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Doctors MetroDoctors THE JOURNAL OF THE EAST AND WEST METRO MEDICAL SOCIETIES

Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Thomas B. Dunkel, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Doreen M. Hines WMMS CEO Jack G. Davis EMMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the East and West Metro Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at Minneapolis, Minnesota. Postmaster: Send address changes to MetroDoctors, East and West Metro Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote their objectives and services, the East and West Metro 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 EMMS or WMMS. Send letters and other materials for consideration to MetroDoctors, East and West Metro Medical Societies, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com. For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (952) 903-0505 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com. MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Doreen Hines at (612) 362-3705.

MetroDoctors

CONTENTS VOLUME 10, NO. 1

2

Ramsey Medical Society Becomes East Metro Medical Society

3

Hennepin Medical Society Becomes West Metro Medical Society

4

LETTERS

Index to Advertisers

5

Physicians Can Be a Powerful Voice for Public Health

8

Winter Medical Update 2008

9

COLLEAGUE INTERVIEW

Frank J. Indihar, M.D., FACP, MBA

12

Minnesota Physicians Carry Resolutions to the AMA

13

Portico Healthnet: A Local Solution for Covering the Uninsured

15

YOUR VOICE

17

The Case for Adaptive Leadership (Part 2)

19

Major Compensation Changes Under Medicare

21

Collaborating on Statewide Cessation

23

Minnesota Ambulatory Health Care Consortium Holds Annual Meeting Societies Sponsor Lunch ’n Learn U of M White Coat Ceremony Minnesota Health Care Dinner Party—Naples Florida

24

Members in the News EAST METRO MEDICAL SOCIETY

25 26 27 28

President’s Message EMMS In Action/Annual Meeting 2008 Election Results/New Members “Ethical Issues in Pay for Performance”/New Board Member/ Senior Physicians/In Memoriam/Caring Hearts WEST METRO MEDICAL SOCIETY

29 30 31 32

Chair’s Report WMMS In Action/Career Exploration for Students Annual Board Meeting/“First a Physician” Award New Members/In Memoriam

The Journal of the East and West Metro Medical Societies

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JANUARY/FEBRUARY 2008

On the cover: Societies change names to better reflect membership. Articles begin on page 2.

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1


Ramsey Medical Society Becomes

East Metro Medical Society but wanted to not jump into a name change without careful thought and discussion. After much debate, and with an ultimate vote of the RMS board, and a subsequent vote of the RMS membership, the decision to change the name was approved. January 1, 2008 the Ramsey Medical Society ofďŹ cially changes its name to the East Metro Medical Society. With a new name comes the opportunity to have a new look. Our new logo has the circle and latin inscription that have been longstanding symbols of our ICERE INSP organization. In the circle is the symbol of the staff of Asclepius, who SINCE 1870 was the mythological Greco-Roman god of medicine, and is considered a true symbol of RIBERE

INCIDERE

C INS

Ramsey Medical Society officially changes its name January 1, 2008 to the East Metro Medical Society (EMMS). The reason for the change in name is because the medical society membership has become more dispersed throughout the three counties that we serve (Eastern Dakota, Ramsey and Washington) as communities have grown and physician practices have moved to those areas. Many new members verbalized that they understood why they were joining the Minnesota Medical Association, yet did not understand why they needed to join the Ramsey Medical Society when they worked/lived in Dakota or Washington Counties. This disconnect with our name was heard frequently enough by staff and others that it spawned discussions at the RMS Board of Directors in 2006 and 2007. The RMS Board discussed at great length the need to be receptive to the disconnect felt by our members and perspective members,

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January/February 2008

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MetroDoctors

medicine. We hope you like our new name and our new look, and the new opportunity that awaits us. History of Other Logos Eleven physicians gathered in Dr. D. Herman Smith’s ofďŹ ce on Monday, February 14, 1870. Their purpose was to create the Ramsey County Medical Society by reorganizing the 1860 St. Paul Academy of Medicine and Surgery, which had languished since “The Rebellion.â€? The new society’s stated purpose was “the cultivation of the science and art of medicine, the interchange of professional experience, the encouragement of professional zeal, and the promotion of a friendly feeling among its members.â€? As to the Seal of our Society, there was not one until about 1900 when Dr. Brewer Mattocks suggested the legend, “Dissect, observe and write,â€? in the imperative as the Seal for the Ramsey County Medical Society. He wrote Arch-Bishop John Ireland to Latinize the motto. He was kind enough to send his secretary with the suggestion that the imperative be changed to the inďŹ nitive, and wrote the legend as it now stands. The Seal was presented to the Society and was graciously received. The microscope, scalpel and pen were designed by Pharmacist R.O. Sweeney of Sweeney’s Drug Store at Kellogg Boulevard and Wabasha St. The Latin is: Incidere (to dissect); Inspicere (to observe); and Inscribere (to write). The date MDCCCLXX is 1870. On January 1, 1996 the Ramsey County Medical Society merged with Wakota Medical Society. At that time the name was changed to Ramsey Medical Society (the word “countyâ€? was removed) and the logo was revised and now included the counties of Ramsey, Washington and Eastern Dakota.

The Journal of the East and West Metro Medical Societies

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Hennepin Medical Society Becomes

West Metro Medical Society On January 1, 2008, the name of the Hennepin Medical Society officially changes to the West Metro Medical Society (WMMS), incorporating the existing logo graphic with only a color modification. The resolution presented to, and approved by, the MMA House of Delegates last fall stated: Whereas, the Hennepin Medical Society represents physicians in Anoka, Carver, Hennepin, Scott and western Dakota counties; and although the name “Hennepin Medical Society” is recognized and respected nationwide as a front-runner in the medical association field, the name does not appropriately reflect the geographic locality of its membership or organization service area, therefore be it resolved that the name “Hennepin Medical Society” be changed to “West Metro Medical Society.” History The founding of the Hennepin County Medical Society on June 20, 1855, marks the beginning of the oldest medical organization in continuous existence in the state of Minnesota. Minneapolis, the site of its birth, could hardly have seemed a more unlikely setting for a scientific group, being an unorganized settlement perched on the banks of the Mississippi in the midst of a wilderness territory still three years from attaining statehood. Its official name was The Saint Anthony and Minneapolis Union Medical Society. In 1869 the Society was incorporated and its name changed to the Hennepin County Medical Society. (The above is excerpted from the Special Anniversary Issue of The Bulletin of the Hennepin County Medical Society, 125 Years of Service, A History of the Hennepin County Medical Society, Supplement to Volume 51, No. 3, June 1980.) No record can be found of the use of an official logo for The Saint Anthony and Minneapolis Union Medical Society, however, a cover of a program from the 1918 annual meeting of the Hennepin County Medical Society showed the use of the caduceus and a picture of Minerva, the Patron Goddess of Medicine. The use of the caduceus, and later the Asclepius (the single snake entwined about MetroDoctors

a knotty staff of Asclepius, the Roman god of medicine and healing) was found on copies of the letterhead of the Hennepin County Medical Society throughout the 1970s and early 1980s. In 1983, under the leadership of S. R. Maxeiner, Jr., M.D., chair of HCMS, a new logo was selected which included a map of all the counties. An entry from the HCMS Bulletin, May/June 1983, states: In an action which recognizes the growing importance of marketing physician services and the growth of HCMS into a medical society which now encompasses Anoka, Scott, Carver and Hennepin Counties, the HCMS Board of Directors have selected a logo for HCMS letterhead, envelopes, and other communication vehicles. The design is intended to demonstrate the geographic area represented by HCMS. Eleven years later, in November 1994, the

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The Journal of the East and West Metro Medical Societies

Metro Doctors JanFeb08.pdf 5

name of the HCMS was officially changed to drop the word “County” and add the tag line, “Representing physicians from Anoka, Carver, Hennepin, Scott and Western Dakota Counties.” And then, in 2006, the logo was given a fresh new design that portrays each of the counties comprising the Hennepin Medical Society as a segment of the whole. We hope you agree that the name West Metro Medical Society does, in fact, truly reflect the inclusiveness of our membership throughout the west metro communities.

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3


LETTERS

T

he recent (November/December) MetroDoctors article by Dr. Penny Wheeler, addressing the proposed new medical school by the University of St. Thomas and Allina Hospitals and Clinics, contains some basic misconceptions. Just as St. Thomas unwisely created an additional law school several years ago, exacerbating the surfeit of attorneys, another medical school would only further contribute to our frightening health care cost inflation. More doctors equate with more costs; each new physician generates upwards of a million dollars in annual costs. Current health care costs exceed 16 percent of GDP. How soon will costs reach 20 percent? When health care squeezes out other vital activities, will we then curtail the inflation? The more important question, beyond cost inflation, relates to whether or not more physicians

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January/February 2008

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are needed, either in primary care or any other specialty. Does more medical care equate with increased longevity and better health quality? The evidence to support this relationship is scant. In fact, there appears to be only a modest proportionality between the health of this nation commensurate with the costs. Whereas health care costs in 1970 amounted to almost 5 percent of a smaller GNP, it now is 16 percent of a much larger GDP. Are we that much healthier? Is our longevity significantly increased? Many factors are involved to demonstrate the lack of relationship between our health care costs and quality. Perhaps the major factor is the public perception (or misconception?) that, if we spend more resources and energy in health care, the health of Americans will improve correspondingly. Although Americans regularly state that we have the best health care in the world, data from other Western democracies clearly refute this conclusion. We are behind almost all European nations in overall mortality, infant mortality, obesity, and other parameters, and yet spend more money. The media, government, physicians, and the public parrot this misconception, to the point that we consider any expenditure on health to be worthwhile. A major contributor to health care cost inflation is the substitution of cognitive care by expensive new medical technologies. Instead of talking to patients, eliciting a careful history and a modest physical examination, physicians order imaging and laboratory tests before cognitive activities. Does every stomachache seen in the ER require a CT scan to exclude appendicitis? Wouldn’t a careful history and physical exam come to the same conclusion, but cost one-fourth as much? The justifications are that the public expects and demands tests and affords protection against malpractice litigation. Nonsense! Good medical care avoids suits and also costs less. Why don’t doctors use their heads, rather than write orders for more tests? Another activity contributing to health MetroDoctors

care cost inflation is the lack of evidence-based medicine (EBM). The American approach to medical practice is action, in which new technology is quickly introduced into everyday practice, long before any statistically valid evaluation (EBM) has been performed. As a result, thousands of patients are subjected to diagnostic and therapeutic procedures that are subsequently proven to have no value. Not only is this a factor in cost inflation, but it also subjects patients to the risk of adverse effects inherent in any medical activity. The classic example is the now abandoned bone marrow transplantation to augment high dose chemotherapy in women with advanced and recurrent breast cancers. Before a federally funded random clinical trial was completed to demonstrate that the expensive and morbidityproducing therapy had no value as compared to standard chemotherapy, 42,000 cases had been done. Shouldn’t this formidable procedure be evaluated before subjecting so many patients to a useless procedure? Do we need more physicians in primary care educated in a second-rate medical school? The concept of a medical school designed to “train” primary care physicians without medical school research and investigation is inherently flawed. How can you attract an excellent faculty if research is not part of the three-hat educational environment for faculty? Will this curriculum be inherently low-keyed, turning out physicians no better than nurse practitioners or medical assistants? The problems in our health care system are severe and not really responsive to shortterm solutions. The public must be educated to realize that more care is not necessarily better care. Physicians should use their heads diagnostically, instead of writing orders for additional expensive tests. Above all, this nation would not be harmed if less medical care were practiced. We certainly would be better served if another medical school were not created in Minnesota. Sincerely, Seymour Handler, M.D., Department of Pathology (retired) The Journal of the East and West Metro Medical Societies

