May/June 2000

Doctors MetroDoctors

Physicians Responding to Community Health Needs Timothy Rumsey, M.D. cares for the homeless at Dorothy Day Center

Doctors MetroDoctors THE JOURNAL OF THE HENNEPIN AND RAMSEY MEDICAL SOCIETIES

MetroDoctors (ISSN 1526-4262) is published bimonthly by the Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. To promote their objectives and services, the Hennepin and Ramsey Medical Societies print information in MetroDoctors regarding activities and interests of the societies. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of HMS or RMS. Send letters and other materials for consideration to MetroDoctors, Hennepin and Ramsey Medical Societies, 3433 Broadway Street NE, Broadway Place East, Suite 325, Minneapolis, MN 554131761. E-mail: nbauer@mnmed.org. For advertising rates and space reservations, contact Dustin J. Rossow, 4200 Parklawn Ave., #103, Edina, MN 55435; phone: (612) 8313280; fax: (612) 831-3260; e-mail: djrossow@aol.com. MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available.

CONTENTS VOLUME 2, NO. 3

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M AY / J U N E 2 0 0 0

PHYSICIAN’S SOAP BOX

Robert W. Geist, M.D.

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LETTERS

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FEATURE: COMMUNITY HEALTH

Achieving True Community Health Requires Collaboration

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COLLEAGUE INTERVIEW

William E. Jacott, M.D.

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Is a Nursing Shortage on the Way?

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Minnesota Visiting Nurse Agency Delivers Home Health Care

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The Caring Clinics Pilot Program for the Medically Uninsured

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Take a Step Inside a Community Clinic

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Hennepin Regional Poison Center Serves as Resource and Reference for Physicians

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2000 Winter Medical Conference a Success

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College Students Participate in Community Internship Program RAMSEY MEDICAL SOCIETY

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President’s Message RMS Update/In Memoriam Caring Hearts for the Homeless 2000 Supply Drive RMS Alliance HENNEPIN MEDICAL SOCIETY

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HMS In Action

May/June 2000

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

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New Members In Memoriam HMS Alliance Physicians Responding to Community Health Needs Timothy Rumsey, M.D. cares for the homeless at Dorothy Day Center

On the cover: Achieving true community health requires a collaborative effort. (Photo by Roger Johnson, RMS CEO.)

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PHYSICIAN'S SOAP BOX

Fiduciary Duty and Incentive Payments in Medical Care at the U.S. Supreme Court

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THE MOST RECENT CHAPTER affecting a fiduciary duty of physicians

to patients was when an HMO physician, Pegram, appealed a case to the U.S. Supreme Court from the U.S. 7th Circuit Court of Appeals (Herdrich v. Pegram). As the courts enter the fray, the battle heats up between the primacy of patient interests versus the interests of corporate and state policy makers in controlling the utilization of medical care by American citizens. In 1991 Cynthia Herdrich developed a painful abdominal mass. An ultra-sound of her abdomen was scheduled eight days later at the HMO’s facility 50 miles away when she could have been sent immediately to a local imaging unit and surgical consultation. In the interim her appendix ruptured and peritonitis ensued. She brought suit on two counts in Federal District Court. In the first count of malpractice, she was awarded $35,000. In the second count, she claimed that the HMO incentive arrangement of year-end bonuses caused her to be deprived of proper medical care and that the HMO/Medical Care Organization attempted to reap economic gain from this deprivation. Pegram’s HMO argued that the Federal Employee Income Security Act (ERISA) does not regulate how HMOs design their administrative payment practices such as incentive schemes and are thus shielded from legal challenge. The original Federal District Court agreed with Pegram and threw out the claim. The 7th Circuit Court of Appeals reversed the lower court and sent the claim back for trial. The 7th Circuit Court wrote that HMO financial incentives such as year-end bonuses create a conflict of interest between doctor and patient and are a potential breach of fiduciary duty under ERISA. The HMO then appealed to the U.S. Supreme Court. How did all this conflict between corporations and patients begin? In 1973 Congress and the administration adopted the HMO corporate cost control package in the belief that the profit motives of insurance corporations could better direct the spending of patients’ insurance dollars than could American citizens themselves. Thus, congress endowed HMO insurance corporations with the extraordinary power to decide whether or not use of the benefits insured was necessary, and what, when, and where services could be performed. Thus was contrived a financial conflict of interest to contain the public’s utilization of care. Since early in the 1900s and outside the umbrella of HMO law, state statutes have prohibited a financial conflict of interest between a professional medical business and patient by making referral fee inducements illegal; the interests of the patient always come first and the interests of the professional as trustee are secondary. The professions are unlike commercial business where the interests of the corporation owners come first and those of the customer are second. In either realm, “incentives” paid physicians for the volume of referrals are generically the same whether an illegal split fee

or a legal HMO “bonus reward.” These “incentives” break the fiduciary relationship with patients, because “incentives,” whether for more or fewer services, are always paid for the benefit of the person or corporation paying the inducement. All these statutes, legal interpretations, definitions, and motivations of the players may seem confusing. That’s the way it sounded during oral arguments before the Supreme Court on February 23. The Justices were being asked to decide whether or not this HMO should be held to be a fiduciary when paying bonuses, and if so, a jury should decide whether the HMO properly performed its fiduciary duty under the ERISA law. Yet the Justices seemed to go on a tangent in following conventional socioeconomic rationalizations concerning the economic necessity of HMO cost control measures. It was as if the fiduciary issue for patient protection was secondary. Only Justice Breyer wondered if the HMO Act of 1973 was in conflict with ERISA of 1974. Put simply, the Herdrich case asks which ethic should win. Should patients have someone with a legal fiduciary duty to always hold their interests first? Or should precedence be given to public policy where the ends of cost control justify the means of keeping HMO administrative decisions beyond the reach of ERISA fiduciary clauses regarding the HMO population of enrollees? What are the implications for doctors and their patients regardless of the nature of the Supreme Court decision? The lack of HMO physician statutory fiduciary duty has the potential for serious legal and business liability consequences. First, lawsuits may become a larger rather than a smaller problem. For example, incentive bonuses for denial and/or delay of care may suggest to a jury that there has been bad faith behavior by the physician. Second, HMO physicians bear the sole legal responsibility for decisions and guidelines made by the corporation. Jacobson and Ponfrest, from the University of Michigan, point out that this leaves physicians in the untenable position of being entirely responsible for cost containment policies over which they may have little control. Third, physicians without a statutory fiduciary duty can easily be coerced into global risk contracts (as in “take risk or take a walk”) when a significant portion of their patient base is from one of a few remaining huge HMOs. Many at risk California clinics have already gone broke and it is estimated that 10 percent more will be bankrupt this next year. Below the surface are the remarkable statistics that only 17 percent of physicians feel that HMO incentive arrangements to limit services are ethically acceptable and 50 percent feel these incentives have eroded the trust of their patients. The overwhelming power of the politically created HMO system and the rationale of population ethics mobilized for its existence by corporate and state policy makers has no real countervailing power. A statutory, patient-focused, fiduciary ethic for HMO physicians would be a small yet

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LETTERS

Dear Dr. Moravec: Your writing in MetroDoctors about DTC pharmaceutical advertising is both informative and balanced. As I indicated in a prior piece in the North Memorial Medical Staff News, I am less tolerant of this practice. Perhaps that is the pathologist in me. To me, the gist of the problem stems from its basic motivation. Drug companies are in business to make a profit. If they sell more of a given prescription drug, they increase profits. The initial cost of development and marketing are relatively fixed. Volumes sold above these fixed costs are gravy. I have nothing against drug companies making legitimate profits. However, when pharmaceutical volume has an adverse effect on health care, I draw the line. The notion that health care is improved by consuming more drugs is foreign to me. Anything increasing

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consumption is a negative factor. That is the very reason why our (North Memorial) CME program will not use pharmaceutical industry support. The notion that DTC advertising is beneficial to patients because it increases consumer knowledge is very debatable. The advertising is simplistic, misleading, and does not tell the whole story. Even physicians are lacking the whole story, despite the fact that their patients pay them to do so. The philosophy of an informed consumer is unproven, particularly as it pertains to health care. If consumers were truly informed, they would spend less time visiting chiropractors and consuming herbal supplements from health food and drug stores. Even sophisticated and affluent consumers fall prey to the misinformation of charlatans and quacks. If I had my way, I would curtail or even eliminate pharmaceutical company advertising to physicians. Physicians should get their drug prescribing information from the legitimate medical literature, their peers, and a variety of objective publications. I would not include practice experience as a legitimate source of knowledge; testimonials and anecdotes are hardly reliable information.

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In any event, your writing is a valuable contribution, particularly because it is balanced and complete. Keep up the good work. Sincerely yours, Seymour Handler, M.D. ✦

Physician’s Soapbox (Continued from page 2)

important weight added to the balance in the interests of patients and their physicians. Whatever the Court decides, the overwhelming power of HMOs will continue to generate a battleground. Meanwhile, a statutory double standard exists for the fiduciary relationship between patient and physician depending on the patient’s insurance policy. Organized medicine needs to petition our legislators at State and Congressional levels to make incentive payments for the volume of referrals illegal for all providers. A statutory fiduciary status for physicians gives protection to the primacy of patient interests in medical care. ✦ References are on file and available upon request. Robert W. Geist, M.D., is a retired urologist, residing in North Oaks, MN.

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FEATURE STORY

Achieving Real Community Health Requires the Collaboration of all

Community Health Pieces of the Health Care System as Well as Their Target Populations

A Complicating the challenges of community health is the more basic question, just what is a community?

