in the Ramsey Medical Society and its Alliance are active in both political parties, and have different opinions about important social issues, we are all invested in physician advocacy.

With this in mind, I ran to this year’s political events almost as quickly as I chase my husband to mistletoe.

But seriously, I was excited that Dr. Lyle

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January/February 2000

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The Journal of the Hennepin and Ramsey Medical Societies

CHAIRMAN’S REPORT DAVID L. ESTRIN, M.D.

HMS-Officers

HMS-Board Members

Michael Belzer, M.D. Carl E. Burkland, M.D. Herbert Cantrill, M.D. Penny Chally, Alliance Co-President William Conroy, M.D. Rebecca Finne, Alliance Co-President James P. LaRoy, M.D. Edward C. McElfresh, M.D. Monica Mykelbust, M.D. Joseph F. Rinowski, M.D. Marc F. Swiontkowski M.D. T. Michael Tedford, M.D. R. Douglas Thorsen, M.D. Clark Tungseth, M.D. Joan Williams, M.D. Bret Yonke, Medical Student HMS-Ex-Officio Board Members

E. Duane Engstrom, M.D., Senior Physicians Association Lee Beecher, M.D., MMA-Trustee Karen Dickson, M.D., MMA-Trustee John W. Larsen, M.D., MMA-Trustee Robert K. Meiches, M.D., MMA-Trustee Henry T. Smith, M.D., MMA-Trustee Robert Finke, MMGMA Rep. HMS-Executive Staff

Jack G. Davis, Chief Executive Officer Nancy K. Bauer, Associate Director

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W

WHEN COST PRESSURES INCREASED for

NASA, a new paradigm was advanced: “FASTER, BETTER, CHEAPER.” NASA would deliver space exploration missions in less time, with better outcomes, and costing less money than ever before. Unfortunately, the consequences of not being able to deliver all three have been disastrous for some missions. Witness our two most recent Mars attempts.

When pressures on healthcare intermediaries (health plans, insurance companies, and managed care organizations that stand between patients and physicians) to reduce costs to the purchasers of healthcare (primarily employers and government, not patients) increased, a similar paradigm arose. Physicians would see more patients and do more paperwork in less time; follow prescribed rules regarding medication, treatment, and referral options so as to produce better outcomes; and do it all for lower reimbursement. Though physicians have done everything in their power to prevent disastrous consequences for their patients, the healthcare system does not always work the way it should.

Witness the recent Institute of Medicine report on medical mistakes and our President’s response to it.

Cutting corners sometimes works, but not always. As we enter the new millennium, perhaps both NASA and healthcare could use new paradigms.

Who should develop the new paradigm for our healthcare system? The answer, I believe, has to be all of us. But I believe that at the nucleus must be physicians and patients.

Patients want the best healthcare for themselves and their families, and they want employers to pay. Employers want to provide healthcare benefits for their employees, but they want the cost to be minimized. Health plans set premiums to attract business, but often at levels insufficient to cover increased utilization. Pharmaceutical companies and medical device manufacturers want to develop newer, better products, but must sell them at enough profit to be able to fund future research and develop-

The Journal of the Hennepin and Ramsey Medical Societies

ment. Hospitals want to provide high quality care, but with lower reimbursement levels are forced to make do with less.

New physicians need to be trained to replace those leaving practice. Medical schools and some hospitals want to devote part of their revenues to train residents, but insurance companies don’t want to pay them any more than they pay to hospitals that don’t train residents. The government wants to reduce its own costs for medical care. Because it believes there is widespread fraudulent billing, it has imposed on physicians cumbersome documentation requirements that add nothing to the quality of care.

Managed care organizations, in attempting to reduce their cost to payers, often set fee schedules that do not even cover the direct costs of providing a service. Physicians want to do what is best for their patients, but in advocating for more and better, short-term costs may increase for payers.

From the perspective of each stakeholder, it is doing the right thing. However when the healthcare system is considered as a whole, contradictions become apparent. Clearly there is work cut out for us if we are to create a new paradigm. Getting agreement on a broad range of issues and moving forward will not be easy.