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Physicians Can Be a Powerful Voice for Public Health

I

IN THE NOVEMBER/DECEMBER issue of

MetroDoctors, James Hart, M.D., and Jennifer Gunn, Ph.D., eloquently described the strong marriage between public health and medicine during the earliest years of our state. They went on to suggest that the marriage has become strained in recent years, partly due to changing priorities. They encouraged public health and medicine to renew their vows and to form a stronger union to promote the health of all Minnesotans. In my new role as commissioner of the Minnesota Department of Health (MDH), I hope to serve as a catalyst for nurturing a closer relationship between medicine and public health. The mission of MDH is to protect, maintain and improve the health of all Minnesotans. I provide examples in this article of how physicians can be a powerful voice for supporting Minnesota’s public health priorities. My first examples are true-life stories in which physicians recently influenced the community debate on secondhand smoke. St Louis County

St. Louis County Commissioners began a public hearing process in the summer of 2006 on a smoke-free ordinance, similar to the current Freedom to Breathe law. The county was the scene of the most intense opposition even though public opinion polls showed 70 percent support for smoke-free policies. County commissioners held hearings in cities across the county. Local physicians were briefed about the policy debate through the Lake Superior and Range Medical Societies. They received training materials, including

BY SANNE MAGNAN, M.D., Ph.D.

MetroDoctors

A Physicians Guide to Influencing Health Policy, and The Science and Politics of Secondhand Smoke, an issue-based synthesis of current research. Physicians fanned out to meet the opposition head-on. They testified at hearings, presenting important research and data. Most importantly, they conveyed personal stories of the harmful effects of secondhand smoke on their patients. They also submitted letters to the editor and corresponded with commissioners and legislators. One clinic system even sent a letter to commissioners signed by all medical staff. Hennepin and Ramsey Medical Societies

Members of the Hennepin and Ramsey Medical Societies also played an important role in promoting smoke-free policies in the Twin Cities. They participated in public hearings and community events to discuss the dangers of secondhand smoke. Their involvement was based on the premise that people listen to health professionals when important public health issues are discussed. The Hennepin Medical Society also served a pivotal role in implementing the Minneapolis “Done Smokin’, Still Hot” campaign, which promotes Minneapolis as a great place to visit with clean indoor air. The multifaceted plan included billboards, media events, newspaper articles and television commercials. The physicians of these counties, through their clinic systems, medical societies, and as individuals, really answered the call and quickly became masters of local advocacy. Efforts like these across the state contributed to the ultimate passage of the statewide Freedom to Breathe law, which is a major milestone in public health.

The Journal of the East and West Metro Medical Societies

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Getting Engaged

Working together, medicine and public health can be a powerful force. Below, I have outlined three priorities I intend to emphasize as commissioner. I encourage you to consider how you can become engaged in working on these and other important public health issues. Prevention

The old adage, “an ounce of prevention is worth a pound of cure,” is as meaningful today as it was back in 1872 when Dr. Hewitt established Minnesota’s first Board of Public Health in Red Wing. We have made great strides over the past century in preventing many infectious diseases. As acute diseases such as smallpox and polio declined in the last century, we witnessed an increase in chronic diseases such as heart disease, diabetes, lung cancer and asthma. Likewise, obesity rates have skyrocketed and chronic conditions have worsened as people became less active and made unhealthy food choices. By focusing on the top four preventable causes of illness and death — tobacco, physical inactivity, poor nutrition and alcohol —we can begin to turn the tide on this growing epidemic of chronic disease. This will require a broad range of environmental, social, public health and medical strategies. How to get involved: s #ONTINUESUPPORTINGIMPORTANTPUBLICHEALTH policies. For example, present a thank-you certificate to local legislators for their support of important health policies, such as Freedom to Breathe. s 7ORKWITHYOURLOCALOFlCIALSTOMAKEYOUR community more walkable and bikeable. s %NCOURAGEYOURCITYANDLOCALSCHOOLSTOSEEK (Continued on page 6)

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Voice for Public Health (Continued from page 5)

designation as “Governor’s Fit Cities� and “Governor’s Fit Schools.� Achieving this designation means they have made a strong commitment to creating environments that promote good health. s )MPLEMENTSYSTEMSINYOURCLINICTOREGULARLY address the top four preventable causes of illness and death. Measure your progress individually and collectively for quality improvement. s 2EVIEWTHESTATEWIDESTRATEGICPLANS-$( has developed with many partners to address such diseases as cardiovascular disease, diabetes, cancer and asthma. s #ONTACTYOURLOCALPUBLICHEALTHDEPARTMENT about possibly serving as a medical advisor. Also, make sure you are included on their health alert network. Public Health Infrastructure and Emergency Preparedness

Over the past several years, we have witnessed a number of serious public health threats, including SARS, West Nile virus, foodbornedisease outbreaks and natural disasters. We are also facing the real possibility of another inuenza pandemic. As a nation and state, we have made signiďŹ cant investments in preparing for serious emergencies. Among other things, Minnesota has developed a comprehensive pandemic u plan; we established the codeReady campaign, which is encouraging Minnesotans to be prepared for emergencies; and MDH has been working with local public health departments and emergency management ofďŹ cials to plan how to respond to emergencies. Having a strong public health infrastructure means maintaining a robust disease

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January/February 2008

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surveillance system, a state-of-the-art laboratory, sophisticated information systems, and a highly qualiďŹ ed workforce of epidemiologists, researchers, sanitarians, health educators, public health nurses, doctors, statisticians and others. We need to look for opportunities to further enhance our infrastructure so we can effectively address the routine and not-so-routine public health challenges that will come our way. How to get involved: s %NCOURAGEYOURFAMILY NEIGHBORSANDPATIENTS to become better prepared for emergencies. 2ECOMMEND THAT THEY USE THE INFORMATION ANDTOOLSAVAILABLEATCODE2EADYORG s 6OLUNTEER TO HELP RESPOND DURING AN emergency by signing up for the MinNESOTA2ESPONDS -EDICAL 2ESERVE #ORPS AT www.mnresponds.org.

s 7ORKWITHLOCALELECTEDOFlCIALSTOMAKESURE the community is ready to respond to emergencies. s !DVOCATE IN YOUR COMMUNITY AND THROUGH your professional associations for a strong public health system. For more information about your local Community Health Board, go to www.health.state.mn.us/trailhead. Health Care Transformation

Even though Minnesota already has a health care system envied by many others, we have room to improve. We need to move from an acute care, doctor-focused system that rewards visits and procedures to a system that is patient-centered, focusing on how to support people staying healthy and managing chronic conditions. We need redesigned care and payment models, with transparency and the right blend of collaboration and competition to

Dr. Sanne Magnan (SAN-ee MAG-nan) was appointed Minnesota Commissioner of Health by Governor Tim Pawlenty on September 28, 2007. Commissioner Magnan is responsible for directing the Minnesota Department of Health. MDH is the state’s lead public health agency, responsible for protecting, maintaining and improving the health of all Minnesotans. The department has approximately 1,300 employees in the Twin Cities area and in seven ofďŹ ces in Greater Minnesota. Professional Background Prior to being appointed commissioner, Dr. Magnan served as president of the Institute for Clinical Systems Improvement in Bloomington. An independent, non-proďŹ t organization, ICSI facilitates collaboration on health care quality improvement by medical groups, hospitals and health plans that provide health care services to people who live and work in Minnesota and adjacent states. Commissioner Magnan has also served as a staff physician at the Tuberculosis Clinic at St. Paul-Ramsey County Department of Public Health and a clinical assistant professor of medicine at the University of Minnesota. She was also vice president and medical director of consumer health at Blue Cross Blue Shield of Minnesota where she was responsible for case management, disease management, and consumer engagement. Commissioner Magnan also was lead physician at Lino Lakes Correctional Facility and a staff physician at various other clinics. She has served on several boards, including Minnesota Community Measurement. Commissioner Magnan was named one of the 100 Inuential Health Care Leaders by Minnesota Physician in 2004. Educational Background Commissioner Magnan holds a medical degree and a Ph.D. in medicinal chemistry from the University of Minnesota. She earned her bachelor’s degree in pharmacy from the University of North Carolina.