A 1995 MENINGITIS OUTBREAK IN MANKATO kills a healthy, young student and strikes six others. Twenty-seven cases of measles in the Twin Cities in 1996 are eventually narrowed down to an unvaccinated community in St. Paul. A skyrocketing murder rate in the early 1990s labels Minneapolis “Murderapolis.” Salmonella in a popular brand of ice cream affects hundreds of persons across Minnesota. School gun violence and domestic abuse arrive as new “ills” of society. The resurgence of TB and the challenge of Hepatitis C and AIDS puts a new face on infectious disease. Toxic spills in a south metro community bring cancer fears. The ever-increasing cultural diversity created by thousands of new Minnesotans enriches as well as challenges every health care provider. The medically uninsured rate of Twin Cities residents is twice the state average. Public health, population based health care, community health. Call it what you will, the health of communities in this country in 2000 is more challenging and complex than ever before. Which then begs these questions: Just what is community health and who is responsible for it? What happens to community health and public health services in the era of managed care? What are communities themselves doing about their collective health? And should individual health care providers, hospitals and clinics be providing population based care? What is Community Health? The Minnesota Hospital and Healthcare Partnership defines community health as the promotion of well being in a defined group or population. Public health agencies enumerate their mission of promoting health and preventing disease through epidemiology, protection from environmental hazards, injury prevention, encouraging healthy behaviors, responding to disasters and assisting communities in recovery, and by assuring the quality and accessibility of health services. All well and good. But with the litany of what ails our country and our state and our Twin Cities, where do we begin? Is it even possible to address real population based issues as our health care system is being challenged by severe fiscal constraints and the public health system faces government downsizing and privatization? What Is Community? Complicating the challenges of community health is the more basic question, just what is a community? During the first 50 years of the American 20th century, there was no doubt about it, community was the neighborhood. The place where you could walk to

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work, worship, play and shop. Throw in a doctor’s office and a school and there you have it. A real, geographic community. Today, community is a popular buzzword. Everything is “community.” Community policing, community building, community based. In reality, we haven’t really figured out yet just what is a community in the 21st century. What we do have is subsets of places where people live, work, go to religious services or the doctor, go to school and shop; most often none of which coincide geographically. You can even add a “health insurance community” where patients are directed to a clinic and hospital within approximate geographic boundaries. Then there is the Internet which enables people all over the world to communicate regularly on any subject—health not withstanding. America as a whole, let alone the health care industry, still may be longing for the old neighborhood which may never be again. Community Health and Public Health in the Era of Managed Care Public health departments know their communities, usually bounded by city or county lines, inside and out. They do sophisticated community assessments that tease out numbers, genders, age, race, socio-economic status, and health and welfare concerns of everybody within those boundaries. They identify health promotion and disease/injury prevention goals and measure that too. Health departments are not about to be replaced. Who would look at the health of our waters and air? Who would mobilize for TBs resurgence; who would look after the homeless or persons without insurance? Who else can track the incidence of neighborhood violence? Managed care plans are poised to do a good job monitoring their members’ health, but a measles outbreak still demands the epidemiologic machinery of the Minnesota Health Department. It does not appear that public health services compete with managed care or vice versa. Blue Cross Blue Shield, state and local health departments, and managed care giants, like Allina and HealthPartners, have collaborated on tobacco cessation and violence prevention initiatives. Regions Hospital, (once Ancker and then Ramsey County) is essentially a “private,”

Dr. Rumsey administers to a patient.

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(Continued from page 7)

HealthPartners’ institution having once been the “city-county hospital.” The HMO leases the facility from Ramsey County with the proviso of continuing the county hospital tradition of caring for the indigent. Allina Health System spent eight million dollars in 1996 on community health programs with no promise of any financial return doing the sorts of things that one would think government should be funding: opening a school clinic in a disadvantaged neighborhood, training paramedics to do recreational safety training for kids and lobbying for tobacco taxes and gun control. Allina CEO, Gordon Sprenger, sees aggressive community health as the only way to stay in business. “Every social problem becomes an expensive medical problem” Sprenger says, “and not confronting these issues could be far more expensive.” While Sprenger’s remarks embrace true community health values, the cold reality of market forces can compromise broad-based population needs. A CDC study published in JAMA in 1996 was concerned that in the short run, capitation and managed care could possibly hurt preventive efforts more than help them. Current demographic diversity with greater variation of ethnic origins combined with the so called “new generation” of diseases, which includes environmental hazards, resistant and reappearing infections, and complicated psycho-social pathology will only enlarge the demand for public health services. Nevertheless, the CDC has reported that funding for the U.S. Public Health System has essentially been stagnant in the early 1990s. This is not the time to write off state and local health departments as obsolete just as the 21st century brings revisited as well as daunting new health challenges. 8

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The problems of access, quality and cost control have not yet been solved by managed competition. Regardless of the direction of managed care, a strong public health infrastructure will be needed to address the challenges from control of infectious disease to the regulation of the quality of resources such as food and water. A whole smorgasbord of social, economic, and epidemiologic developments still make the case for a strong public health system to address issues that will remain beyond the scope of HMOs and health plans. In an ideal world, the resources of today’s managed health care plans, their member data collection, and penetration into the health care market make for ideal collaborations with local and state health departments who have over 100 years of real-life experience in community health. Communities and Community Health Just who is responsible for the health of a community? Managed care takes care of its members. Public health departments take care of their geographic regions. What about the communities themselves? Minnesota has a number of aggressive advocates for the health of its people. The Children’s Defense Fund educates the public and lobbies for the rights of children. The Urban Coalition does the same for minority health issues. The Metropolitan Health Care Council, a trade association of 30 health care institutions from the seven county metro area, has an impressive database tracking hospital admissions, ER use, public safety, prenatal data and mortality statistics as well as a host of very specific regional demographic data. The Wilder Foundation has outstanding statistics on local populations of need.

broad goals for the health of our country: 1) increase the healthy life span of Americans; 2) reduce health disparities among Americans; and 3) achieve access to preventative services for all Americans. Healthy People 2000 spawned literally thousands of local hospital, health plan, and grass-roots initiatives across the nation based on those three broad objectives and 300 other measurable outcomes. Blue Cross Blue Shield promoted Healthy People 2000 objectives and tracked the progress of its own health plan members. The University of Minnesota, local hospitals and health departments, and foundation seed money helped neighborhoods form grass-roots level coalitions of citizens, service providers and health care workers who conducted their own information gathering and set goals that they, themselves, formulated and followed. The Frogtown Community Partnership for a Healthy Environment (St. Paul), Healthy Powderhorn (Minneapolis), and the West 7th Community Partnership (St. Paul) are but three outstanding examples of those real life coalitions working house to house, neighbor to neighbor to truly look at the health of the “village.”

The Communities Themselves Healthy People 2000, a 1990 U.S. Public Health Service initiative, presented three

Providers, Clinics/Hospitals and Community Health Traditionally, America’s medical perspective has focused on individual patients while the public health perspective has focused on populations. What would happen if the twain should meet? Today’s health care providers are becoming more holistic in the true sense of the word. Lifestyle and behavioral counsel, domestic abuse recognition, cultural sensitivity and attention to access are now included in at least primary care providers’ black bags. But these are issues that cannot be faced without an integrated clinic team of social workers and mental health providers as well as a working

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knowledge of community resources. A model of population based health care delivery has developed over the past 20 years known as Community Oriented Primary Care (COPC). COPC is just what it says: population based health care in a primary care setting done in partnership with community. Far from idealistic theory, working models of COPC whether labeled as such or not, exist throughout the Twin Cities in the Community Clinic Consortium network, primary care residency training sites, our two “county” hospitals, and at least one HMO sponsored clinic in St. Paul. COPC is a realistic, holistic approach to health care delivery that looks beyond the exam room to the patient’s needs in housing, employment, education, personal safety, and mental health in concert with other service providers and neighborhood resources. COPC works most dramatically with the underserved, but can be extended to any population. While “alternative medicine” is a current favorite child among medical care reformists, COPC may well offer an approach to true health care delivery reform.

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Environmental safety. The City of St. Paul recently tore down an otherwise sound structure that became a “sick building,” allegedly responsible for a number of ills of employees within. So much so that it was felt necessary to tear the building down rather than fix what ailed it. Domestic abuse/gun violence. These “new diseases” are frightening conditions that cannot be ignored. They are health problems equal to cardiovascular disease, cancer and infectious disease. Infections. The resurgence of old infections (TB) and the emergence of new ones (Hepatitis C, AIDS). Mental Health. Pervasive mental health issues including access to care, housing and treatment.

When all is said and done, there is plenty of work for all of us in health care to do for the health of our communities. Health plans, managed care clinics, hospitals, public health departments, providers, communities themselves. Real community health (realistic holistic) can only be achieved with the collaboration of all pieces of the health care system as well as their target populations. ✦ References are on file and are available upon request. Timothy J. Rumsey, M.D., is the lead physician at United Family Health Center, St. Paul, Minnesota and member of the St. Paul Homeless Health Care Team, providing three hours of clinic a week at the Dorothy Day Shelter.

The Challenges Need we hear the litany again: • Access. While Minnesota’s 6 percent uninsured rate is second only to Hawaii (where no one else can get to!), the 12 percent uninsured rate of the Twin Cities more closely approximates the national average of 15 percent. • Cultural Diversity. Minnesota has the largest Somali population in the U.S. Hmong ranks behind English as the most spoken language in Minneapolis and St. Paul schools. Six to seven thousand immigrants from the former Soviet Union now reside in Minnesota, most in the Twin Cities.

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COLLEAGUE INTERVIEW

William E. Jacott, 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. In this issue, interview questions were asked by: Drs. Jane E. Flad, Robert Beck, Paul Sanders, Jamie Santilli, Diane Dahl, Alfred Michael and Marc Swiontkowski. Dr. Jacott has served as Associate Professor and Head, Department of Family Practice and Community Health, University of Minnesota School of Medicine since 1995 and is currently Chair of the Joint Commission on Accreditation of Healthcare Organizations. He was a Trustee to the American Medical Association from 1989-98.

Q A

What are some of the ways outside of their own practices that physicians can work to ensure the health of the community? For years we have talked about care for a population as contrasted with care for the individual, but the reality is that not much has changed. We physicians can make an impact by volunteering in community clinics, speaking out at county boards or the legislature, providing volunteer care in a number of areas like summer camps, athletic events, and youth activities. Finally, we can be promoters of health by speaking at service clubs and school events. We must stand up for important issues like sex education in the schools and genetically altered foods.

Do you feel health fairs and mailings are valuable in community health? These have become a common activity but there’s little data to suggest these events have altered behavior or changed the health of the community. Getting people sensitized about their health has been one accomplishment.

Describe how the medical school is training physicians in community health. In my view, there’s great variability. The students who elect the Rural Physician Associate Program (RPAP) or Urban Community Ambulatory Medicine (UCAM) receive excellent exposure to community health. Others are involved in electives, but the great majority may achieve exposure through individual rotations. The school is initiating a two year review of the total curriculum and I suspect community health will receive an increased emphasis.

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Do you have a viable solution for funding the training of primary care physicians? There appears to be a primary care backlash among some students and educators. At the same time, the medical school is attempting to regain its top 20 standing in research primarily with the National Institute of Health (NIH). As a result, primary care funding has taken a back seat. We are a large enough school to maintain an adequate blend of primary care and research to serve all the needs of our public and academic communities. The funding of primary care through Health Research and Services Administration (HRSA) training grants, state funds, and clinical revenue remains an important priority.

What is your vision for medical school education in the next 20 years. Medical education must be responsive to the changing needs and values of society. We must eliminate/set aside many of the traditional methods and content of medical education and respond to an ever changing menu of health care delivery. Medical school education will be influenced by many factors including new technology, an aging population, global epidemics, human genetics, life styles, and socio-economics. I believe our current initiative to review the entire curriculum of the medical school will be responsive to those needs. Along with a review of content, we need to be progressive in developing new methods of teaching using new technologies and self learning.

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What are you most proud of during your time as head of the Department of Family Practice at the University of Minnesota?

Is there a need for both the JCAHO and the NCQA? Couldn’t one organization serve as the accrediting body for both institutions and health plans?

Being the head of the largest family practice department in the country has been a great honor and significant challenge. There are many areas that make me proud like our hard working and talented faculty, our residency graduates, most of whom practice in Minnesota, geriatrics, our world class Program in Human Sexuality and our significant involvement in medical student curriculum and education. As Chair of the Board, I am most proud of our HMO, UCare, which has grown to an enrollment of more than 80,000 and provides significant support for the underserved and family practice education and research.

Yes, there is a need. JCAHO has eight accreditation programs including hospitals and nursing homes, whereas NCQA has basically one program which accredits health plans.