As a starting point, I submit that our healthcare system should be “ACCOUNTABLE, BALANCED, CARING”: accountable — for its stewardship of individual and societal resources and for outcomes; balanced — patients, physicians, and others who deliver patient care should not be disadvantaged vis-à-vis health plans and insurers that dominate a particular market; and caring — health care should be delivered with compassion and access must be assured for all.

(Continued on page 32)

January/February 2000

29

Hennepin Medical Society

Chair David L. Estrin, M.D. President Virginia R. Lupo, M.D. President-Elect David L. Swanson, M.D. Secretary Richard M. Gebhart, M.D. Treasurer Michael B. Ainslie, M.D. Immediate Past Chair Edward A.L. Spenny, M.D.

HMS NEWS Mary K. Johnston, M.D. Albany Medical College Family Practice Lakeview Clinic, Ltd.

Thomas W. Hoban Scholarships Awarded

Helen Kim, M.D. State University of New York at Buffalo School of Medicine Psychiatry Hennepin Faculty Associates Pamela S. Kolacz, M.D. Indiana University School of Medicine Family Practice Soteria Family Health Center Keena Yue Leung, M.D. Oregon Health Sciences University School of Medicine Pediatrics Park Nicollet Clinic HealthSystem MN

Thomas W. Hoban (left) and Scholarship Committee Chair H. Thomas Blum, M.D., (right) presented the 1999 Thomas W. and Mary Kay Hoban Scholarships to: Kim DeRosier, Eric Nielsen, Lora Taylor and (not pictured) Kristine Rhodes.

John P. Loftus, M.D. Mayo Medical School General Surgery Surgical Consultants, P.A. Adam T. Lottick, M.D. Washington University School of Medicine Internal Medicine Minnesota Heart Clinic

New Members HMS welcomes these new members to the Society as of November 17, 1999. Schools listed indicate the institution where the medical degree was received.

William H. Fabian, M.D. University of Minnesota Medical School Internal Medicine/Cardiovascular Disease Metropolitan Cardiology Consultants

Patricia Adam, M.D. University of Virginia Family Practice University Family Physicians-Smiley’s Clinic

Lucia A. Garino, M.D. University of Turin, Faculty of Medicine & Surgery Internal Medicine Hubert H. Humphrey Cancer Center

Kathrine P. Postiglione, M.D. University of Minnesota Medical School Anatomic & Clinical Pathology Fairview Southdale Hospital

Mark John Austin M.D. University of Minnesota Medical School Radiology Minneapolis Radiology Associates,Ltd.

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

Julie C. Reddan M.D. University of Minnesota Medical School Otolaryngology Ear, Nose & Throat Specialty Care

Jonathan J. Bates, M.D. University of Iowa College of Medicine Family Practice Columbia Park Medical Group-Brooklyn Park

Brian H. Ip, M.D. The London Hospital Medical College Internal Medicine/Cardiovascular Disease Minnesota Heart Clinic

Franz Josef Reisdorf, M.D. Univerity of Minnesota Medical School Cardiovascular Disease St. Paul Heart Clinic, P.A.

Julie A. Braunscheidel, M.D. University of Chicago-Pritzker School of Medicine OB/GYN Mork Clinic

Lisa R. Irvin, M.D. University of Minnesota Medical School Pediatrics Partners in Pediatrics, Ltd.

Gail M. Schauer, M.D. Temple University School of Medicine Anatomic Pathology & Pediatric Pathology Dept. of Pathology Children’s Healthcare-Mpls.

30

January/February 2000

MetroDoctors

Patrick J. O’Brien M.D. University of Minnesota Medical School Radiology Imaging Associates, P.A.