MetroDoctors

The Journal of the East and West Metro Medical Societies

12/26/07 2:46:42 PM


achieve results. The system should be exible for innovation to produce desired quality and value outcomes. We all know examples of underuse, misuse and overuse of health care services. Our challenge is to improve quality and patient experience while decreasing waste and overuse. It is clear that with increasing costs of health care, the uninsured rate rises. Our goal must be access to quality, affordable care for all Minnesotans. This will be no easy task. As Mark McClellan, M.D., Ph.D., former administrator, Centers for Medicare and Medicaid Services, said recently, “For those of you who think there is no health care system in this country, just try to change it.â€? Thankfully, in Minnesota, we have providers, consumers, health plans, employers, policy makers and public health ofďŹ cials who want to ďŹ nd common ground for change. There is a window for transformation, and we should not let it pass. How you can get involved: s 0ARTICIPATEINSTATEANDLOCALPOLICYDISCUSsions related to improving our health care system. Anticipate a lively discussion about health care transformation during the 2008 session. s %XPLOREOPPORTUNITIESTOTESTNEWMODELSOF care and payment, such as health care homes (or medical homes) and chronic disease management. s -AKEVALUEQUALITYANDPATIENTEXPERIENCE for the dollar cost) a strategy within your organization. Support changes within our payment system that allow you to design for value.



       

      

                                    

                                                               

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The Journal of the East and West Metro Medical Societies

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Sanne Magnan, M.D., Ph.D., Commissioner, Minnesota Department of Health can be reached at commissioner@health.state.mn.us. The Department OF(EALTHS7EBSITEISWWWHEALTHSTATEMNUS MetroDoctors

     

                

Your Power as a Physician

Never underestimate your power as a physician. As trusted counselors with the health of your community at heart, you can be effective advocates in advancing health-promoting policies and legislation. By joining forces around common priorities, medicine and public health can renew their vows so that Minnesota remains one of the healthiest states in the nation for decades to come.

    

    

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January/February 2008

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FEBRUARY 23-MARCH 1, 2008 Ramsey Medical Society Foundation sponsors

11th Annual Winter Medical Update 2008 SPONSORED BY RAMSEY MEDICAL SOCIETY FOUNDATION ENDORSED BY RAMSEY MEDICAL SOCIETY AND HENNEPIN MEDICAL SOCIETY

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MetroDoctors The Journal of the East and West Metro Medical Societies Visit: www.metrodoctors.com for complete brochure.

12/26/07 2:46:47 PM


COLLEAGUE INTERVIEW

Frank J. Indihar, M.D., FACP, MBA

Frank Indihar, M.D., FACP, MBA, is board certified in internal medicine and a fellow of the American College of Physicians. He is a vice president of HealthEast Care System and is the CEO/medical director of Bethesda Hospital in St. Paul. Dr. Indihar is also a consultant to the Social Security Administration’s Office of Hearings and Appeals and an adjunct professor at the University of Minnesota Medical School. Dr. Indihar practiced general internal medicine and pulmonary medicine with St. Paul Internists, P.A. in St. Paul from 1973 to 2000 and has served as president of the Ramsey Medical Society. First elected as an alternate delegate to the AMA in 1992 and a delegate in 1996, Dr. Indihar currently serves as chair of the Minnesota delegation to the AMA. In addition, Dr. Indihar served as the President of the Minnesota Academy of Medicine (2006-07). Questions were submitted by: Lee Beecher, M.D., Robert Christensen, M.D., Peter Dehnel, M.D., and Lisa McGinnis, M.D.

Q A

Given the graying of America, what is the AMA doing to improve Medicare funding for long-term care and rehabilitation services? It is an unfortunate reality that with the shrinking availability of health care funding at all levels of government reimbursement programs (Medicare, Medicaid, etc.), the funding that has seen little or no increase has been for patients requiring long-term acute care, long-term care in a TCU or SNF, or rehabilitation services. In fact, in addition to decreasing reimbursement, the governmental funding agencies have been placing an increasing regulatory burden on long-term acute care hospitals and rehabilitation units to limit the patients that are admitted. The AMA and the AHA have vigorously fought these cuts in reimbursement and regulatory issues at the federal and state levels. It has long been an agenda priority of the AMA to seek comprehensive coverage for our patients’ needs. I have long been interested in the issues of long-term acute care — the decreasing reimbursement, increasing regulation of the industry, the limitation on diagnoses that we can care for have been challenging. The future, of course, holds that the need for these services will burgeon, and the complexity of cares for these seriously ill individuals will become even more needed. It has taken all of our lobbying efforts to keep the long-term acute care industry solvent thus far in the face of increasing CMS regulation and reimbursement adjustments (downward, for the most part).

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The AMA’s Council on Medical Service issued an excellent white paper on the financing of long-term care in December 2004. The premise of this paper is that publicly financed programs such as Medicare and Medicaid will be financially overwhelmed by 2030, leaving millions of Americans unprepared for the heavy financial and non-financial burdens of long-term care services. The report describes and encourages the utilization of various private sector options to ameliorate this burden, including long-term care insurance, Health Savings Accounts, conversion of life insurance policies and development of life care communities across the nation. The Council recommended targeted tax incentives to encourage Americans to utilize these options rather than depend on shrinking Medicare and Medicaid dollars.

How can specialists in geriatrics earn a living since they are dependent on Medicare funding and what financial incentives are there for young doctors to go into geriatric treatment specialties? The Medical Group Management Association has compiled data for the Midwest that indicates that the median annual income for a specialist in geriatrics is currently $184,237 with some practitioners at the 90th percentile earning $266,027 annually. While there are other specialties that have more earning potential (and many with less), the MGMA’s data would indicate to me that a specialist in geriatric’s annual income is actually quite reasonable. Rather than focusing on income, however, a young doctor’s temperament, interests, and sense of fulfillment should be the determinant of their life’s work focus. (Continued on page 10)

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Colleague Interview (Continued from page 9)

How did you transition to an administrative role in health care and what characteristics makes for a good ďŹ t for pursuing a medical career through administration? I actually spent 27 years as a practicing internist/pulmonologist with St. Paul Internists in St. Paul, where we served as hospital intensivists, internal medicine consultants, and general internists to a large cadre of ofďŹ ce-based patients. It was this basis, I believe, that prepared me for my current administrative role as a vice-president at HealthEast and the CEO of Bethesda Hospital (where I started the Respiratory Care Unit in 1979 for ventilator patients). However, I did get my MBA in 1992 when it became apparent that to run one’s practice and speak the language of the practice managers, the additional training was needed. I also served as the medical director of Bethesda Hospital throughout this period and it was a natural transition to becoming the CEO. I’ve enjoyed both aspects of my career and view both as playing a vital role in providing health care to our patients. As a physician, I was involved in the micro-management of individual patient’s needs, but as a CEO I am involved in the macro-management of the health care of a population of patients. I strongly believe that all physicians should continually explore their personalities and make transitions throughout life that will allow them to experience the fullness and broad approaches to medical

care that exist — from providing 1:1 patient care to becoming leaders in organized medicine and the community to exploring new ways of contributing to the medical ďŹ eld.

What is the AMA doing about the increasing problem of obesity in America’s children and adults? The AMA has long been interested in the epidemic of obesity in America. A task force has been formed and a white paper written on this issue (and many other public health problems facing America) under the direction of the AMA’s Council on ScientiďŹ c Affairs and Public Health. The AMA has also been the fulcrum of forming partnerships with other like-minded organizations (like the various diabetic and endocrinology societies) to examine the etiologies and formulate a plan to combat this “growingâ€? problem. Many of the advertisements in both print and video media have occurred as a result of the AMA’s development. It should be noted that the AMA’s public health and scientiďŹ c agenda is a major pillar of service to American physicians and public. The wide range of issues studied by this group is a major impetus of the AMA’s efforts and use of resources. In addition to sponsoring a National Summit on Obesity, the AMA has published, with support from the Robert Wood Johnson Foundation, and developed in collaboration with the U. S. Department of Health and Human Services, a series of booklets that provide roadmaps for clinical

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The Journal of the East and West Metro Medical Societies

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approaches to the management of obesity. Minnesota’s own J. Michael Gonzalez-Campoy, M.D., Ph.D., a former Ramsey Medical Society president and former president of the Minnesota Medical Association, has been vigorously involved in the problems of obesity at the AMA. As a Delegate to the AMA’s House of Delegates from the Minority Affairs Consortium (MAC), Mike continually addressed the subject of obesity in minority populations via active participation with the AMA Councils and brought the subject forward to the House floor and Reference Committees on many occasions as a major public health hurdle.

What is the outlook for membership in the AMA and what can be done to improve membership? Membership is the number one agenda item of the AMA’s Board of Trustees. And, indeed, their efforts are paying off as we’ve seen a gradual decline in the hemorrhaging of membership and, in certain categories, actually seen a rise in membership as new programs have been initiated to attract members. However, a number of interesting factors come into play as the AMA continues to struggle with maintaining membership (it should be mentioned, however, that the AMA is fiscally very strong and financially solvent, but membership is needed for the AMA to fulfill its mission). First, it is my observation that we in America have lost a sense of belonging to anything; memberships in most organizations have fallen in recent years as we’ve developed a more inward focus in our population. Second, and peculiar to medicine, is that the rise of large clinics and employment of physicians has decreased the need for an association to provide for our education/representation/social requirement — these are all provided by the employer. Third, the provision of dollars to pay for associations is generally part of a smorgasbord of limited dollars provided by the employing organization, which can be used for education, association dues, specialty dues, insurance plans, vacation/seminars, computers and computer educational programs, etc. Fourth, most physicians belong to their specialty organizations and rely on them for their lobbying and educational benefits. The AMA (as well as our state MMA and our county organizations) need to continually provide value to the membership and this value must be proven again and again. The AMA lobbied very diligently and successfully this year to reverse the Medicare physician payment cuts proposed by CMS in January. These efforts, of course, benefited both AMA members and non-members. But, will this success be remembered by the physicians next year when we ask them to join organized medicine organizations? We must all pitch in on these expensive state and federal efforts by personally becoming members of the MMA and AMA — and recruiting others to join!

How are policy issues brought to the AMA House of Delegates and how can one become a candidate to serve on the Minnesota Delegation to the AMA House of Delegates? The Minnesota AMA Delegation is nominated by the MMA’s Nominating and Leadership Development Committee based on an individual’s MetroDoctors

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participation in county and state leadership roles or committee work on both levels. The Delegation’s number is based on the number of AMA members in Minnesota, with one delegate and one alternate for each 1,000 members. In Minnesota, the terms of service on the Delegation are limited, always making way for “new” members to be nominated and elected at the MMA’s Annual meeting on a rotating basis. In addition to serving as the basis for electing the delegation, all policy items that are brought to the AMA originate at the MMA’s Annual Meeting. Resolutions can be brought by individuals or counties through the reference committee process at the meeting. Those items that request AMA action are then forwarded to the AMA Speaker of the House for placement in the appropriate AMA Reference Committee where your delegates argue for the validity of the position. Eventually the Reference Committee’s disposition is brought to the full AMA House of Delegates for action.