How has your participation in organized medicine added to your professional life? In many ways, my participation has enriched my professional life and made me a more effective and productive practitioner, leader, teacher, and administrator. It has kept me up to date with the issues impacting healthcare delivery and medical education while making friends and meeting colleagues from all over the world at all levels.

What is the relevance of membership in organized medicine? Organized medicine needs to be relevant and add value in order to maintain membership. We can’t be that to our members if our initiatives and policies are archaic, outdated, parochial, and self-serving. If we maintain that posture, our numbers will dwindle. We must find the hook to bring physicians together for common goals. In many attempts, we have not achieved that goal and been willing to change, be proactive, consolidate, collaborate, etc. Many barriers have been removed, but we have a long way to go.

What are you most proud of during your time as an AMA Trustee? There were many experiences and activities that made me proud, but most important were the people I had the pleasure to work with and meet. I am very proud of my many friendships who represent leaders and professionals from all aspects of our enterprise.

Why is accreditation of hospitals, training programs, healthsystems, nursing homes, etc. so important? In this era of accountability, public disclosure, and increased concern for quality, accreditation is essential. The Institute of Medicine report on medical errors has driven the need for evaluation of organizations and analysis of serious adverse events to center stage. No group in healthcare can avoid the public scrutiny and government oversight to evaluate quality. Accreditation can facilitate and validate that process.

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What is the future of the Academic Health Center? It is very guarded in this climate of scarce resources. Some will close, others will consolidate/merge, still others will downsize. Services need to be non-duplicative and relevant to practice. We have not been effective in measuring the healthcare workforce needs and this further complicates the planning for educational programs and numbers of health professionals. The emphasis will be on centers of excellence and the research engine will have to focus according to the needs of society.

Recent innovations in medical technology and pharmaceuticals have greatly increased the cost of health care. The aging population and the demand for the best care possible have added to these costs. Personal habits such as alcohol, drug use, tobacco, decreased exercise, and poor nutritional choices have added to preventable illness. What can the medical community do to insure the health of the community and responsible resource allocation in an era of increasing health care costs? This is not solely a medical community problem and must be addressed by all elements of society. It is very complex. If I had the answer to this one, I would run for Governor of our state.

What can be done to strengthen the relationship between primary care and non-primary care specialists? A level of trust must be established and this includes mutual respect. Parochial attitudes must be set aside and all should agree upon what is best for the patient or our students. Involvement in and by organized medicine can facilitate these behaviors. We can’t allow the number crunchers and regulators to fragment and split our profession even more.

What advice do you have to avoid burnout for the physician when he/she has been in practice for 20 years. Many of our colleagues have been captured by burnout. After 20 years of practice, a significant number of routines and habits have been solidified. We must dispel the attitude that our patients/practice can’t function without us. Being in a practice group is essential, but also, being able to prioritize family, recreation and time off is critical. Often a career change will prevent a third degree burnout, i.e., moving from full-time practice to an academic or administrative position. ✦

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Is a Nursing Shortage on the Way?

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DURING THE PAST YEAR, professional journals have queried: “Is a nursing shortage on the way?” The question surrounds us in staff meetings, conversations among colleagues in health care, and special commissions appointed to study the question. The subject of a nursing shortage has moved from deliberations and studies to a front line reality. There is a nursing shortage. In a recent report, the Minnesota Hospital and Healthcare Partnership (MHHP) reported more than 5,300 job openings in hospitals in the Twin Cities and Rochester alone, many of which are in nursing. This same statistic is mirrored in hospitals and clinics throughout the country. Throughout healthcare history, periodic nursing shortages have existed. These have been referred to as cyclic shortages, typically mapped to an increased demand for specialized nursing care. In response to these shortages, recruitment into the profession included nurse-refresher courses to prepare nurses who stopped practicing to re-enter the workforce; increasing enrollments in nursing programs; creating accelerated curricula; and offering associate-degree programs to decrease cycle time from student enrollment to practice. Foreign nurses were brought to the United States on work visas through staffing agencies that sprung up to meet the demand. We’ve been resourceful, endured, and solved the shortages. The Demand for Nursing Care Today The population in our country is growing at about 1 to 2 percent per year. The need for health care will not only remain constant, it will con-

B Y J U L I A N N E M O R AT H , RN, MS

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tinue to increase. Additionally, people are living longer than ever before, and many of our country’s seniors will continue to seek health care for aging-related conditions and chronic illnesses. In Minnesota, more than one million baby boomers will reach age 65 by 2030. Ever increasing knowledge, technology, and the pharmaceutical armament are creating cures and treatments to save and prolong lives, but also are creating medically fragile survivors, and greater risk and complexity in our care-giving systems. So, what’s different about the shortage forecasted now? It differs in two ways: 1) Many nurses currently practicing will retire in this decade; and 2) There are diminished enrollments in nursing programs and a subsequent weaker pipeline into the profession. In other words, this is not a cycle to get through and wait out. Fewer Students, Fewer Nurses When the subject of nursing shortage comes up in conversation, many point to the obvious: recruit more students, train more nurses, and repeat successful strategies from past shortages. Unfortunately, exclusively relying on these strategies isn’t enough. Demographics continue to illustrate that by the year 2008, the number of high school students in our country will begin to decrease. A presentation from the Minnesota Colleagues in Caring Collaborative indicates that the total post-secondary enrollment is not likely to surpass 1990 enrollment for the next 20 years. That’s nearly an entire “work generation” that will feel the pinch of fewer workers. With diminished enrollments specifically in nursing, this issue is compounded. Another twist to this is that nurses have employment opportunities beyond traditional care-giving arrangements — such as managed MetroDoctors

care organizations, insurance companies, and disease-management enterprises. The American Association of Colleges of Nursing (AACN) recently reported that the predicted shortages in direct-care nursing practice has generated a demand for nurses whose educational programs specifically prepare them for care management and leadership roles — away from the bedside. A Changing Workforce Another strategy used in the past was the development of creative staffing plans to reassign nurses into areas of most need. A common approach, for example, would be to recruit parttime nurses to increase their time to full-time positions. However, one economic forecast for Minnesota’s labor pool suggests that we have tapped into as many full-time workers as are available. In other words, unemployment rates remain low, so most of the working-age population currently is employed. And individuals who currently work part-time plan to remain working part-time. Consequently, the consideration of part-time nurses moving into fulltime roles is unlikely. Healthcare is faced with a nursing workforce that also is getting older; nearly 40 percent of Minnesota nurses are between ages 41 and 50. Yet fewer nurses are entering the profession to fill the impending vacancies of retirement. One solution is to allow nurses to work until they are 65 to 70 years old, but that, too, is only a small step toward remedying the problem. In examining demographics of nurses unit-by-unit in our hospital settings, we are at risk of losing entire senior staff in a given year due to retirements. This has huge implications for highly technically specialized areas, such as operating rooms and intensive care settings. Those who have received or provided care recognize the The Journal of the Hennepin and Ramsey Medical Societies

implications in the above forecasts. And the implications are alarming. A Call to Action The nursing shortage is not an issue to be resolved by the discipline of nursing alone. This is a call to action for all of us in healthcare to examine what aspects of current work activity can be streamlined or eliminated, how work can best be designed and efforts improved, how to fully engage all healthcare workers in the care process, and how environments of healthcare can instill pride, joy, meaning, and learning in work to recruit and retain the best. Critical Implications Care is becoming increasingly complex. The explosion of knowledge and technology — while powerful tools to cure and treat illness and injury — also introduce new risk and hazard. In the hospital, clinic, and community, the nurse is often the final defense against a risk reaching a patient to produce an accident or error. As complexity in healthcare continues to increase, a key resource we have depended on to create safety at the point of care is reduced. “To do no

harm” requires importing new knowledge and skills to design safety into our inherently riskprone systems and processes of care. This includes decision-support; automatic and redundant checking systems, such as bar-coding; explicit protocols; checklists; and meticulous systems of teamwork and communication. Nurturing, caring, and the maintenance of a therapeutic healing environment are aspects of nursing care less visible but related to a positive experience of care and positive clinical outcome. Nursing has valued, studied, and embraced care in practice. Other disciplines and individuals have great capacity, often untapped, to create an environment of care and healing. Most importantly, the family as a partner in the care-giving relationship is an under-developed resource. Inviting family members into the caregiving relationship through exchange of information, participation in decision-making, and skill transfer can further enhance their ability to contribute and to experience the reward and privilege of competently helping another person. Skilled technical nursing care can be extended through appropriate and judicious delegation of aspects of care. This is an area of leg-

endary professional conflicts regarding scope of practice and jurisdictional issues. It calls for clearly focusing on the essence of the profession and leaning into changes that may be required to best serve those who need care in the midst of the changing circumstances we face. The nursing profession is aging. This raises questions of physical requirements of long hours, shift work, intense pace, lifting, prolonged standing, alertness. Implications for employers to support the nurses in the clinical setting include increased applications of robotics, motorized transport and lifts, scheduling and staffing innovations. What Can Physicians Do? Effective collaborative relations are an essential ingredient to create pride, joy, meaning and learning in work. An effective collaborative relationship between physicians and nurses is a professional obligation for both. Demonstration of respect and recognition of contribution is a recurring theme that nurses say they value. This includes interactions of mutuality, a respectful (Continued on page 14)

Hospital Bed Availability in the Twin Cities

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he Minnesota Medical Association responded to increasing questions and concerns about the availability of hospital beds in the Twin Cities by forming a task force to examine the issue in-depth. The task force was comprised of a working group of physicians and administrators; all with day-to-day, practical experience in dealing with acute care hospital bed availability. The task force met in 1998 and 1999 and issued their report in July 1999. The focus of the task force was twofold: first, it examined, through data review and informal surveys, the availability of acute care beds in the metropolitan area and compared these findings to the availability of beds in other states and regions; second, it examined the issue of emergency preparedness in the metropolitan area in the case of a mass disaster requiring large-scale access to medical services. Policy recommendations of the task force centered around improved data collection by the appropriate state regulatory bodies and a higher level of preparedness planning for potential disasters requiring large-scale access to medical care. The task force believed that a review of the efficacy of the state’s hospital bed construction moratorium law is warranted along with examination of potential alternatives to the law. The task force urged stakeholders, including

MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

consumers, hospital management, regulatory agencies, physicians and planners to form a broad-based coalition to review bed capacity issues before critical bed shortages occur. Since the task force report, there has been interest in the topic of hospital bed capacity on the part of the Ventura Administration, particularly within the Department of Health. It is anticipated that the Commissioner of Health, Jan Malcolm, will convene a study group to review statewide issues related to hospital beds and staffing. The MMA remains involved in this issue and will take part in this work group to the fullest extent possible. Additionally, the MMA continues to study the issue of emergency preparedness and has recently been involved with the Minnesota Department of Health’s flu pandemic work group and also took part in a national conference on local response planning in the event of an emergency or civic disaster. The conference was sponsored by the American Medical Association and the U.S. Department of Defense. Look for more updated information on these topics in upcoming MMA publications. For further information on this topic, contact MMA Legal Counsel Christina Rich at (612) 378-1875 or for a copy of the complete report of the task force, go to www.mnmed.org and search under News and Publications. ✦