The Journal of the Hennepin and Ramsey Medical Societies

Norman B. Ratliff, M.D. University of Minnesota Medical School Internal Medicine/Cardiovascular Disease Minneapolis Cardiology

Chuen Yin Tang, M.D. College of Medicine, University of Lagos Cardiovascular Disease Minneapolis Cardiology Associates

Peter W. Waldusky, M.D. University of Minnesota Medical School Internal Medicine Hennepin County Medical Center

William C. Whisler, M.D. University of Iowa College of Medicine Family Practice Univ. Family Physicians-North Memorial Clinic

Student

Shaista K. Zareef, M.D. McGill University Family Practice Allina Medical Group-Coon Rapids Medical Center

Resident Peter M. Abadir, M.D. Al Fatch University Internal Medicine James George Capes M.D. University of Illinois College of Medicine at Peoria Pediatrics Fairview-University Medical Center Krisa K. Christian, M.D. University of Minnesota Medical School Internal Medicine Hennepin County Medical Center William Scott Hays M.D. University of New Mexico School of Medicine General Surgery Fairview-University Medical Center Tun Jie M.D. State University of New York Downstate College of Medicine Brooklyn Surgery Fairview-University Medical Center Arthur Hong Kim, M.D. Korea University College of Medicine Surgery Northfield Hospital Mitchell N. Palmer, M.D. University of Minnesota Medical School Emergency Medicine Emergency Physicians

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(from the University of Minnesota)

Todd Allan Anderson Benjamin John Baechler Andrew John Barnes Mandi Lynn Beman Melena Dawn Bellin Joshua Alan Bodie Christopher S. Boehlke Jenni L. Bradley Abram Hans Burgher Christina H. Bustin de Jong Annelisa May Carlson Nicole Schartner Christian Molly Klarre Christianson Bruce Gerald Cornelius Melissa Ann Danielson Teague A. Dombeck Paul Englund Drawz Karla Kathleen Dunning Erik S. Eckman Barbara Ercole Milan Elmer Folkers, III Elizabeth A. Frankman Ethan Michael Fruechte Scott Joseph Greenley Shawn Spencer Groth Travis William Groth Eric Joseph Hazen Tonya M. Henninger Jesse Lenhardt Hennum Christine Beth Hills Jennifer Erin Hirshfeld Joleen Marie Hubbard Emily J. Irwin Bradford Victor Johnson Anne Marjorie Keating Adam S. Kim Thomas Y. Kim Kyle Eugene Kingsley Mark James Macedon Amelia Mari Merz Nissrine A. Nakib Emuejevoke Joseph Okah Jonathan Cooper Pohland Bryan David Post Scott P. Prawer Minhuey Chen Ryan Amy Marie Sandnas Thomas C. Sanneman

The Journal of the Hennepin and Ramsey Medical Societies

Robert Edward Schwartz Melissa Marie Seibel Geoffrey John Service James Thomas Steen Jessica Yvette Taylor Jennifer Lynn Veal Joseph Clinton Wahlberg Stephanie Marie Walters Mark Andrew Weisbrod Tonya Renee Wickre Scott David Wissink Ted Robert Wissink Angus Brennan Worthing

Hennepin Medical Society

William D. Sypura M.D. University of Illinois College of Medicine Family Practice Columbia Park Medical Group-Andover

Transfer into HMS Kenneth P. Batts, M.D. Wayne State University School of Medicine Pathology Hospital Pathology Associates, P.A. Thomas C. Tunberg, M.D. University of Minnesota Medical School General Surgery Columbia Park Medical Group Gene G. Winkelmann, M.D. University of Minnesota Medical School Anesthesiology Buffalo Hospital Annette Zwick, M.D. Case Western Reserve University School of Medicine Anesthesiology Midwest Anesthesiologists, P.A.

Student Transfer into HMS Jason Beckermann Matthew G. Bertram Vu The Ho Joel V. Oberstar Sarah B. Schmitz Scott A. Sundby âœŚ

In Memoriam FREDERIC F. WIPPERMANN, M.D, 87,

died November 26. He earned his medical degree at the University of Minnesota Medical School. An ophthalmologist, he was in private practice in Minneapolis for 52 years. During his career, Dr. Wippermann was a consultant for the Minneapolis Society of the Blind-Low Vision Unit; an Associate Clinical Professor at the University of Minnesota; and an ophthalmological consultant for the state of Minnesota. âœŚ January/February 2000

31

HMS ALLIANCE NEWS REBECCA S. FINNE

O

HENNEPIN MEDICAL SOCIETY Alliance

has had a very busy fall. Both Child Health Month and SAVE (Stop America’s Violence Everywhere) are recognized during the month of October. HMSA joined with the MMA Alliance for “You are Gloved” by collecting and distributing new mittens and gloves to the Leech Lake and Grand Portage Reservation Elementary Schools. HMSA recognized a need locally and thus decided to expand this project for children at Banneker Elementary School of Minneapolis. It is our hope that these gloves convey a subtle message to the children that they have choices regarding violence (that hands are not for hitting) and that someone cares about them.