If you could wish for one thing related to health care in the Twin Cities, what would it be? By far and away, it is important that ALL of our citizens, whether they be low income, students looking for their first job, individuals between jobs, families, etc. HAVE health insurance and a basic coverage plan. It is unthinkable that in a country with such resources, we have not provided a basic health insurance program for all of our citizens. And, we all know that the uninsured ultimately raise the cost of medical care by seeking their care in expensive settings, such as emergency rooms and that quality of care suffers since there is no one who is in “charge.” I know that the devil is in the details of &RVPHWLF'HUPDWRORJ\ ‡%RWR[‡&KHPLFDO3HHOV‡'HUPDO)LOOHUV providing such a ‡+DLU5HGXFWLRQ‡)DFH /HJ9HLQV plan, but the MMA’s ‡7DWWRR5HPRYDO‡0LFURGHUPDEUDVLRQ ‡6FDUV :ULQNOHV‡6XQ'DPDJH universal coverage ‡%RG\&RQWRXULQJZLWK&HOOXOLWH5HGXFWLRQ ‡/LSRVXFWLRQ‡6NLQ5HMXYHQDWLRQ‡)DFHOLIW program is a start in ‡$JH6SRWV‡6NLQ&DUH3URGXFWV‡/DVHUV the right direction. ‡6NLQ7LJKWHQLQJ‡:ULQNOH5HGXFWLRQ And, whatever the 0HGLFDO 6XUJLFDO ‡0RKV6NLQ&DQFHU6XUJHU\DQG funding mechanism 5HFRQVWUXFWLRQ‡/HVLRQV‡5DVKHV or vehicle for pro‡(F]HPD‡'HUPDWLWLV‡3VRULDVLV ‡/DVHUV‡<HDUO\6NLQ&KHFNV viding this coverage ‡$FQH$FFXWDQH‡(DU/REH5HSDLU ‡)DFLDO6XUJHU\‡0ROHV‡:DUWV might end up being, we need to star t NOW. Task forces (2724) are working on this Ruth A. Rustad, M.D. O.J. Rustad, issue, as they have for %RDUG&HUWL¿HG,QWHUQDO0HGLFLQH M.D. , F.A.A.D. )RFXVLQJLQ'HUPDWRORJ\ %RDUG&HUWL¿HG'HUPDWRORJLVW my entire professional 0RKVDQG&XWDQHRXV6XUJHRQ Cynthia Anderson, PA-C $GMXQFW$VVRFLDWH3URI8RI0 &HUWL¿HG3K\VLFLDQ$VVLVWDQW career. What we need Voted one of the TOP Larry Weidell, PA-C Dermatologists by &HUWL¿HG3K\VLFLDQ$VVLVWDQW Mpls/St. Paul Magazine is action and a positive first step toward providing this basic coverage for all.

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January/February 2008

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Minnesota Physicians Carry Resolutions to the AMA

T

THE MINNESOTA DELEGATION to the

American Medical Association’s House of Delegates Interim Meeting, held November 13-17, 2007, met with considerable success in presenting resolutions from Minnesota. The Delegates representing Minnesota at this meeting included Frank J. Indihar, M.D., (Chair of the Delegation), John M. Van Etta, M.D. (Vice Chair of the Delegation and Chair of the North Central Medical Conference Caucus), Kenneth Crabb, M.D., Raymond Christensen, M.D., Anthony Jaspers, M.D., Sally Trippel, M.D., MPH, Robert Grow, M.D., (Resident Delegate) and Jason Meyers (Student Delegate). The Alternate Delegates representing Minnesota were John Abenstein, M.D., MSEE, Gail Baldwin, M.D., Blanton Bessinger, M.D., David Estrin, M.D., Benjamin Whitten, M.D., James J. Dehen, M.D. (President of the Minnesota Medical Association) and Dionne Hart, M.D. (Resident Alternate Delegate). The Delegates strongly supported Minnesota Resolution 815, which dealt with the Joint Commission’s Interpretation of Medication Reconciliation. It was strengthened to include that “all Joint Commission standards including medication reconciliation...” be consistently interpreted.... The Reference Committee indicated that there was strong supportive testimony on the resolution and that the Joint Commission representative present at the hearing said the Commission recognized the existence of the problem and was taking steps to address the issues raised in the resolution. Interestingly, the Joint Commission recently sponsored a Summit on Medication Reconciliation where many

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of these issues were raised by the AMA and others. The Minnesota Resolution requesting the development of a “Tiering System for Third Party Payers” was referred to the Board of Trustees for study. Testimony was mixed from the hearing attendees, with concerns being raised by many about the methodology and even the feasibility of evaluating insurers and placing their offerings in a tiered ranking system. Many at the hearing reflected frustration over the related issue of insurer evaluation of physicians. It was determined that the Board of Trustees would need to study the issue and develop an advocacy approach in a coordinated fashion. Resolution 714, from the Minnesota Delegation, was referred to Reference Committee J where it received widespread and passionate acceptance with the goal to allow care for returning servicemen and women and their families under the TRICARE system be simplified to reduce the complexities associated with the contracting process. The North Central Medical Conference strongly supported this resolution and the audience at the Reference Committee strongly emphasized that it is the health of veterans and their families that is at stake and the government should ensure that they receive the care they need in their local communities. A fourth resolution, dealing with Specialty Societies’ representation in the AMA’s House of Delegates was not heard at this meeting, which was primarily focused on advocacy issues. We will bring that resolution to the AMA’s Annual Meeting in June, 2008.

The Journal of the East and West Metro Medical Societies

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Portico Healthnet: A Local Solution for Covering the Uninsured

I

IMAGINE YOU ARE THE parent of four

children and work as a dishwasher to support your family. Your spouse needs treatment for depression. One of your children needs eyeglasses. Another child suffers from severe asthma and respiratory problems, and he experiences migraines so debilitating that you need to repeatedly bring him to the emergency department. You and your family are also uninsured. Your family does not qualify for publicly subsidized health care coverage. Health insurance is prohibitively expensive for your family, and it’s impossible for you to pay out-of-pocket for health care. What do you do? Fortunately, this family found Portico Healthnet. Portico currently provides coverage for the family, paying for a continuum of health care services, as well as care management. All of the children received complete physicals and recommended follow-up care within the first six months of enrollment in the program. The parent suffering from depression receives ongoing treatment. The family’s care management coordinator helped obtain eyeglasses for one child, and arranged for an in-home pediatric provider to treat the severely ill child, who was recently diagnosed with lead poisoning. Based on his medical condition and with advocacy by the care management coordinator from Portico, the child has been enrolled in the state’s Emergency Medical Assistance program, which covers all of his health care needs. The other five family members continue to access care through Portico’s coverage program — the only viable option they have. Over the past 12 years, Portico has helped hundreds of families in similar circumstances access health coverage and care. Over 6,000 uninsured children and adults have enrolled in Portico’s safety-net coverage program, and B Y D E B R A H O L M G R E N , M . A . , M PA

MetroDoctors

another 5,000 have been enrolled in public coverage programs with assistance from Portico. What is Portico Healthnet?

Portico Healthnet (formerly MetroEast Program for Health) is a nonprofit health and human services organization created and sustained by east metro hospitals working together to provide regular access to health care for community members with low incomes and no insurance. This successful partnership transcends competition among the nine hospitals and maintains a single focus: to reduce the number of people without coverage for health care services. Portico provides health care coverage for low-income uninsured residents of the threecounty east metro area who do not qualify for public programs and who have no other affordable options. Portico’s hospital partners pay for the medical care provided for enrollees, including primary and preventive care, specialty and urgent care, eye exams, outpatient procedures, outpatient mental health services, prescription medications, interpreter services for medical appointments, and care management. With annual contributions from hospital partners totaling approximately $1 million, Portico provides ongoing health care services for 800 to 1,000 individuals per year. In other words, at a cost of just $1,000 to $1,250 per person per year, Portico provides a continuum of preventive, primary and specialty medical services to uninsured people in the community, keeping them healthy and no longer dependent on emergency care. Portico’s unique model includes individualized, in-person care management assistance. Portico’s care management coordinators (who are licensed social workers) help enrollees navigate the health care system and use services

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appropriately. Shortly after enrollment, care management coordinators meet face-to-face, one-on-one with each individual and family receiving coverage through the program. This initial meeting is the foundation for the trusting relationship built between care management coordinator and enrollee that ultimately results in reduced emergency department and inpatient hospital admissions. Reaching the Uninsured

In order to connect with uninsured community members before their medical needs become urgent, Portico pursues vigorous, communitybased outreach. Portico’s community health workers establish relationships with hundreds of metro-area human service agencies, schools, health care organizations, workforce centers and other organizations serving the uninsured. As a result of their networking efforts, Portico’s community health workers are able to meet with uninsured individuals at numerous locations throughout the Twin Cities. Portico’s community health workers screen uninsured individuals and families for a variety of coverage options. The Minnesota Department of Health estimates that over 50 percent of uninsured Minnesotans are eligible for Minnesota Health Care Programs but have not enrolled. Although one may qualify for subsidized coverage, actually applying for and enrolling in a state program can be overwhelming, if not impossible, to accomplish on one’s own. The application for Minnesota Health Care Programs is 24 pages long (not including the instructions), and many applicants face obstacles as they try to obtain the required verifications and documentation. That’s why Portico also provides comprehensive enrollment assistance and advocacy support for those potentially eligible for public programs. (Continued on page 14)

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Portico Healthnet (Continued from page 13)

Why Coverage Matters

Health coverage and affordable access to care are key components of economic self-sufficiency. The Kaiser Foundation estimates that among the uninsured, gaining health care coverage can increase annual earnings by as much as 30 percent. Healthy workers are productive workers, and when children stay well,

parents experience less absenteeism at work. A study recently published in JAMA found that after an injury or onset of a chronic condition, uninsured persons, compared to their insured counterparts, were less likely to receive any medical care, less likely to receive recommended follow-up care, including prescription medications, and less likely to fully recover. Survey data from Portico’s coverage enrollees consistently indicate that, as a result of the program, participants are less likely to