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(Continued from page 13)

harassment-free work environment, clear communications, and coordination of action. Physicians practice in the context of a care team. The nurse is a pivotal and essential member. Failure to acknowledge this diminishes the opportunity for full contribution by all involved and the patient misses the opportunity for optimal care. Physicians carry enormous credibility and influence in our society. Therefore, they can help by talking to people about considering nursing as a profession or second career. We can encourage the field as worthy of exploration and represent the practice of nursing as intellectually and interpersonally challenging, spiritually satisfying, and esteemed work with mobility and many options. What is Being Done? Nationally, organizations like the American Nursing Association, American Society of Healthcare Human Resources Administration

at the American Healthcare Association, and the American Association of Colleges in Nursing are developing strategies. Locally, professional nursing organizations and organizations like Minnesota Hospital and Healthcare Partnership already are taking steps to attract a broader audience to health care professions. Recruiting materials are being produced in multiple languages to draw in more diverse candidates. Training grants and scholarships are being awarded to help people find jobs in healthrelated fields. Healthcare recruiters are at job fairs and using the Internet to appeal to a wider national audience. Partnerships are being strengthened between health care facilities and schools. Mentorship programs, providing one-on-one interaction between trained professionals and students, are increasing. Nurse executives, managers, and clinical nurses are exploring ways to enhance work environments. Nurses themselves are examining their roles in inviting, preparing, and mentoring the next generation of nurses to be successful

and the current generation to remain in practice. While recently talking with a nursing colleague, I learned the following. Her daughter, a recent university graduate with a degree in mathematics, made an appointment with a nursing admissions counselor to explore entering into the nursing profession. She was drawn to the profession. The counselor told her she was too intelligent to be a nurse and she was dissuaded from her interest. The profession lost a potential nurse. Stereotypes persist around gender, scholarship, and professional self-determination. Each day, every interaction is an opportunity to break through old molds that threaten a pillar in healthcare. The shortage is real, and the time is now for us to do our part within our spheres of influence. ✦ References are on file and are available upon request. Julianne Morath, RN, MS, is the chief operating officer for Children’s Hospitals and Clinics.

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Products and Services Offered to RMS Members by RCMS, Inc. For more information call 612-362-3704. 14

May/June 2000

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The Journal of the Hennepin and Ramsey Medical Societies

Minnesota Visiting Nurse Agency Delivers Home Health Care

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MINNESOTA VISITING NURSE Agency (MVNA) delivers Public Health/Family Health Care services and traditional Home Health Care services to clients and their families in the Twin Cities area. As Public Health/Home Health Care nurses, we have the opportunity and challenge to complement medical services from the hospital, clinic, and nursing home setting. Our clients are generally considered very vulnerable and at “high risk” for abuse and neglect due to combinations of multiple barriers; low-income, different spoken language, mental illness, limited cognitive functioning, low level emotional stability, chaotic and/or unsafe living conditions, substance abuse, isolated/without adequate social supports, frequent health and/or social crises due to an unstable family system, disease process/condition. As a home visiting nurse, we rely upon a multitude of community resources and close communications with the primary physician in order to promote the health and welfare of the client/family. Noted below, are two client situations with successful outcomes, which involved extensive interactions with the home visiting nurse, physician and community resources.

Case #1: “Amani,” a homeless 25-year-old Somali woman, pregnant in her second trimester, was referred to MVNA in August 1999 due to hyperemesis. Amani had no immediate family members living in Minnesota. The Public Health Nurse, Sue, made her first visit at Amani’s “friend’s” home. This apartment (#1) was small, clean and another couple lived there with three young children. Sue began teaching Amani preliminary steps to manage IV hydration, via a peripheral access, daily in the home. This visit and all others, required a Somali interpreter to be present BY MARY ANN BLADE C h i e f E x e c u t i v e O f f i c e r, M V N A

MetroDoctors

throughout the nursing intervention process. Sue made her second visit to Amani at a different residence (apartment #2). Unfortunately, Amani moved out of this apartment shortly thereafter due to an “emergency situation” of the occupants. Sue made her third home visit to apartment (#3) occupied by an adult Somalian couple, an infant, another young child and often times the presence of four-six other Somali men and women. Amani’s hyperemesis, nausea and vomiting continued into September. Despite regular IV hydration, it was necessary to institute Total Parenteral Nutrition, 12 hours/day via a P.I.C. line. Amani proved to be a reluctant learner, however, Sue persevered and was able to successfully teach Amani to self-manage her T.P.N. therapy from 10 a.m.-10 p.m. daily. Amani improved, gained weight, and started eating the last few weeks of her pregnancy. All of Sue’s nursing interventions required extensive communications with the primary physician, pharmacist and IV supply company. Our family health aide, Oum (one of our best Hmong employees!) assisted Amani in completing subsidized housing applications, procuring basic infant supplies and teaching basic parenting skills related to newborn care. An elated Amani called Sue from the hospital after delivering a 6 lb. daughter at 38 weeks gestation in early January. Amani’s daughter remained hospitalized for three additional days due to an elevated bilirubin level. After hospital discharge, Sue returned to apartment #2 to resume home visits for the new postpartum mom and newborn. Sue initiated basic postpartum checks, teaching, monitoring breast-feeding results, and newborn assessment. Case #2: The home health care visiting nurse likewise has the opportunity to interface with the adult cli-

The Journal of the Hennepin and Ramsey Medical Societies

ents/families of many cultures in the Twin Cities area. One such scenario occurred in October 1999, when a 59-year-old, low income Hmong woman was referred to MVNA. Terry, the primary nurse case manager, was to provide professional nursing interventions for “Mou,” newly diagnosed with insulin-dependent diabetes, cirrhosis of the liver, abdominal pain of unknown origin, and poor vision. Terry, through a Hmong interpreter, provided basic instructions regarding a culturally specific diet, self-administration of insulin, foot care and the necessity of compliance with physician clinic appointments. Terry and another nurse partner, Amy, through regular three times a week visits, learned Mou was a respected elder Shaman. Many other Hmong women learn, via word-of-mouth teachings, various spiritual rites and rituals so they may “heal themselves.” For instance, Hmong Shaman may not eat any foods touched by children or mishandled foods during preparation. Thus, when Mou became more acutely ill due to dehydration, malnutrition, and her unstable diabetes, she moved into her son’s home (with his spouse and ten children). Mou’s diet was supplemented by Glycerna (canned) as this was considered safe to consume. Terry and Amy have been able to refer Mou successfully to the Hmong Senior Care Center, twice a week. Home visits by the nursing team have been decreased also, to twice a week, with the goal of once a week, despite the fact Mou’s unstable diabetes necessitates hospitalization for intensive re-evaluation and adjustment of her insulin. She has demonstrated success with selfinjections, compliance with oral medications and physician appointments. Terry, as nurse case manager, is responsible for the continued care coordination to ensure access to clinic appointments, transportation, medication procurement/dispensation and frequent communications with the hospital and clinic staff. MVNA nurses are challenged daily to address the environmental, psychosocial and health needs of a very culturally diverse population in the Twin Cities area. Their success is clearly dependent upon their ability to provide culturally competent care, in conjunction with close communication with the physicians. The visiting nurse carries with them a complex knowledge base of nursing science, community resources, and exceptional communication and organizational skills to fulfill this task. ✦

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The Caring Clinics Pilot Program for the Medically Uninsured

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WE ARE FORTUNATE that the medically uninsured population in Minnesota ranks among the lowest in the United States, i.e. 6-8 percent. However, for the 350,000 to 400,000 affected individuals and families it is a devastating worry and concern. Even one relatively minor medical condition can reduce a low income, self-sufficient family to poverty and dependency. To address this problem, the Sisters of St. Joseph of Carondelet in 1992 established St. Mary’s Health Clinics to care for people on marginal incomes without health care coverage and who are ineligible for government subsidy programs. Since 1992 eleven primary care neighborhood clinics have been developed around the metro area in churches, schools and community centers. The clinics operate one or two half days per week, are free, and staffed with volunteer physicians, nurses and other ancillary personnel — all volunteers. Agreements are in place to provide hospital, pharmacy and specialty services without charge or at significantly discounted rates. Working in collaboration with several community organizations in the west metro area, St. Mary’s Health Clinics (SMHC) and two HealthSystem Minnesota (HSM) clinics agreed to initiate a pilot program, called Caring Clinics, in October, 1998. The purpose was to evaluate the feasibility of caring for uninsured individuals in mainstream primary care clinics. This was based on the premise that if SMHC could appropriately screen those in need and if the two pilot clinics, Creekside Family Physicians and Wayzata Internal Medicine, could define their capacity to care for those referred to them,

BY CHRIS J. JOHNSON, M.D. AND SISTER MARY MADONNA ASHTON

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perhaps the concept could be expanded to a broader network of primary care clinics throughout the metro area. Continuity of care would be enhanced for those patients who eventually obtained employee medical benefits or qualified for MinnesotaCare since they could remain with the same provider. Volunteer physicians would see patients in their offices and eliminate travel time to clinic sites.

…pharmaceutical companies need to join their other medical and health care colleagues in carrying their share of this community responsibility. The pilot clinic assumes responsibility for all physician and laboratory services. Methodist Hospital provides in-patient and out-patient services for those qualifying for the Caring Clinics program. These services are provided voluntarily as a community contribution and at no charge to patients or SMHC. Medications are provided through HSM Pharmacies with the HSM Foundation granting $19,000 initially to MetroDoctors

support the acquisition cost of these pharmaceuticals. An additional grant has been approved to continue this support, but the escalating costs of prescription drugs presents a serious problem to the success of the project. Attempts to enlist support from pharmaceutical companies on this issue have thus far been unsuccessful. However, further dialogue is being pursued and alternative options are being considered by HSM and SMHC. From October, 1998 through December, 1999 approximately 300 individuals were screened by SMHC and referred to the pilot sites. Patients averaged two to three visits each with over two-thirds being young people under 35 years of age. Acute or episodic medical conditions accounted for 64 percent of visits followed by chronic disease management and preventive care visits at 16 percent and 6 percent respectively. Medications were prescribed at 57 percent of the encounters. Laboratory and/or x-ray services were provided on-site at 32 percent of visits. Eight percent of patients were referred for specialty care or out-patient diagnostic services through SMHC’s network of volunteer specialty providers. About 50 percent of the enrolled patients received all of their care during a one month period of time. Thirty percent have been actively enrolled and receiving care for over six months. Individuals enrolled in the pilot program are re-screened periodically for continued eligibility. To date the pilot program has demonstrated success in the ability of SMHC to appropriately screen those in need. In addition, the operational systems developed between the participating HSM clinics and SMHC to schedule appointments, provide pharmacy vouchers and refer patients to specialty providers has func-