Also, during October, HMSA sponsored a joint event with our Ramsey County neighbors which included a tour of the newly opened Crisis Nursery in Golden Valley, lunch at the Golden Valley Country Club and a delightful presentation by author and illustrator of children’s books, Barbara Knutson. The Crisis Nursery facility was most impressive both in structure and organization and will be an area that the Alliance will continue to support.

November was a month of planning and behind the scenes work. A request was issued and our members responded most generously with contributions to the AMA Foundation. By supporting the Foundation, the Alliance works in partnership with the AMA to raise money in support of medical schools across the country.

The Alliance has worked steadily over the years with various fund-raising efforts and fully appreciates the need to be of help in educating tomorrow’s doctors.

On Sunday, November 21 the Alliance participated in a Magical Evening of Giving at Southdale Mall. We are most grateful to the Hennepin Medical Foundation for designating that the proceeds from this event go to the HIV/ AIDS Folder. We were able to sell almost $2,000 in advance tickets besides helping with ticket sales that night. Thank-you to the Hennepin Medical Foundation and to all who bought these tickets so generously in support of our folder.

32

January/February 2000

The Alliance is so proud of the HIV/AIDS Education folder, now in its fourth year. During 1998 the folder was offered at no cost to 800 public middle schools within Minnesota.

The response to this project was beyond all expectations and over 70,000 HIV/AIDS Education Folders were ordered and distributed to 160 schools in the state. This year, 80,000 folders were printed; distribution began in September and later orders continue to be filled on a weekly basis. The folder supports abstinence based preventative health education and engages teenage citizens of our community in a dialogue about responsibility for their bodies and their relationships. This year’s folder has updated phone numbers and added information regarding Hepatitis C. We are told that it costs an estimated $119,000 to care for one person diagnosed with HIV until death with AIDS. If this folder (22 cents each) saves just one young person from this fate, it will pay for itself many times over!

Our goal with this folder is that it will help young students make educated choices so they can develop and maintain healthy, active lives.

The Holiday Tea and Silent Auction on Friday, December 10, was the highlight of our December activities. A special thank-you is extended to Sue Christiansen who very graciously shared her home for this most popular event.

The Silent Auction was chaired by Trish Vaurio and Kathy Larson and we are most grateful to them and all who donated and purchased items for this fun auction. Thanks, also, to Jan Kleven and Mary Anderson who planned and organized the food treats. All Silent Auction proceeds are used to support Body Works.

The Alliance is a very active and dedicated organization that does much to impact the community. We are proud of our accomplishments and cherish our friendships. We welcome anyone who is a physician spouse or partner to become involved and help support our various volunteer opportunities. Upcoming events to watch for are Day at the Marsh (January 12), Body Works 2000 (February 28 - March 3) and the North Central Meeting at the Double Tree MetroDoctors

Hotel, Mall of America (February 25 - 27). For more information, you may contact the HMS office (612) 623-2881. ✦

President’s Message (Continued from page 29)

As we enter the next millennium, it is my hope that healthcare stakeholders can look beyond their individual differences and learn to work together for the betterment of all patients and for the betterment of society. We are all on this earth together for finite lifetimes. Physicians have chosen to spend their time caring for patients. We want what is best for our patients, and we often have made personal sacrifices in pursuit of that goal. Who is in a better position than physicians caring for patients to see the possibilities for improving our healthcare system?

Working together we can accomplish much. What better time has there been to join with fellow physicians advocating first for our patients than at the dawn of a new millennium?

If not us, who?

If not now, when? ✦

The Journal of the Hennepin and Ramsey Medical Societies

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