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utilize emergency department services, more likely to receive complete physicals and keep immunizations current, and less likely to be hospitalized. The Kaiser Foundation estimates that coverage for health care would reduce the mortality of the uninsured by 15 percent. A Wise Investment

In addition to improving the health and quality of life of those it serves, Portico also provides a significant benefit to the community in terms of dollars and cents. Over $3 million is infused into the metro area’s health care system each year through medical reimbursements from Minnesota Health Care Programs for patients enrolled with Portico’s assistance, reducing uncompensated care burden of health care providers. A recent analysis of Portico’s services found that for every $1 invested in Portico’s programs, there is a Return of Investment to the community of about $3. This ROI was calculated with a model that considered: (1) the savings resulting from decreased utilization of the emergency department among Portico enrollees; (2) the savings resulting from decreased hospital admissions among Portico enrollees; (3) increased earnings of enrollees due to access to primary care; and (4) increased care system payments from enrolling the uninsured into public programs. Former enrollee Lorna R. can’t say enough about Portico’s coverage program. She no longer lives in the coverage program’s service area, having moved from St. Paul to Minneapolis. “It’s the best program I’ve ever seen, and the people there are so compassionate and caring,” said Lorna, owner of a coffee shop and freelance photographer. “They’re just great at making you feel important and like you matter and you count, and they’re not going to leave you in the dust. I was just really grateful to even have it.” Lorna would like to see the coverage program expanded to other areas of the Twin Cities. We, at Portico, want to make that happen. Until policymakers settle the debate on how to expand coverage to the uninsured, Portico offers a solution.

Debra Holmgren, MA, MPA, is President of Portico Healthnet and can be reached at dholmgren@porticohealthnet.org.

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YOUR VOICE

Why Health Care is Not a Right “If some men are entitled by right to the products of the work of others, it means that those others are deprived of rights and condemned to slave labor.” Ayn Rand “If we can prevent the government from wasting the labors of the people under the pretense of caring for them, they will be happy.” Thomas Jefferson

T

here are serious problems in American health care. The issues of double digit inflation and the uninsured cannot be ignored. It is tempting to believe that by simply putting pen to paper we can create a “right” to health care and solve these problems. Sadly, such a legislative solution does not address the root cause of the issues and will make things worse rather than better. In all sectors of the economy outside of health care, consumers restrain their purchases based on price and value forcing providers to drop costs and raise quality. This does not happen with health care. With first dollar payment, whether by an insurance company or the government, the patient perceives costs as zero. With a perception of zero costs, demand is potentially infinite. Even wealthy insurance companies and governments do not have infinite financial resources. Patients have no incentive to function as savvy shoppers; therefore, someone must limit expenses. Any third party payment system must do exactly that. This holds true whether it be the British National Health Service, the Canadian Ministry of Health or American insurance companies. No measure of compassion or “political will” can alter these economic facts. The current government created third-party payment system has someone other than the patient footing the bill. Such payers attempt to pay out as little as possible. Providers bill as much as possible to recoup costs. The hapless patient without insurance may be saddled with an enormous bill that bears no resemblance to what the costs would be if health care were a marketplace commodity where patients functioned as consumers. Why not let patients’ control the money they spend rather than having corporate or government bureaucrats do so? The claim that health care is too complicated is an elitist insult. Cars and computers are complex also but somehow we can all figure out when we are getting value for our dollar. One method of attempting to guarantee a “right” to health care is a government run single-payer system. Under such a system, doctors will not be reimbursed fairly nor will patients have their needs met. In normal markets, the allocation of resources is determined by the intelBY LEE KURISKO, M.D., FRCPC

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ligence of the marketplace in which we all democratically partake with the free exchange of dollars. Instead, in government systems of health care, resources are allocated by those few who can get their hands on the levers of political power. The United States was unique among nations in that it was originally based upon the value of liberty. Freedom, as originally conceived, was limited to the field of politics. The term simply meant freedom from the coercion of others. It certainly was not a claim to the property or labor of others. The claim that “A hungry man is not free” is absurd. It confuses the political concept of freedom with the biological fact that we all have needs for food and shelter. Food is even more necessary to sustain life than is medical care. Food is not deemed a right and yet virtually everyone in this country gets fed. In fact, the poor in this country have a problem with obesity, not emaciation. Liberty requires rights. Rights originally defined freedom of action. They were not a guarantee of being provided for. The original rights were all “negative” rights in that they simply defined the freedom to act. The only obligation was to refrain from interfering with the actions of others. On the other hand, positive rights impose an obligation for someone to do something for others. All rights listed in the Bill of Rights are negative rights. They simply allow the freedom to act with no imposed obligation. All legitimate rights are negative rights or liberty rights. “Rights” such as health care imply that someone must act to provide them. What of the liberty rights of the providers of health care? They have to be violated and therefore positive rights such as health care are pseudo-rights. The liberty rights of doctors, nurses, taxpayers and health care entrepreneurs must be abrogated to provide such care. Implicit in health care as a “right” is that these people must be coerced. For example, the proposed Clinton Health Security Act of 1993 was based on compulsion. The word prison shows up seven times in the legislation; penalty 111 times; fine six; enforce eight; prohibit 47; mandatory 24; limit 231; obligation 51; and require 901. The Republican counter proposal was also based on forcing people to do what government believed to be the right thing. Prison was used once; enforce 37 times; penalty 64; fine 12; prohibit 19, and require 482.1 It is simply inescapable that the government provision of goods and services is based on government compulsion of its own citizens. Countries based upon coercion of its citizens, rather than liberty, have not fared well. The lesson has been well demonstrated in the Soviet Union, China and North Korea. (Continued on page 16)

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Your Voice (Continued from page 15)

In my home country of Canada, their system of government medicine started merely as a payment system. Because no government has inďŹ nite resources, government in Canada has had to insidiously take over and control all of health care. This necessitates a system of Soviet-like centralized planning and co-ordination of the resources. Such a model is a proven failure with the collapse of the Soviet economy. Simply look at food production and distribution in the former U.S.S.R. versus the availability of food on Manhattan Island. In the U.S.S.R. people were starving and waiting in lines for basic items like eggs, milk and ďŹ&#x201A;our. On Manhattan Island, you can get any type of food 24/7 whether it be Peking duck, take-out lasagna or a diet caffeine-free Coke. This illustrates the clumsiness of central planning versus the agility of free markets. Market solutions work brilliantly and socialism is a dismal failure. It is often mistakenly believed that health care is so important that we cannot entrust it to free markets when the reality is that because it is so important we must entrust it to free markets. Just as importantly, in a government system, reimbursement is on a ďŹ xed fee schedule. This is a form of wage and price controls. As Milton Friedman had said, â&#x20AC;&#x153;Wage and price controls lead to shortages â&#x20AC;&#x201D; always.â&#x20AC;? That is why 16.8 percent of the Canadian population has no access to primary care2 and the average wait to see a specialist is 18.3 weeks3.

Those that really care about the current state of health care in America should abandon claims of health care as a right or demands for a single payer system. We do not want to further empower clumsy government or privileged insurance companies to spend our money. The truly thoughtful should demand that patients, in conjunction with their doctors, be empowered to spend their own money as they see ďŹ t to obtain the services that are needed. This can be achieved by using insurance as originally intended for unlikely events and not for ďŹ rst dollar coverage of routine and expected care. Deregulated high deductible insurance, and HSAs are the path to marketplace innovation and lower costs. Look at the prices for Lasik surgery. Lasik is not covered by most insurance policies. Costs have plummeted and ophthalmologists are paid precisely what the marketplace sees as fair payment. Public monies currently used for the poor could be redirected into HSAs for them. Such strategies could unleash the awesome productive power of the marketplace that has created the wealth, abundance and low costs prevalent in every other sector of the mighty American economy. Best of all, no one will have to have their liberty sacriďŹ ced for a bogus right to health care. ,EE+URISKO -$ &2#0#ISONTHE"OARDOF$IRECTORSOF#ONSULTING 2ADIOLOGISTS ,TDANDTHE-INNESOTA0HYSICIAN 0ATIENT!LLIANCE (Endnotes) 1) Browne, H., Why Government Doesnâ&#x20AC;&#x2122;t Work, St. Martinâ&#x20AC;&#x2122;s Press, 1995, p. 101. 2) Canada AM, CTV Web site, July 4, 2007, http://www.ctv.ca/servlet/ArticleNews/story/ CTVNews/20070704/immigration_doctors_070704/20070704/ 3) Waiting Your Turn. Hospital Waiting Lists in Canada. 17th Edition, N. Esmail, M.A. Walker, October 15, 2007, http://www.fraserinstitute.org/commerce.web/ publication_details.aspx?pubID=4962

â&#x20AC;&#x153; The only constant we see is change.â&#x20AC;?  +(#)0$,)(-$(.&&2 / &)*$("02,-)*+)- -2).!+)'(-)# &*2). prevent medical malpractice lawsuits. For more than 27 years, weâ&#x20AC;&#x2122;ve seen how malpractice issues can challenge physicians. Weâ&#x20AC;&#x2122;re here to help protect your assets with malpractice insurance coverage that is backed with: 5(,.+*,,& +$,%'(" ' (-(*-$ (-,! -2+ ,).+ , 5)'* -$-$/ *+$$("-#+)."# !! -$/ .( +0+$-$(" 5-+)(" ! (, '$( *#$&),)*#2-)*+)- -2).+$(- + ,-, 5 +/$ (,.**)+--#-*.-,2).4rst )& +(')+ ).-#)0(# &**+)- -2).&&    361 && (-+-$("!+)' ,Exclusively endorsed and recommended by the Minnesota Medical Association.