The Journal of the Hennepin and Ramsey Medical Societies

tioned well. Physicians at the pilot sites have not found the number of patients seen excessive or displacing other patients from their schedules. Aside from the need to be aware of procedures for specialty referrals and pharmacy vouchers, there has been no reason to set up different operational procedures for care of SMHC patients. The pilot program population reflects the two clinics usual group of patients in terms of medical problems and service requirements. The program also highlighted the need for SMHC and HSM personnel to develop more aggressive follow-up procedures to assure completion of MinnesotaCare application forms for those identified as potentially qualifying. Reports from community agencies referring individuals from their clientele has been extremely positive regarding the Caring Clinics program. The high cost of prescription drugs along with escalating aggregate medication expenses of patients with chronic illnesses enrolled in the program stand out as the main problem facing its continuation. Encouraging expansion of the program to other clinics and health systems is dependent upon solving the pharmaceutical problem. Since this program relies on the voluntary goodwill of providers to extend health care to a neglected segment of our society, pharmaceutical companies need to join their other medical and health care colleagues in carrying their share of this community responsibility. The Caring Clinics program undertaken by SMHC and two HSM clinics with the assistance of a network of interested parties represents a collaborative model that has the potential for being replicated throughout the metropolitan area. It demonstrates the goodwill present in the physician and provider community, and it challenges others to participate. In so doing, the medical needs of the uninsured could be addressed within the present mainstream health care system until such time as universal health care coverage is available to all. ✦

Chris J. Johnson, M.D., is a family physician and former Sr. Vice President, Primary Physician Network, HealthSystem Minnesota. Sister Mary Madonna Ashton is the former CEO, Carondolet Lifecare Ministries. MetroDoctors

The Journal of the Hennepin and Ramsey Medical Societies

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May/June 2000

17

Take a Step Inside a Community Clinic

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IF YOU HAVE YET TO SET FOOT into a community clinic or stepped in 20 years ago, you are in for an eye opening experience. The community clinics that started out over 25 years ago in basements of churches and storefronts are today the safety net for the uninsured and those looking for the community clinic model of health care. No longer staffed only by volunteers and surviving on donations, the clinics have become an integral part of the health care system of the Twin Cities. The clinics are primarily staffed by paid personnel and governed by their own boards of directors. Over the years, they have become stable fixtures in their communities. To stay viable, they have been proactive and creative in establishing new funding sources and developing relationships with HMOs and government entities. These innovative approaches are what the clinics need to do to survive in the competitive health care market of today and serving a diverse patient base. Step Inside Neighborhood Health Care Network and its 17 member clinics that operate 46 clinics in the metro area represent what many are looking for in health care services. Community clinics provide high quality, accessible, affordable health care to everyone regardless of income or insurance status. They provide health care that is inclusive of the family needs and appropriate for all ages. Neighborhood Health Care Network (NHCN) is a management services organization (MSO). As an MSO, NHCN provides centralized business and administrative support to member clinics. NHCN was established in 1995 through a merger between two health care agenB Y LY N N A B R A H A M S E N AND JOLEE MOSHER

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cies working for community clinics: Community Clinic Consortium and East Metro Community Health Network. The merger to form NHCN integrates over 25 years of experience serving the community clinics into a single organization. NHCN neighborhood clinics emphasize quality health care services that serve the health needs of everyone, from newborn to elderly. The types of community clinics represented in NHCN’s membership include primary care clinics, reproductive health clinics, adolescent clinics, school-based clinics, mental health and dental clinics. The clinics offer a far more comprehensive health package than offered by most private clinics. Patients are able to receive medical care as well as supportive and stabilizing services. Some of the types of services offered by the clinics include: diabetes maintenance programs; prenatal care and classes; smoking cessation classes; annual physicals; preventive health; patient education; counseling; and social services. Take a Look Around The primary care clinics are staffed by board certified physicians, registered nurses, physician assistants, nurse mid-wives and other trained medical professionals. Patients receive primary care on site and when necessary, are referred to specialists and hospitals for services. Many choose a primary care clinic for the variety of support services and classes available to them. School-based clinics assure teenagers access to services that many times would go unmet. The clinics offer services aimed at preventing health problems and helping youth gain knowledge about integrating health, wellness, and pregnancy prevention into their daily lives. Care is available to pregnant women and their babies, too. Services are there to support the lives MetroDoctors

of young adults and their families. Adolescent clinics provide the essential services and support teenagers need during this time of experimentation and change. The professionals delivering services are experts in working with teens. Time is spent with teens; listening to their needs and helping them make informed decisions about their own health care. Reproductive clinics provide a wide range of services for women, men, and teens. Education on intimacy, sexual development, family planning, STDs and HIV/AIDS are offered on and off site to individuals, schools, organizations, and community groups. Care is provided in an environment respectful of family and community, where individuals are engaged as active participants in promoting their own health. What makes the clinics unique is their sensitivity in working with uninsured, underserved, and limited speaking English patients. Many times these populations will not seek healthcare until the problem manifests itself that care is needed at an emergency room or length of ongoing care is long, costing the patient and the system more. It has been found that if a patient has a relationship with a primary care clinic they are more likely to be seen and treated before the health concern worsens. The community clinics are available to insured patients as well, their fees help offset the costs of seeing uninsured patients. It is a winwin situation for everyone. In 1998, NHCN member community clinics provided health care services to 89,000 people, accounting for 318,000 face-to-face encounters. Thirty-nine percent of patients were uninsured and 54 percent had incomes below federal poverty level. Demographics indicated an almost equal ratio of Euro-American to minority-status patient enrollment, with EuroAmerican 39 percent, African-American 23 per-

The Journal of the Hennepin and Ramsey Medical Societies

cent, Asian-American 11 percent, Latino 11 percent, Native-American 2 percent, multi-racial 1 percent, other 1 percent and unknown 12 percent. Of the patients, 64.3 percent were female and 35.7 percent were male. Eyes Wide Open Utilizing both grant funds and member dues, NHCN provides essential services and organizational support to member clinics. In addition to expertise in resource development and grants management, areas of programmatic support to member clinics include: • A central telephone referral system for locating low cost care 489-CARE; • Assist callers and patients in applying for MinnesotaCare and Medical Assistance; • Marketing and outreach to hard to reach populations; • Continuous quality improvement; • Public education and advocacy on behalf of the clinics and target population;

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Administration of a reporting system to analyze the clinics’ patient and financial data; and Joint contracting of member clinic services.

The centralized patient intake phone line 489-CARE (651-489-2273) helps callers locate affordable and accessible community clinics that charge on a sliding fee basis according to the family income and size. For many uninsured patients, calling 489-CARE relieves the pressure of being denied service by a private clinic and having to hunt around for clinic that will see them. Callers are asked questions about their health insurance status, health concern, living/ job location and then referred to the appropriate clinics as well as informed about health care programs that may benefit their current situation. Patients can make their own appointments or 489-CARE intake specialists can assist callers, if needed. Callers are also able to have the Minnesota

The Journal of the Hennepin and Ramsey Medical Societies

Health Care Programs Application sent to their homes via 489-CARE. Follow-up calls and assistance is provided to those in filling out the application and answering questions. Applications and face-to-face support is provided at NHCN member clinics, too. Those that receive assistance in completing the application or have a place to turn for answers are more likely to complete the application and get enrolled on a program. These two programs at NHCN help patients find a community clinic and resources that they may never have known existed. Community clinics are an integral part of the health care system for the Twin Cities. Patients do not see county or city borders as a deterrent when needing accessible and culturally sensitive care. Community clinics offer the essential wrap around services patients need for their well being and their families. ✦ Lynn Abrahamsen is NHCN executive director, and Jolee Mosher is the community relations coordinator for NHCN.

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Hennepin Regional Poison Center Serves as Resource and Reference for Physicians

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WHAT DO YOU RECOMMEND to a patient who is short of breath after mixing bleach and toilet bowl cleaner together? What would you tell a patient who calls with her eyes and face burning after accidentally spraying mace into her face? Should the patient who has accidentally taken a second dose of her cardiac medication worry? What type of hazard can firefighters expect to find in a metal plating factory? These are all important questions that need immediate answers based on very specific knowledge of drugs, chemicals, and their toxic effects. Most physicians cannot answer these specific questions with great confidence because the information is not right on the tip of your tongue. Luckily, there is a way to get this information immediately by calling the poison center. The Hennepin Regional Poison Center (HRPC) was started in 1954 and has had dedicated staff since 1972. It is currently designated by the Minnesota Department of Health to provide poison information to the entire state with a toll-free line (1-800-POISON1). Residents and health care professionals from every county in the state use this service everyday. The HRPC is staffed around the clock by specially trained pharmacists certified as specialists in poison information by the American Association of Poison Control Centers (AAPCC). In addition, the HRPC meets stringent criteria set forth by the AAPCC and is nationally certified as a regional poison center. In 1999 the poison center handled nearly 45,000 human exposures, with children under six as the most likely patient. About three quarters of the calls to the poison center are from the home and, not surprisingly, parents were the most common callers. Clinics and other health care facilities comprise almost 16 percent of calls. The BY LOUIS LING, M.D.

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experienced staff at a certified regional poison center are able to safely triage and manage these cases at home or work site, as well as identify high-risk patients who need to have further medical evaluation and treatment. Because the expertise for these problems can be centralized and coupled with an extensive database and information resources, the poison center staff is able to serve as a resource and reference for physicians and other health care providers who are caring for these patients. In many common cases, the poison specialist can give advice without even looking up any reference material. As with any public health effort, public education is a key portion of the poison center’s mission. In 1999 there were over one half million pieces of printed material distributed as a direct request of Minnesota residents and health care providers. In addition, there were appearances at health fairs, press releases, and broadcast television appearances in an effort to heighten poison prevention and increase the center’s visibility throughout the state. A national study in 1997 demonstrated that for every dollar spent on poison centers, an estimated $6.50 is saved by eliminating care for MetroDoctors

cases that can be safely managed at home. Until July 1999, poison services were a partnership of the state health department, Regions Hospital, and Hennepin County Medical Center with each contributing about onethird of the operating expenses. With the financial stress of local hospitals, Regions has opted out and Hennepin County was no longer able to fully subsidize the system. The Minnesota Department of Health has asked the state legislature for an increase in the state contribution by $790,000 to make up the deficit. This additional sum would fully support 70 percent of the expenses, which nationally averages $32/ human exposure. This cost includes home management of 80 percent of exposures without the need for further medical evaluation, except for repeat telephone assessment of the patient by the poison center, educational materials, and frequent calls for drug information. Nationally, Congress has allocated funds to develop a single phone number across the country. Although poison centers will work in a more integrated fashion, one single national center could never replace the regional centers that have a working relationship with the physicians, hospitals, and resources in the state. The Hennepin Regional Poison Center is a resource available to the lay public and all health care providers in the state. It is proud to play its part safeguarding the public’s health and assisting you with your patients, 24 hours a day, 365 days a year. Please visit our web site at www.mnpoison.org to read our annual report or to download poison safety brochures. We are always just a phone call away whether you need a consult or general information. ✦ Louis Ling, M.D., has served as the Medical Director of the Hennepin Regional Poison Center since 1986, and is the Associate Medical Director at Hennepin County Medical Center. The Journal of the Hennepin and Ramsey Medical Societies

2000 Winter Medical Conference a Success

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THE 2000 RMS/HMS Winter Medical Conference attracted more than 70 participants including 28 physicians to the warm and sunny beaches of the Gala Resort Playacar near Playa del Carmen, Mexico, south of Cancun. Sixteen proscribed credits by the American Academy of Family Physicians on topics ranging from an Asthma Update and Breast Cancer 2000 to Treatment of Myocardial Infarction and Osteoporosis: The Hard Facts, were presented in the lecture room with all the latest audio-visual assists. Many members of the group enjoyed the excursions organized by our travel agency, Hobbit Travel, to the Mayan ruins at Tulum, the Xcaret national park, and to the Mayan Capitol, Chichen Itza. The perfect weather, a beautiful resort, informative lectures and a location offering many interesting activities all contributed to the very high evaluations of the 2000 Winter Medical Conference. âœŚ

More than 70 people participated in the 2000 Winter Medical Conference.