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MetroDoctors

to help your practice thrive

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The Journal of the East and West Metro Medical Societies

12/26/07 2:46:55 PM


The Case for Adaptive Leadership

When Physicians and Their Organizations Face DifďŹ cult Problems: Electronic Medical Record Implementation

Editorâ&#x20AC;&#x2122;s note: This is the second of a three part series discussing adaptive leadership as a model for addressing the difďŹ cult problems that health care organizations face. The ďŹ nal article will describe the remaining principles of the model developed BY$R2ON(EIFETZ

I

Instructions to medical staff regarding EMR usage, as recently printed in a medical staff newsletter: â&#x20AC;&#x153;Avoid selecting any order with â&#x20AC;&#x153;HCHGâ&#x20AC;? as the ďŹ rst letters in the order. Any order entry items that have â&#x20AC;&#x153;HCHGâ&#x20AC;? as the ďŹ rst part of the order title are for charging only. They do not initiate an action to do a procedure or test. The majority of the time you will not see these items because they do not appear on the initial search results list. However, if you choose the facility or database lists these HCHG orders may be seen. The HCHG items need to be available to workers to correctly complete patient billing. Be observant of the wording as you select the order. Other than this designation, the order may appear identical to the actual procedure order. Be sure to read the full line for the order. You want to be sure it is the correct order and is available at the hospital where the patient is located.â&#x20AC;? In the September/October 2007 issue of MetroDoctors, we introduced the leadership model developed by Ron Heifetz, a psychiatrist working at Harvardâ&#x20AC;&#x2122;s Kennedy School of Government. Through observation and application of principles in psychology, group dynamics and organizational behavior, he describes a model of leadership that takes commonly encountered obstacles to signiďŹ cant change into account. The model describes adaptive challenges and distinguishes them from situations that require BY

C A S C A D E PA R T N E R S

MetroDoctors

technical work. He emphasizes the beneďŹ t of understanding the complexity of the values an organization holds, including values that compete, contrasted against the hard reality that the organization faces. Identifying competing values (i.e., meeting patient needs vs. quality improvement vs. cost containment) and mobilizing people to perform the work needed to make progress is adaptive leadership. In the Heifetz model, one begins to exercise leadership by determining whether a situation requires technical or adaptive work. Situations requiring a technical approach involve applying skills that already exist, either in the organization or available elsewhere, following the formal authorityâ&#x20AC;&#x2122;s vision. Technical work can be difďŹ cult and complex, such as running a code, but it is work we know how to do. In technical situations the role of authority is to provide direction, protection, role orientation, conďŹ&#x201A;ict resolution and maintenance of norms. While technical problems entail work we know how to do, adaptive problems require us to learn something new. According to Heifetz, â&#x20AC;&#x153;adaptive work is required when our deeply held beliefs are challenged, when the values that made us successful become less relevant, and when legitimate yet competing perspectives emerge.â&#x20AC;? In adaptive situations, attitudes, beliefs and behaviors must change. Adaptive change is difďŹ cult and any of us, whether in a clinic, hospital or boardroom, will encounter resistance in the form of avoidance of necessary work. Heifetz renames the resistance that we are all familiar with in the therapeutic relationship â&#x20AC;&#x153;work avoidance.â&#x20AC;? Individuals facing the painful work of adaptation will naturally avoid it. Avoidance mechanisms include silence, denial, holding onto the past, confusion, laying blame, sabotage, attack on authority, fake solutions (structural adjust-

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ments, task forces, disingenuous agreement, deal making) and sterile conďŹ&#x201A;ict that involves no listening, curiosity or creative engagement. Work avoidance may be triggered by too little distress â&#x20AC;&#x201D; not believing that a problem is important, for instance â&#x20AC;&#x201D; or too much distress â&#x20AC;&#x201D; when many problems are encountered at once and people or systems are overloaded. Our current struggles with the electronic medical record (EMR) are a springboard to discuss adaptive leadership principles in action. The Electronic Medical Record Implementation: Technical or Adaptive Work?

Patient stories are at the heart of our work. Even though we have lists of symptoms, physical ďŹ ndings, ďŹ&#x201A;ow schemes and decisionmaking trees in our heads guiding the creation of differential diagnoses, clinical narratives are imperative to care. Often our work depends on the stories within stories. The medical record is primarily a device used to advance the patientâ&#x20AC;&#x2122;s care. The doctor becomes the author of the patientâ&#x20AC;&#x2122;s story that serves as a hub of human relationships when caregivers focus attention on the patientâ&#x20AC;&#x2122;s needs. Creating the record is a shaping process in which the patientâ&#x20AC;&#x2122;s circumstances, with emphasis of some aspects of the story and minimizing or completely eliminating others, are worked into a manageable unit of information. The story is then easily and effectively communicated, framing relationships between clinicians and their patients. As medicine uses the computer as a new recording tool, how can this essential task of preserving the patientâ&#x20AC;&#x2122;s story be best undertaken? There are many values tradeoffs with the EMR. The data template challenges the value of the narrative as effective communication. (Continued on page 18)

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17


Adaptive Leadership (Continued from page 17)

A record used to guide best care delivery is also a business and compliance tool. Care delivery systems use the record to balance quality of care with cost containment. The familiar physician-driven written or dictated medical record located in one physical chart is replaced by simpler, easier workflows for nurses, pharmacists, health unit coordinators, materials management staff, available at many locations simultaneously while also requiring physicians to type. This challenges older physicians more than younger doctors. All of these challenges are weighed against the value of how care is improved by the availability of the record simultaneously throughout the hospital and clinics. Many efforts to implement electronic records have failed. Failure could be blamed solely on technical issues, such as difficult data entry or cumbersome usability. However, behind possible technical flaws lie the questions: What do we want the EMR to be? A recording tool? A quality improvement tool? A cost savings measure? A billing and coding

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tool? Who decides what is the EMR’s primary purpose? When and how are the physicians who will use the electronic record involved in decisions? In the development phase? In the implementation phase? After software is purchased and during training? Which physicians are involved in decisions? Those who have computer technological savvy only or also those who do not, yet will still be required to use the EMR? What are the unintended consequences of implementation of the EMR, i.e., shifting data entry burden from clerical to medical staff? What losses and gains will ensue, such as fundamental alterations in the physician-patient relationship? How will these changes be dealt with? Ideally, each system will ask, well in advance of implementation of an EMR, how do we want to do our work? How can an electronic medical record help us function at our best? And, what consequences of an EMR can be anticipated and planned for? Implementing the EMR is technical and adaptive work. Heifetz says, “the most common cause of leadership failure is using a technical fix for an adaptive challenge.” On the surface, implementing a hardware and software system and training people to use it seems like technical work that a formal authority could orchestrate, as simple as weighing the pros and cons to make a logical decision. But the many cultural and behavioral changes required by the electronic record users makes implementation far more complex. The exercise of leadership is required to hold people in the adaptive work when the losses become evident. With change in attitudes, beliefs and habits comes the pain of loss. The discomfort of adaptation is felt by the spine surgeon—and everyone he speaks to — after he spends more time entering postoperative orders into the computer than he did performing the surgery. The sense of loss that our colleagues feel, including the loss of sense of competence when we sit before a computer screen with software we do not know how to use to perform the basic functions of our work, is analogous to the loss our patients feel confronting illness or injury. Physicians are uniquely prepared to exercise adaptive leadership. Through a therapeutic relationship based on understanding, empathy and validation, we create the environment nec-

MetroDoctors

essary for our patients to cope. We recognize their resistance. We pace their adaptation to a future they do expect by carefully monitoring their level of distress and balancing the amount of information they need with the amount that they can tolerate. We draw attention to tough questions, give people more responsibility than they are comfortable with and bring conflicts to the surface. We lower distress by addressing the technical aspects of treatment, breaking the problem into parts or temporarily reclaiming responsibility by saying “don’t worry, we will take care of that.” All the same principles to maintain a productive level of distress apply when physicians exercise leadership by helping their organizations make progress on difficult problems. In the face of work avoidance, physicians exercising leadership can use their formal or informal authority to redirect attention to the adaptive challenge at hand. We can reframe the problem and focus attention on the tough aspects, drawing the issues out rather than quelling conflict. We can reorient our colleagues from their current roles to new ones so different relationships develop. We can challenge the way we execute our duties, distinguishing values and norms that must endure from those that should be eliminated. Basically, we can help our colleagues feel the pinch of reality, rather than protect them from the pain of adjustment, just as we must help our patients face their losses. By distinguishing technical from adaptive challenges in health care, defining the competing values that make some problems especially difficult and using our clinical understanding of the process of adaptation, every physician has the capacity to exercise leadership in our community’s effort to make progress in health care delivery. In the next issue of MetroDoctors we will address the personal aspects of leadership. *Heifetz, Ronald, Leadership Without Easy Answers (Cambridge, MA: The Belknap Press of Harvard University Press, 1994)

CascadePartners offers leadership education and coaching to health care professionals and the organizations they serve. Cascade Partners principals include: Kathleen Brooks, M.D., MBA, MPA; Tom Gilliam, R.N., MBA; Mary Jo Lewis, M.D.; Michael Tedford, M.D., MBA; Valerie Ulstad, M.D., MPA, MPH.

The Journal of the East and West Metro Medical Societies

12/26/07 2:46:56 PM


Major Compensation Changes Under Medicare

T

THE CENTERS FOR Medicare and Medicaid

Services (CMS) recently published the final 2008 Medicare Physician Fee Schedule (the “Fee Schedule”) and the long-awaited “Phase III” of the Stark Regulations. The Phase III rules were effective December 4, 2007 and the Fee Schedule became effective January 1, 2008. These regulations may require the restructuring or termination of many common business arrangements within the health care industry, such as: s A space and/or equipment lease between a physician group and a hospital. This arrangement was previously acceptable as long as the payment did not take into account referrals. Now, these arrangements will likely need to be restructured to meet the criteria for Stark’s lease and equipment exceptions. s A medical director agreement between a specialty group and a hospital. While these agreements are still acceptable, they may need to be more formalized to meet the requirements of a Stark exception. s Management services agreement between a group practice and a hospital. Unless properly structured to fit within a Stark exception, referrals between a group practice physician and the hospital will be prohibited. s A physician group’s operation of an off-site diagnostic testing facility. Unless the physician group furnishes “substantially the full range of services furnished by the group” in the off-site facility, the physician group will be significantly limited in its ability to mark up the professional and technical components furnished in the offsite facility. B Y R YA N S . J O H N S O N , E S Q . A N D K AT H E R I N E J . D O U G L A S , E S Q .

MetroDoctors

There are also changes contained in the regulations that are beyond the scope of this article, such as changes to independent diagnostic testing facility enrollment requirements. Without addressing all of the regulations, this article will discuss those provisions that are likely to have the biggest impact on most health care providers. Stark Phase III The Stark Prohibition

The Stark law prohibits a physician from making a referral for certain designated health services to an entity with which the physician (or an immediate family member) has a financial relationship, unless one of its many exceptions applies. Stark also prohibits entities from submitting claims for designated health services provided pursuant to a prohibited referral. Stark is a strict liability statute, meaning that the intent of the parties is irrelevant for purposes of determining whether the law has been violated. Stark provides for penalties of $15,000 per violation, plus requires the refund of amounts paid for illegally referred designated health services. Stand in the Shoes

For purposes of determining whether a physician has a direct or indirect compensation arrangement with an entity to which the physician refers patients for designated health services, the physician will now be deemed to “stand in the shoes” of his or her physician organization. A large number of business arrangements are likely to be affected by this change. Thus, if a hospital enters into a contract with a large physician group practice (for example, a space or equipment lease), the hospital will be deemed to have a direct compensation arrangement with all physicians in the groups, and the

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hospital contract must fit into one of Stark’s direct compensation exceptions. Prior to Phase III, the hospital would have been viewed as having an indirect compensation arrangement with the physicians in the group, meaning that the business arrangement would be eligible for Stark’s indirect compensation exception. Compensation arrangements entered into prior to September 5, 2007 that satisfied the indirect compensation exception will not need to be amended during their current term to comply with a direct compensation exception. Such arrangements may continue to use the indirect compensation exception during the original and renewal term of the agreement. CMS has delayed the applicability of the “stand in the shoes” provision until December 4, 2008 with regard to academic medical centers (AMC) and integrated 501(c)(3) health systems. For AMCs, the “stand in the shoes” provision will not apply to compensation between a faculty practice plan and another component of the same AMC. For integrated 501(c)(3) systems, the provision will not apply to compensation between an affiliated designated health services entity and affiliated physician practice within the same integrated system. Recruitment Exception

Another significant change contained in the Phase III regulations affects a hospital’s ability to provide recruitment assistance to physician groups. Phase II prohibited a hospital from providing financial assistance for recruitment if the physician group required the recruited physician to enter into a noncompete agreement. Phase III eliminates this prohibition by allowing reasonable noncompetition restrictions. (Continued on page 20)

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19


2008 Fee Schedule

Medicare (Continued from page 19)

Anti-markup Rule

Other revisions to the recruitment exception include a modiďŹ ed method for determining a hospitalâ&#x20AC;&#x2122;s service area. Phase II prohibited recruitment payments to a physician who had been practicing for more than two years. Phase III excepts from this prohibition payments made to a physician who has practiced in a prison, Veteranâ&#x20AC;&#x2122;s hospital, or for the Indian Health Service and did not maintain a private practice. There are also slight revisions to the requirement that a physician group allocate only its actual, incremental costs attributable to a physician with an income guarantee. For groups in rural areas or health professional shortage areas, if the recruited physician replaces a physician who left the practice and geographic area within the previous 12 months, the group may allocate up to 20 percent of its overhead to the recruited physician.

Effective January 1, 2008, CMS imposed a signiďŹ cant change to the anti-markup rule for diagnostic tests. Previously, the anti-markup rule prohibited a physician/group from â&#x20AC;&#x153;marking upâ&#x20AC;? the fee for a diagnostic test that the physician purchased from a third party. A physician may bill Medicare no more than what the physician paid for the test. The previous rule applied only to the technical component of the test. The new rule expands the prohibition to the professional component of such tests. A physician/group is prohibited from marking up technical or professional components of a diagnostic test if the test is purchased or if it is performed in a place other than the physician/ groupâ&#x20AC;&#x2122;s ofďŹ ce. For physician organizations (sole practitioners, physician practices and group practices), the â&#x20AC;&#x153;ofďŹ ceâ&#x20AC;? is the space where the physician organization provides substantially the full range of patient care services that it provides generally. The anti-markup rules require the billing physician/group to bill the lowest of: 1) the

  

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performing physicianâ&#x20AC;&#x2122;s/supplierâ&#x20AC;&#x2122;s net charge to the billing entity; 2) the billing entityâ&#x20AC;&#x2122;s actual charge; or 3) the fee schedule amount. The â&#x20AC;&#x153;net chargeâ&#x20AC;? excludes any amounts provided to the billing entity for lease of space and equipment. So if a physician contracts with a radiologist to perform a scan with equipment the radiologist leases from the physician, the physician must consider those lease payments when determining the radiologistâ&#x20AC;&#x2122;s â&#x20AC;&#x153;net charge.â&#x20AC;? The practical effect of the new anti-markup rule could be signiďŹ cant. For example, the rule prohibits a physician group from marking up the fee for the professional component of a test performed at an off-site diagnostic testing location, even if the group operates the location exclusively. Proposed Revisions that Were Not Adopted

CMS did not adopt many of the proposed changes to the Stark Law that were included in the July, 2007 proposed physician fee schedule. These include changes to the deďŹ nition of â&#x20AC;&#x153;entityâ&#x20AC;? under Stark, per-click arrangement restrictions, services provided â&#x20AC;&#x153;under arrangements,â&#x20AC;? set in advance and percentage-based requirements, and the alternative criteria for satisfying a Stark exception. However, CMS indicates that these changes will resurface in future rulemaking. [Note that this summary is not comprehensive.] Conclusion

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Metro Doctors JanFeb08.pdf 22

MetroDoctors

Business arrangements among physicians/ groups, hospitals and independent contractors should be reviewed for compliance with the most recent Stark law changes and the anti-markup provisions of the 2008 Medicare Physician Fee Schedule. The changes are farreaching and will likely have an impact on almost all providers. Please note that this article does not address all of the changes that may be relevant to a particular provider. If you have any questions about any of the other changes not addressed in this article, please feel free to contact the authors. Ryan Johnson and Katherine Douglas are attorneys in Fredrikson & Byronâ&#x20AC;&#x2122;s Health Law Practice Group. They can be reached at rjohnson@fredlaw.com and kdouglas@fredlaw.com.

The Journal of the East and West Metro Medical Societies

12/26/07 2:46:57 PM


Collaborating on Statewide Cessation: A Win-Win for Health Care Professionals and Patients

O

OCTOBER 1, 2007 marked the beginning

of Minnesota’s statewide smoke-free law covering all indoor workplaces, including bars and restaurants. This major milestone now protects all Minnesota workers from the harms of secondhand smoke. The thousands of health care professionals, policy makers, and concerned citizens who had the courage to lead on this issue are to be commended. October 1 was significant for another reason as well. That day also marked the launch of a program that now makes it easier for physicians to help their patients who want to stop smoking. The Minnesota Clinic Fax Referral Program allows health care professionals in participating clinics across the state to easily refer a patient to stop-smoking phone coaching support, regardless of the patient’s health care coverage. The new program allows physicians to fax a single, HIPAA-compliant quitline referral form to a central triage system. The result: an outbound call to the patient from that patient’s appropriate quitline service. (Individuals without health care coverage or who are underinsured are referred to QUITPLAN® Services.) The outbound call explains the program and invites the patient to enroll. Prior to this system, health care providers were required to look up a patient’s insurance in order to get patients directed to the correct quitline service offered by their health plan, then identify the corresponding quitline phone number, and then give it to the patient. The process was time consuming and the patient still had to call to initiate the coaching. Telephone coaching for smoking cessation is available to all Minnesota residents at no charge and is an effective alternative to

B Y M A R C W. M A N L E Y, M . D . , M . P. H .

MetroDoctors

face-to-face counseling with physicians in an often-busy clinical setting. We also know that when medical professionals encourage their patients to stop smoking and offer assistance, people pay attention. However, only a small fraction of tobacco users access these quitlines, and few physicians were referring patients to this valuable assistance. So to help physicians connect patients to this service, Blue Cross and Blue Shield of Minnesota led the research and the successful pilot of the new program that is now being rolled out statewide. The Minnesota Clinic Fax Referral Program is supported collaboratively by all Minnesota organizations that offer helplines to those who want to quit smoking. The collaboration, named Call it Quits, includes the following organizations: Blue Cross and Blue Shield of Minnesota, ClearWay MinnesotaSM, HealthPartners, Medica, Metropolitan Health Plan, MMSI, PreferredOne, and UCare. Unlike some other states where a single quitline is run by the state health department, Minnesota quitlines are offered through several health plans and through ClearWay MinnesotaSM. Making referrals easier was the goal. Asking a clinic to fax to seven different quitlines would not have worked. To overcome this barrier, Call it Quits established an integrated clinic fax referral system to a single phone number. The pilot project also explored what effect an incentive at the clinic level — otherwise known as a pay-for-performance program — would have on the physician referral rates to a single state tobacco quitline. Results from a 22-month pilot program funded by Blue Cross and directed by Lawrence An, M.D., assistant professor of medicine, University of Minnesota, demonstrated both the feasibility and the positive impact of this referral and incentive method. Forty-nine Fairview Physician Associates (FPA) clinics participated

The Journal of the East and West Metro Medical Societies

Metro Doctors JanFeb08.pdf 23

in the pilot program. FPA was chosen because it is a large, multi-specialty group providing both primary care and specialty care in Minnesota, and because FPA records tobacco use as a vital sign. The study used a two-group clinic randomized design. In the first group, 25 clinics received “usual care,” i.e., they received cessation information and materials and their electronic medical record (EMR) system was modified to allow for electronic “fax” referral. The “intervention” group of 24 clinics received a launch meeting, monthly feedback, and financial incentives based on the number of referrals to quitlines. The financial incentives were available to clinics that referred at least 50 patients during the study period. Characteristics of all clinics in both the “usual care” group and the “intervention” group did not differ significantly. The primary outcome measure was the percentage of smokers referred to phone counseling. A secondary measure was clinic characteristics including: number of providers, type of practice, presence or absence of EMR, the clinic’s past history of engagement with quality improvement activities. The final measure took into account costs, including development staff costs and computer configuration, implementation costs, and financial incentives. Results showed that clinics in the “intervention” group had a much higher rate of referral (11.4 percent) than the “usual care” group (4.2 percent). For clinics that had a history of being very engaged with quality improvement activities, the offer of financial incentives had little impact on the referral rate. In contrast, for clinics with less history of engagement with quality improvement, offering the incentives (Continued on page 22)