Dr. Michael Gonzalez-Campoy and Dr. John Gates.

Dr. Diane Dahl and Dr. Thomas Dunkel.

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The Journal of the Hennepin and Ramsey Medical Societies

May/June 2000

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College Students Participate in Community Internship Program

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HEALTH POLICY 101 is not at all what it used to be! Thirteen Macalester College students participated in the joint Hennepin and Ramsey Medical Societies Community Internship Program, March 6-13. The students, all enrolled in Duchess Harris’ Policy Analysis: Issues in Health Care, petitioned to participate in this class and were chosen based on academic excellence as well as an interest in a future in medicine or public policy. Topics discussed throughout their course included: • Is there a conflict of interest when an insurance company owns a hospital;

• • • •

Minnesota immigration patterns; The language barriers of immigration and the particular health issues of refugees; Patient’s responsibilities and should health care be a business; and Is it still a good idea to enter Medical School in the twenty-first century?

In addition, the students were required to track a bill on the internet, attend a committee hearing about a health care issue at the State capitol, critique the health agenda for one of the presidential candidates, and finally, to par-

ticipate in the joint Hennepin/Ramsey Medical Societies Community Internship Program. As pure coincidence, the American Academy of Pediatrics Minnesota Chapter, was conducting their “Day at the Capitol” during the scheduled time of the “Internship.” A special “thank you” to Dr. Charles Oberg for arranging for nine of the interns to follow pediatricians on their legislative visits during this session! Throughout the two days these 13 students saw patients die, and babies being born, but in the end the most fascinating aspect of their experience was the diversity of physician opinion

“Professional Projects for the Professional” • Clinics • Professional Buildings • Hospitals • Drew Bergman and James Hart, M.D.

Morcon Construction, Inc. 5905 Golden Valley Road Golden Valley, MN 55442 763-546-6066 Phone: 612-546-6066 Bill Jundt Medical Construction Specialist Member MMGMA/Gold Sponsor

morcon@isd.net Holly Hinman and Charles Oberg, M.D.

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about policy solutions. One student wrote that her four doctors had four different solutions for health care reform: 1) single payer; 2) putting insurance policies in patients’ names and vouchers for welfare recipients; 3) Medicare should cover the costs of preventive care; and 4) Nationalized Health Care. Despite the fact that the students were somewhat discouraged that the physicians couldn’t come up with viable policy

solutions, they were reminded that Congress hasn’t either. Thanks to all the physicians who participated in this Community Internship Program. Without your commitment and sharing of your time and expertise, this program could not succeed. To participate in future programs, please contact Nancy Bauer, HMS, at (612) 623-2893 or Doreen Hines, RMS, at (612) 362-3705. ✦

Students participating as Community Interns included: (back row) Drew Bergman; Cain Oulahan; Melanie Blom; Bryce Miller; John Shepard; (middle row) Auyana Orr; Holly Hinman; Jessica Huie; Jenny Mann; Dana Holland; (front row) Kyla Hayford; Sara Sommarstrom; and Anna Person.

Thank you to the following physicians for participating in the Community Internship Program. Janiece Aldinger, M.D. Mark Bixby, M.D. Carl Blegen, M.D. Joseph Bocklage, M.D. James Burdine, M.D. Dennis Callahan, M.D. Kenneth Casey, M.D. Robert Collier, M.D. Mark Conterato, M.D. Gary Coon, M.D. Kenneth Crabb, M.D. Peter Daly, M.D. Stephen England, M.D. Douglas Godfrey, M.D. Michael Gonzalez-Campoy, M.D. Eugene Gullingsrud, M.D. James Hart, M.D. Andrew J. Houlton, M.D. Lanning Houston, M.D. David S. Johnson, M.D. Peter Kelly, M.D. Martin Klatzko, M.D. Charles Li, M.D. Ann Lowry, M.D. Stacene Maroushek, M.D. Charles Oberg, M.D. Eugene Ollila, M.D. Brian Patty, M.D. Charles Pexa, M.D. Marc Pritzker, M.D. Regions Hospital Emergency Dept. William Rupp, M.D. Selma Sroka, M.D. Brett Teten, M.D. Jon Thomas, M.D. David Thompson, M.D. Elisa Wright, M.D. Patrick Wright, M.D.

Auyana Orr and Peter Kelly, M.D.

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May/June 2000

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PRESIDENT’S MESSAGE J O H N R . G AT E S , M . D .

RMS-Officers

President John R. Gates, M.D. 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. RMS-Board Members

Kimberly A. Anderson, M.D. Charles E. Crutchfield, III, M.D. Peter J. Daly, M.D. Kelly duFord, Medical Student Thomas B. Dunkel, M.D. Michael Gonzalez-Campoy, M.D. James J. Jordan, M.D. F. Donald Kapps, M.D. Charlene E. McEvoy, M.D. Ragnvald Mjanger, M.D. Joseph L. Rigatuso, M.D. Thomas F. Rolewicz, M.D. Paul M. Spilseth, M.D. Jon V. Thomas, M.D. Randy S. Twito, M.D. Russell C. Welch, M.D. Mark E. Wiest, M.D. RMS-Ex-Officio Board Members

Blanton Bessinger, M.D., MMA President-Elect Raymond Bonnabeau, M.D., Sr. Physicians Association President Kenneth W. Crabb, M.D., AMA Alternate Delegate Stephen P. England, M.D., Community Health Council Chair Michael Gonzalez-Campoy, M.D., Education Resource Council Chair Duchess Harris, Alliance Co-President Nicki Hyser, Alliance Co-President Frank J. Indihar, M.D., AMA Delegate William Jacott, M.D., U of MN Representative F. Donald Kapps, M.D., Council on Professionalsim & Ethics Chair Melanie Sullivan, Clinic Administrator Lyle J. Swenson, M.D., Public Policy Council Chair Russell C. Welch, M.D., Communications Council Chair

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THIS ISSUE OF MetroDoctors is devoted to Community Health issues. A significant community health issue that I would like to discuss this month is: What is the future of our metropolitan specialty care? Though HealthPartners recently suggested in an expensive insert into both metropolitan papers that patients should approach their doctors and ask them to lower their fees, physicians in the metropolitan area have one of the lowest fee schedules in the entire United States. As a result, I hear increasing reports of metro physician specialty groups having difficulty in recruiting new associates. Infectious disease, dermatology, and neurosurgery are cases in point where recruitment efforts have been ongoing by some specialty groups for several months, without any obvious takers. Assuredly, some of this frustration is due to the lack of adequate specialty trained graduates, especially in infectious disease to fill the nationwide demand. There is strong evidence that the residency training programs over-reacted to the alleged impending oversupply of specialty physicians, at least in some areas. However, the factor of Minnesota’s non-competitive reimbursement environment must be considered. Already, significant discussion for restricting infectious disease services only to certain hospitals are ongoing in the east metro. What does this mean for the future of comprehensive medical services in the metropolitan area? Are resident physicians who complete our own state-subsidized training programs finding better job opportunities elsewhere? Are more senior, experienced physicians retiring early

rather than spending ten more years in frustrating, undervalued, under-reimbursed practice? Are other specialty groups finding it difficult to recruit compared to other geographic areas? We don’t know. We can only rely on anecdotal reports. I am gravely concerned for the future of our medical services in the metro area. Our current quality of care is second to none, despite the assault of reimbursement erosion. It is a true tribute to the physicians of RMS and HMS that they are committed to the highest quality of medical care in the face of major intrusions into every aspect of how we deliver care, as well as reimbursement. In the future, however, it may be a much different story. Simple supply and demand economics may overwhelm all aspects of established practice and community commitments. Resident physicians with $100,000-$200,000 of medical student debt and no burning established community ties or commitments will work for Willy Sutton — elsewhere (where the money is), and many physicians with over 20 years in the trenches, who have paid their societal dues, will go elsewhere, too. I don’t believe that is what the community wants. Let’s get the data! I would like to know when the Titanic will hit the iceberg, or if it will truly miss it. Until then all I can do is sit in my full immersion suit and rearrange the deck chairs! ✦

RMS-Executive Staff

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

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R M S U P DAT E ROGER K. JOHNSON, RMS CEO

RMS Call for Resolutions The 27 RMS delegates and the alternate delegates to the MMA House of Delegates will caucus on Wednesday, May 17, 2000, in room 4057 in the new Gardenview Medical Building adjacent to United Hospital at 347 North Smith, and again on Tuesday, June 6 at the same location. All RMS members are urged to submit resolutions for the RMS Caucus to consider carrying to the MMA House of Delegates in September in Duluth. This is your opportunity to influence MMA policy and AMA policy at the national level. The RMS delegates carried 13 resolutions to the 1999 MMA House of Delegates. RMS Past President Dr. Lyle Swenson chairs the RMS Caucus. Contract Review Program We are hard at work with our partners, the Hennepin Medical Society and the Minnesota Medical Group Management Association in the Metropolitan Medical Practice Forum, to improve and expand this program in 2000. We have contacted the health plans to ask for their cooperation in this project and we will be meeting with Blue Cross Blue Shield soon. Our meetings with Attorney General Mike MetroDoctors

Hatch and legislators have been productive. We are making progress towards our goal of leveling the health plan/physician contract playing field. Benefits Purchasing Pool A survey was recently mailed to clinic administrators to determine if sufficient interest exists to pursue organizing a RMS pool to purchase benefits for physicians and clinic employees. The RMS Board authorized the survey that is being conducted with support from the Flynn Companies of Saint Paul. The goals of the purchasing pool are to lower costs for health, dental, life, and disability insurance. In addition, lower costs and improving retirement packages such as 401(k) plans will also be a part of the purchasing pool planning. RMS Foundation Reorganization The reorganization of the RMS Foundation is proceeding. The RMS Foundation will be reorganized to include the RMS Alliance. Legal counsel from Briggs and Morgan has met with leaders of the RMS and the RMS Alliance to begin the process of drafting revised Articles of Incorporation and new Bylaws. Board representation will include representatives from both RMS and the RMS Alliance. A reorganized and rejuvenated Foundation will prove to be beneficial for both the RMS and the RMS Alliance to carry out future projects. RMS Board Strategic Planning On Wednesday, May 10, the RMS Board will review the RMS Strategic Plan and make needed adjustments to carry RMS into 2000 and beyond. The vision of the Strategic Plan includes developing a Large Enthusiastic Membership, a Strong Physician Voice, and a Credible, Caring Identity. Your strategic planning advice to your RMS leadership is welcome. Make your opinions known to your

The Journal of the Hennepin and Ramsey Medical Societies

RMS officers and Board members. If you wish, call the RMS office at 612/362-3704 or call me at 612/362-3799 and we will share your thoughts with the Board members. RMS Membership for 2000 Thank you to every member who has paid his or her dues for 2000. Your continued support is vital and appreciated. To those members who are procrastinating, we hope you will talk to your practice administrator today to make sure that your check will be in the mail soon. We have a great deal of work to do and we need your support to be successful. ✦

In Memoriam DONALD P. SMILEY, M.D., died April 4. He was 74. Dr. Smiley was an orthopedic surgeon in St. Paul for 32 years. He graduated from the University of Chicago and completed an internship at Ancker Hospital in St. Paul. He completed residencies at the University of Colorado, Denver; the V.A. Hospital in Lincoln Nebraska; and the Shriners Hospital in Minneapolis. Dr. Smiley joined RMS in 1959. ✦

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

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Ramsey Medical Society

Dr. Gates Responds to HealthPartners Ad RMS President Dr. John Gates recently responded to an ad that was inserted in the Saint Paul Pioneer Press and the Minneapolis Star Tribune by HealthPartners. The insert described the various cost factors that contribute to the premium charged by HealthPartners. Many RMS members were angered by the appeal in the ad to “Ask physicians when they intend to lower fees.” In response to Dr. Gates’ letter, HealthPartners President George Halvorson has agreed to meet with RMS leaders to discuss the ad and the reasons for premium increases. RMS members will be informed of the results of this meeting.

Caring Hearts for the Homeless 2000 Supply Drive

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THE EIGHTH ANNUAL “Caring Hearts for Homeless People,” sponsored by Ramsey Medical Society, Ramsey Medical Society Alliance and Health East Care System, began on Sunday, February 13, 2000 and concluded on Sunday, February 27, 2000. This year’s drive was a huge success! Twentyseven medical clinics, 28 churches, HealthEast Care System, and many volunteers from the Ramsey Medical Society Alliance, and many other organizations pitched in to collect more than $45,000 worth of hygiene and medical supplies for the Health Care for the Homeless clin-

ics and Listening House. In addition, more than $1,700 in cash contributions was collected. These organizations rely heavily on donated medications, hygiene supplies, toys, juice and monetary donations to help meet the physical, emotional and mental health needs of their clients. This drive contributes the majority of supplies needed for the entire year. Carole Nimlos coordinated the activities of the RMS Alliance members who worked hard picking up the supplies from the 27 medical clinics.

Preparing to sort materials.

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Allina Medical Clinic — Shoreview Allina Medical Clinic — West St. Paul American Red Cross Arlington Hills United Methodist Church via Melissa Barton, M.D. Capitol Neurology, P.A. Dakota Pediatric Clinic Gastrointestinal Diagnostic Center — Chicago Ave. Gastrointestinal Diagnostic Center — Edina Hadley M. Verwest, M.D., P.A. HealthEast Shoreview Clinic HealthEast Vadnais Heights Clinic Highland Business Association Metropolitan Hand Surgery Assoc., P.A. Midwest Spine & Orthopedics Minnesota Gastroenterology — East Metro North Suburban Family Physicians, P.A. NOW Care Medical Center Partners Obstetrics and Gynecology, P.A. Phalen Village Clinic Physicians Neck & Back Clinic, P.A. Pulmonary & Critical Care Associates St. Anthony Orthopaedic Specialists, P.A. St. Croix Orthopaedics, P.A. St. Paul Surgeons, Ltd. United Rehab Physicians University of Minnesota — Bailey Hall Yankee Square Family Practice

The supplies collected include diapers, towels, and blankets.

The numerous supplies collected are sorted and ready for distribution.

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Thank you to the clinic managers, staff, and physicians of the following clinics that participated:

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The Journal of the Hennepin and Ramsey Medical Societies

RMS ALLIANCE NEWS DUCHESS HARRIS, Ph.D.

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THIS WILL BE MY FINAL COLUMN as co-

April 16-22, 2000 to be the Ramsey Medical Society Foundation and Alliance Week to commemorate the 14th Annual Health Fair for third graders in Saint Paul.

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The Journal of the Hennepin and Ramsey Medical Societies

were eager to discuss strategic planning. One suggestion was to “pitch” our organization as unique because we are “medical families.” Although this is true, dual career couples may not see themselves solely defined by medical culture. Our dialogue inspired me to propose the following: A Vision for the Future 1) Take the word Alliance seriously. There is a reason why we are no longer an auxiliary. 2) Do man stuff. If it needs a hammer, they will come. Maybe we need to plan an event that could let the men live out their “Tool Time” fantasies. 3) Do working woman stuff. Let’s have some night meetings. We don’t have to cook, we’ll get someone to keep the kids, and we’re not worried about rushing back to work. 4) Understand your new audience. Generation X is conspicuously absent from the Alliance. We invented casual Friday. That might be why we toss the country club invites. We’re looking for a cyber-café. 5) Special Interest Groups. Incoming President Eleanor Goodall is a financial planner with PaineWebber who has spearheaded an investment club that meets monthly over the noon hour. This has been one of the most unifying components of the Alliance. Is there a need for a dual-career couple special interest group? My final column is an appeal to dual career households to tell us what we can do better. An organization is only as strong as its willingness to change. Thank you for your readership. Jon Thomas is my muse. ✦

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Ramsey Medical Society

proach to service. Ironically, the same month that Thistle’s article was published, the RMSA held a tea at the St. Paul Hotel. The theme of the event was racial harmony and we chose February 12 as our date, so that we could link the idea of Valentine’s Day with Black History Month. Our goal was to raise money for the Dr. Cassius M.C. Ellis scholarship fund. Our entertainment was the embodiment of racial unity. “Sisters Bell with Stories to Tell” are two adolescent girls, Jessica and Ashley Bell, who are the daughters of an interracial couple. The purpose of their stories is to bridge the racial divide by celebrating both of their parent’s heritage. They conveyed lessons of history, ethnic pride, and peaceful solutions. We enjoyed good food and companionship in a lovely setting, and successfully raised scholarship funds for an African-American medical student. Although this was a successful event, I’ve started to question if “High Tea” has limited appeal. I think that we scored an “A” for substance, but maybe we fell short in terms of style. I’m concerned that some of our events might be cost-prohibitive to medical student’s partners and resident’s spouses. I’m also concerned that our organization’s culture exists within such a “pre-female physician” paradigm that we lack self-reflection. Our Valentine Tea successfully crossed racial barriers, but we have a long way to go with attracting working women and men. On April 6, former State Alliance President Dianne Fenyk, came to my home to discuss membership within the Ramsey Alliance. Ten members Saint Paul Mayor Norm Coleman proclaimed the week of attended the meeting and we

president of the Ramsey Alliance. I would like to leave office with a message about transforming the institutional culture of our organization. I was inspired by Jennifer Thistle’s article, “From Tea Service to Community Service” in the February issue of Minnesota Medicine. According to Thistle, the Minnesota Medical Society Auxiliary, which was established in 1922, used to meet in Dayton’s Tea Room to socialize and discuss shared concerns. In response to this conventional history, the Ramsey Alliance’s only male member, Jeffrey Hill, is quoted as saying, “The Alliance needs to be about service, not a tea party.” As one can imagine, the generational divide within our organization has forced us to ask ourselves how far we have come in our ap-

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HMS IN ACTION JACK G. DAVIS, CEO

HMS-Officers

HMS-Board Members

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

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

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

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

In cooperation with RMS and the Minnesota Medical Group Management Association, letters were sent to Dr. Mark Banks, BC/BS; David Strand, Medica; Marcus Merz, Preferred One; and George Halvorsen, HealthPartners; requesting an advance copy of new or amended contracts.

David Estrin, M.D., David Swanson, M.D., Jack Davis and Nancy Bauer attended the AMA National Leadership Development Conference in March. Robert

Meiches, M.D., newly elected MMA Board Chair, also attended. Drs. David Griffin and Karen Lucas continue to actively participate in the Dakota Healthy Families Initiative, now expanding its efforts to all of Dakota County. The partner agencies have a shared mission to improve learning readiness and prevent child maltreatment. As charged by the HMS Board of Directors, the Membership and Communications Committees are meeting and designing plans for member recruitment and retention programs.

HMS, HMSA, and Minnesota Women in Medicine are co-sponsoring a family event at the Minneapolis Institute of Arts, Friday, May 5. Tickets to the Smithsonian Exhibit of “Star Wars” are available through the medical society. The Adolescent Health Care Coalition and HCMC Department of Pediatrics cosponsored a half-day conference, “Healthy

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Transitions: Best Practices for the Care of Adolescents,” on April 14. Julia

Joseph DiCaprio, M.D., M.P.H., served as the program chair. The HMS Board of Directors met on March 9. The following actions were taken: • Unanimous endorsement of the continuation of the Healthy, Abuse-free Medical Workplace Project,

chaired by A. Stuart Hanson, M.D. and consultant, Deborah Anderson, president, Respond 2, Inc. In addition, the Board endorsed a model medical staff policy on abusive behaviors. • A $15,000 fiscal note was approved for use by the Metropolitan Medical Practice Forum to continue its efforts on payer contract reviews and other activities benefiting the business of medicine. In addition to HMS, RMS and the Minnesota Medical Group Management Association comprise this forum. • A motion was approved to set aside $4,000 in a philanthropic fund for designation by the HMS Board Chair to the charity(ies) of choice as recognition for time and efforts committed to HMS during his/her tenure. The motion is to be re-evaluated/sunset on September 30, 2005. A very successful fund-raiser for Attorney General Mike Hatch was attended by a number of HMS members. The HMS Caucus will be meeting on June 8 at 7 a.m. in the Naegle Auditorium, Park Nicollet Clinic. Delegates and resolutions are needed. (Continued on page 31)

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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

New Members HMS welcomes these new members to the Society as of March 1, 2000. Schools listed indicate the institution where the medical degree was received.

Faisal Ahmed, M.D. Dow Medical College, University of Karachi, Pakistan Internal Medicine Fridley Medical Center Multicare Assoc. of T.C. Zehyani Bankwala, M.D. Dow Medical College, University of Karachi, Pakistan Cardiology University of Minnesota Physicians Jean C. Barton M.D. University of Kansas School of Medicine Pediatrics Hennepin County Medical Center

Patricia L. Fontaine M.D. University of Michigan Medical School Family Practice University of Minnesota

James J. Milavetz M.D. University of Minnesota Cardiovascular Diseases Park Nicollet Heart Center

Walter E. Galicich M.D. Cornell University Medical College, New York Neurological Surgery Neurological Associates, Ltd.

Jens Christian Morkeberg, M.D. University of Denmark Medical School Pediatrics Southdale Pediatric Associates

Fredarick L. Gobel M.D. University of Wisconsin Medical School Cardiovascular Diseases Minneapolis Cardiology Assoc. Minneapolis Heart Institute

Kirsten R. Nelson, M.D. University of Minnesota Pediatrics South Lake Pediatrics

David F. Graft M.D. Johns Hopkins University School of Medicine, Baltimore Allergy and Immunization Park Nicollet Clinic-HealthSystem Minnesota Elizabeth B. Hagberg M.D. University of Minnesota Family Practice

David N. Beddow, M.D. University of Minnesota Internal Medicine Fridley Plaza Clinic Steven D. Bentz M.D. University of Minnesota Family Practice Fridley Medical Center Multicare Assoc. of T.C.

John P. Juola M.D. University of Minnesota Family Practice Fairview EdenCenter Clinic

Kenneth F. Casey, M.D. New Jersey Medical School Neurosurgery Minneapolis Neurological Surgeons Ltd.

Jay H. Krachmer M.D. Tulane Medical School Ophthalmology University of Minnesota

Amy L. Diede, M.D. University of North Dakota School of Medicine Family Practice Apple Valley Medical Center

Sara L. Langer M.D. University of Minnesota Neurology Noran Neurological Clinic

Kathryn E. Dusenbery M.D. Wayne State University School of Medicine Radiation Oncology University of Minnesota

Andrew Wills Larson, M.D. University of Minnesota Pediatrics Partners in Pediatrics, Ltd.

John L. Erickson M.D. University of Minnesota Internal Medicine Fairview Ridges Clinic

Beverly R. Lewis, M.D. University of Minnesota Psychiatry Minneapolis Psychiatric Institute

Jeanne M. Finney, M.D. University of Minnesota Internal Medicine Sharpe, Dillon, Cockson, & Associates

Douglas W. Martin M.D. Mayo Medical School Pediatrics Fridley Plaza Clinic

May/June 2000

Monica L. Norwick M.D. University of Minnesota OB/GYN Lakeview Clinic Ltd. John T. Olsen M.D. University of Minnesota Diagnostic Radiology Suburban Radiologic Consultants, Ltd.

Todd Anthony Holcomb, M.D. University of Minnesota Internal Medicine Lakeview Clinic - Chaska Maryanne Jacob, M.D. University of Cincinnati OB/GYN Drs. Haislet, Wavrin, Wright, Lehrman and Associates

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Vanda R. Niemi, M.D. Ohio State University Neurology Noran Neurological Clinic

John Peter Perentesis, M.D. University of Michigan Medical School Pediatric Hematology University of Minnesota Pediatric Clinic Douglas J. Pryce M.D. State University of New York at Buffalo School of Medicine Internal Medicine Hennepin County Medical Center Craig N. Qualey M.D. University of Minnesota Psychiatry Hennepin County Medical Center Roger W. Rhodes M.D. University of Minnesota OB/GYN Park Nicollet Clinic - Carlson Parkway Douglas M. Soderberg M.D. University of Minnesota OB/GYN Anthony A. Spagnolo M.D. Loyola University Stritch School of Medicine, Maywood Family Practice Park Nicollet Clinic-Shakopee Thomas E. Timmons M.D. University of Minnesota Emergency Medicine

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Teresa Tran-Lim, M.D. Georgetown University Neurology MINCEP Epilepsy Care James R. White M.D. University of Minnesota Internal Medicine MINCEP Epilepsy Care Laurel M. Wills, M.D. Boston University Pediatrics Hennepin County Medical Center

Larry A. Zieske M.D. University of Pennsylvania School of Medicine Otolaryngology-Head & Neck Surgery Ear, Nose, & Throat SpecialtyCare of MN, P.A. TRANSFERS Patricia E. Blumenreich, M.D. University of the Republic, Montevideo, Uruguay School of Medicine Psychiatry Peter E. Fehr M.D. University of Minnesota Maternal and Fetal Medicine Gynecology, Infertility and Obstetrics, Ltd. Stephen J. Firestone M.D. University of Minnesota Family Practice Timothy D. Johanson M.D. University of Minnesota Pediatrics Metropolitan Pediatrics Janet M. Schmitt M.D. Michigan State University College of Human Medicine, East Lansing Family Practice United Family Health Center RESIDENTS Brenda Guyer, M.D. University of Minnesota Hennepin County Medical Center Eric G. Heegaard, M.D. University of Washington School of Medicine Family Practice Associates in Women’s Health Heather Linee Johnson M.D. University of Kansas Pediatrics Fairview University Medical Center-University Campus MetroDoctors

Christine M. McCarthy, M.D. University of Iowa College of Medicine Family Practice Creekside Family Physicians Clinic James Samuel Montana III, M.D. University of Minnesota Internal Medicine Michael J. Nemanich M.D. University of Minnesota Orthopedic Surgery Minnesota Orthopaedic Spec.,PA Ross P. Paskoff M.D. University of Minnesota Orthopedic Surgery Paul N. Trites M.D. University of Minnesota Ophthalmology Vision Medical Wang Ying, M.D. Lingham Medical College, Lingham UniversitySun Yat-sen, Canton China TRANSFERRED RESIDENTS Michael J. Nemanich M.D. Mayo Medical School, Rochester Orthopedic Surgery Minnesota Orthopaedic Specialists, PA Paul N. Trites M.D. University of Minnesota Medical School Ophthalmology Vision Medical STUDENTS Rehana P. Ahmed Nathan P. Anderson Kelsey N. Carignan Bo H. Chao Mark Steven Danahy Ashley Jessica Davies Emily E. Dickman Alex Kopyov Teresa Anne Kurtz Elizabeth Coite Lorenz Narwhals Mating Laura J. Pattison Vadim Pisarenko Alexa A. Pragman Michael John Rogan Shawn M. Ronan Daniel J. Thompson TRANSFERRED STUDENTS Narwhals Mating Carey J. Welsh

The Journal of the Hennepin and Ramsey Medical Societies

In Memoriam RICHARD T. CUSHING, M.D., died April 5 at the age of 74. He was a pediatric allergist with Park Nicollet Medical Center. Dr. Cushing was the founder of Camp Superkids for children with asthma. He graduated from Queens University Faculty of Medicine, Kingston, Ontario, and completed his residency at the University of Minnesota. Dr. Cushing joined HMS in 1957. JOHN (JACK) R. GORDON, M.D., died March 17 from complications associated with Alzheimer’s Disease. He was 77. Before retiring in 1985, Dr. Gordon worked as a full professor in the Department of Anesthesiology at the University of Minnesota. He graduated from the University of Rochester School of Medicine-Dentistry, NY, and completed his residency at Yale University. Dr. Gordon joined HMS in 1957. ✦

HMS In Action (Continued from page 29) Robert Meiches, M.D., west metro

trustee, was elected as chair of the MMA Board of Trustees at their January 2000 meeting. Thirty 1st and 2nd year medical students participated in the “Shadow a Physician” program offered during spring break. Attorney General Mike Hatch was the featured speaker at the medical student “Lunch & Learn” session on April 10, 2000, co-sponsored by HMS and RMS. HMS and RMS members, in a joint Community Internship Program held March 6-13, hosted 13 students enrolled in the Macalester College Health Care Policy Analysis class. ✦

Reminder… metrodoctors.com census sheet can be completed online. www.metrodoctors.com/census May/June 2000

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Hennepin Medical Society

Freeman E. Wong M.D. University of Minnesota Internal Medicine HealthPartners (West)

Mitchell J. LaCombe, M.D. University of Minnesota Family Practice

HMS ALLIANCE NEWS

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HENNEPIN MEDICAL SOCIETY Alliance has just completed a very successful and rewarding year. We are truly grateful to have been a part of all that has happened. The Alliance is composed of many talented and dedicated individuals, including, many unsung heroes among our ranks. We wish to thank the Board of Directors and general members for their time, commitment and support! Special thanks, also, is extended to the Hennepin Medical Society and Hennepin Medical Foundation, including Dr. Estrin, Dr. Dahl, Jack Davis and Nancy Bauer, for their encouragement and financial support. Your backing was instrumental in the success of our major projects, Body Works and the HIV/AIDS folder. This year the Alliance participated in many traditional and several new projects. Some of these projects included: a garage sale to benefit our philanthropic efforts; SAVE (Stop America’s Violence Everywhere); a shelter shower with gifts for the Minneapolis Crisis Nursery; Book Buddies; “A Magical Evening of Giving” for the HIV/AIDS folder; and the Holiday Tea and Silent Auction to benefit Body Works. Members contributed generously to the AMA Foundation in support of U.S. medical schools for student financial aid and other programs, “You are Gloved!” was well received this year. After collecting gloves and mittens for Leech Lake and

Grand Portage Reservation Elementary Schools as a State project, HMSA continued the project locally for children at Banneker Elementary School located in a low income community of Minneapolis. Letters from both the principal and social worker at Banneker expressed extreme gratitude for our donations. The 17th annual Body Works health fair for third graders of Minneapolis was held during the week of February 28 through March 3. This event, co-sponsored by Diane Gayes and Judy Nagel, was a tremendous success and nearly 2,700 students attended. We are told that it is one of the most popular field trips available and classrooms are scheduled on a first come, first serve basis. We are always grateful for all the HMSA members and friends who come to help so enthusiastically with this project—it seems to be just as rewarding for us as it is for the children. Mayor Sharon Sayles Belton highlighted the week by coming on Thursday to talk with the children and presenting us with a Proclamation of Body Works Week in the City of Minneapolis. A unique opportunity occurred during January 30 - February 1 when five HMSA members participated in a National Leadership Training Confluence in Chicago. Diane Gayes attended along with upcoming HMSA co-presidents, Trish Vaurio and Dianne Fenyk. In addition, HMSA has recognized two very special resident spouse leaders, Dionne Miesterling and Nichole Baker, and voted unanimously to sponsor these two individuals as well. Confluence is an action packed event of information, training and networking with other leaders from across the country. All had a great time and have returned energized and ready for the coming year. Two individuals within our Alliance make us especially Minneapolis Mayor Sharon Sayles Belton at Body Works with proud at this time. Diane HMS Alliance Co-Presidents, Penny Chally and Becky Finne.

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May/June 2000

MetroDoctors

Penny Chally Co-President

Rebecca S. Finne Co-President

Gayes will be serving as upcoming Minnesota Medical Association Alliance President and Dianne Fenyk has been appointed as the National Membership Chair for the American Medical Association Alliance. We offer both of these outstanding leaders our support and best wishes in the coming year. Our annual event and installation of new officers is scheduled for Friday, May 5 at the Edina Country Club. Brian Russ, Executive Director of the Annex Teen Clinic, will be on hand to tell us more about that facility and the services offered. The Annex Teen Clinic, West Suburban Teen Clinic (WSTC) and TeenAge Medical Services (TAMS) are all working collaboratively to provide counseling, education and health care services to adolescents and young adults in our area. These are programs that HMSA hopes to actively support in the near future. So many good things have come to fruition this past year. In addition to the various projects and programs, we were able to finally develop our own web page (www.hmsa.net) and also, to produce a beautiful new membership brochure, thanks to the computer talents of Emily Wagner. It will be a very valuable tool in our membership recruitment for the future. Our membership enrollment remains healthy but recruiting and retention will always be important. Our mentoring program for Resident and Medical Student Partners continues to be successful and we place great value on these younger members and what they have to share. Eleanor Goodall is leading a new HMSA investment club which will be a great learning opportunity for those involved. Already, plans are underway for new programs for next year — sometimes it is hard to see where one year ends and another begins. It has been a great year and we have been blessed to be part of such a wonderful group of people. Thank you all! ✦ The Journal of the Hennepin and Ramsey Medical Societies