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21


Statewide Cessation (Continued from page 21)

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Functional Neuro-Imaging Wenbo Zhang, MD, PhD

Appointments (651) 241-5290

,!79%234(!4 $/#4/2342534 i`Â&#x2C6;VÂ&#x2C6;Â&#x2DC;iĂ&#x160;Â&#x2C6;Ă&#x192;Ă&#x160;VÂ&#x153;Â&#x201C;ÂŤÂ?Â&#x2C6;V>Ă&#x152;i`°Ă&#x160;Ă&#x160;-Â&#x153;Ă&#x160;>Ă&#x20AC;iĂ&#x160;Ă&#x152;Â&#x2026;iĂ&#x160;Â?>Ă&#x153;Ă&#x192;Ă&#x160; Ă&#x152;Â&#x2026;>Ă&#x152;Ă&#x160; `Â&#x153;VĂ&#x152;Â&#x153;Ă&#x20AC;Ă&#x192;]Ă&#x160; Â&#x2026;Â&#x153;Ă&#x192;ÂŤÂ&#x2C6;Ă&#x152;>Â?Ă&#x192;Ă&#x160; >Â&#x2DC;`Ă&#x160; Â&#x2C6;Â&#x2DC;Ă&#x192;Ă&#x2022;Ă&#x20AC;>Â&#x2DC;ViĂ&#x160; VÂ&#x153;Â&#x201C;ÂŤ>Â&#x2DC;Â&#x2C6;iĂ&#x192;Ă&#x160; Â&#x2026;>Ă&#x203A;iĂ&#x160; Ă&#x152;Â&#x153;Ă&#x160; Â&#x201C;>Â&#x2DC;>}i°Ă&#x160; Ă&#x160; Â&#x153;VÂ&#x17D;Ă&#x20AC;Â&#x2C6;`}iĂ&#x160; Ă&#x20AC;Â&#x2C6;Â&#x2DC;`>Â?Ă&#x160; >Ă&#x2022;iÂ&#x2DC;Ă&#x160; Â&#x2C6;Ă&#x192;Ă&#x160; Â&#x153;Â&#x2DC;iĂ&#x160; Â&#x153;vĂ&#x160; Â&#x2C6;Â&#x2DC;Â&#x2DC;iĂ&#x192;Â&#x153;Ă&#x152;>½Ă&#x192;Ă&#x160; Â?i>`Â&#x2C6;Â&#x2DC;}Ă&#x160; Â&#x2026;i>Â?Ă&#x152;Â&#x2026;Ă&#x160; V>Ă&#x20AC;iĂ&#x160; Â?>Ă&#x153;Ă&#x160; vÂ&#x2C6;Ă&#x20AC;Â&#x201C;Ă&#x192;°Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160;Ă&#x160; "Ă&#x2022;Ă&#x20AC;Ă&#x160; Â&#x2026;i>Â?Ă&#x152;Â&#x2026;Ă&#x160; V>Ă&#x20AC;iĂ&#x160; VÂ?Â&#x2C6;iÂ&#x2DC;Ă&#x152;Ă&#x192;Ă&#x160; >Ă&#x20AC;iĂ&#x160; Ă&#x192;Â&#x153;Ă&#x160; Ă&#x192;>Ă&#x152;Â&#x2C6;Ă&#x192;vÂ&#x2C6;i`Ă&#x160; Ă&#x152;Â&#x2026;iĂ&#x17E;½Â?Â?Ă&#x160;Ă&#x153;Ă&#x20AC;Â&#x2C6;Ă&#x152;iĂ&#x160;Ă&#x2022;Ă&#x192;Ă&#x160;>Ă&#x160;Ă&#x20AC;iviĂ&#x20AC;Ă&#x20AC;>Â?°Ă&#x160;Ă&#x160;

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Ă&#x2C6;ÂŁĂ&#x201C;Â&#x2021;xÂ&#x2122;Ă&#x2C6;Â&#x2021;{äÂ&#x2122;Â&#x2122;  JÂ?Â&#x153;VÂ&#x17D;Â?>Ă&#x153;°VÂ&#x153;Â&#x201C;

-ARC7-ANLEY -$ -0( ISTHEVICEPRESIdent and medical director for Population Health, Blue Cross and Blue Shield of Minnesota.

Â&#x2DC;Ă&#x152;i}Ă&#x20AC;Â&#x2C6;Ă&#x152;Ă&#x17E;Ă&#x160;Ă&#x160;UĂ&#x160;Ă&#x160;Â&#x153;Ă&#x17E;>Â?Ă&#x152;Ă&#x17E;Ă&#x160;Ă&#x160;UĂ&#x160;Ă&#x160; Ă?ViÂŤĂ&#x152;Â&#x2C6;Â&#x153;Â&#x2DC;>Â?Ă&#x160;-iĂ&#x20AC;Ă&#x203A;Â&#x2C6;Vi

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January/February 2008

Metro Doctors JanFeb08.pdf 24

substantially increased the number of patients referred. Attrition after referral was identical for the â&#x20AC;&#x153;interventionâ&#x20AC;? group and the â&#x20AC;&#x153;usual careâ&#x20AC;? group, so the intervention did not result in a higher rate of inappropriate referrals. Through this study we demonstrated that an integrated fax referral system is feasible and that incentives do increase referral rates. In total, all FPA clinics generated more than 3,000 referrals to stop-smoking coaching. Those referrals resulted in a 27 percent enrollment rate in stop-smoking programs, which is comparable to other successful recruitment strategies. As the statewide program is rolled out, Blue Cross will offer incentives to those clinics that choose to register for the Minnesota Clinic Fax Referral Program and also participate in Blue Crossâ&#x20AC;&#x2122; pay-for-performance program. Given the pilot studyâ&#x20AC;&#x2122;s success, implementation in medical clinics across the state is the Call it Quits collaborationâ&#x20AC;&#x2122;s main priority. As of mid-November, 350 clinics have registered to participate in the Minnesota Clinic Fax Referral Program. More than 400 referrals were received in the ďŹ rst month. The collaboration estimates that, at this rate, more than 4,000 referrals will be received in the ďŹ rst year, which could result in approximately 1,200 enrollments and ultimately 350 people successfully quitting through this program each year. This project succeeded because all members of the collaboration were committed to removing barriers and improving systems in a coordinated fashion, and patient-centered care was at the very core of the effort. Together Call it Quits achieved a win-win situation for patients and their caregivers. This new program should help clinicians easily connect their patients who smoke to effective stop-smoking assistance. The collaborative hopes that many more smokers can quit successfully and live healthier lives in a supportive, smoke-free Minnesota. To learn more about Call it Quits or sign up to participate in the Minnesota Clinic Fax Referral Program, call (651) 662-4054 or visit www.preventionminnesota.com and click on the Call It Quits icon on the home page.

MetroDoctors

The Journal of the East and West Metro Medical Societies

12/26/07 2:46:58 PM


Minnesota Ambulatory Health Care Consortium Holds Annual Meeting

T

he Minnesota Ambulatory Health Care Consortium (MAHCC) held its annual meeting on Thursday, November 15 at the Four Points by Sheraton in Minneapolis. Speakers included the newly appointed Minnesota Commissioner of Health, Sanne Magnan, M.D., Ph.D.; House Minority Leader Representative Marty Seifert (R) 21A; Representative Erin Murphy (DFL) 64A. There were over 40 physicians in attendance at the meeting representing various outpatient ambulatory surgery centers and imaging centers.

Representative Marty Seifert (R) 21A .

Representative Erin Murphy (DFL) 64A.

Commissioner of Health, Sanne Magnan, M.D., Ph.D. addresses the group.

Societies Sponsor Lunch ‘n Learn

D

r. Stuart Cox, president of the Ramsey Medical Society, addressed 75 first and second year medical students at the University of Minnesota campus on Wednesday, October 24, 2007. The event was sponsored by the Ramsey Medical Society and the Hennepin Medical Society and addressed the role of the independent physician in practice versus those who are in practice and employed by a system. The medical students had a lot of questions and some stayed after the meeting to talk with Dr. Cox about his presentation.

ATTENTION all Minnesota Physicians Residing in Naples, Florida

A handful of first and second year medical students had additional questions for Dr. Cox following the meeting.

U of M White Coat Ceremony

O

n November 17, 2007, the University of Minnesota Medical School class of 2011 received their white coats during a ceremony that symbolizes the undertaking of professionalism and responsibility in the medical profession. Drs. James Rohde, past HMS Chair, and Peter Wilton, RMS president-elect, presented each of the 185 students with an engraved reflex hammer. MetroDoctors

The Journal of the East and West Metro Medical Societies

Metro Doctors JanFeb08.pdf 25

6th Annual Minnesota Health Care Dinner Party Tuesday, March 18, 2008 Pelican Marsh Golf Club, Naples, Florida Cocktails: 6:00 p.m. Dinner: 7:00 p.m. Cost: $55.00 per person (estimated) Spouse/guest invited Contact Tom Hoban at (239) 948-4492 or th8159@earthlink.net (2007 attendees watch for a written invitation in late January)

January/February 2008

12/26/07 2:46:59 PM

23


Members in the News The Members in the News section recognizes the appointments, presentations, awards, honors and other professional accomplishments of EMMS and WMMS members. Submit physician news by fax (612) 623-2888, e-mail (dhines@metrodoctors.com) or mail to Editor, MetroDoctors, 1300 Godward Street NE, Suite 2000, Minneapolis, MN 55413 for consideration by the editorial board. Questions? Call Doreen Hines at (612) 362-3705. LEE BEECHER, M.D. was presented with the First a Physician Award by the Hennepin Medical Society at their annual Board of Directors meeting in October. This award recognizes a member of the Hennepin Medical Society who exempliďŹ es the profession of medicine. The work of this â&#x20AC;&#x153;unsung heroâ&#x20AC;? has resulted in an outstanding contribution and/or the governance and success of the Hennepin Medical Society. Community service, work on public policy issues, or other noteworthy volunteer service contributing to improving the health of the population deďŹ nes the leadership and commitment to medicine by

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January/February 2008

Metro Doctors JanFeb08.pdf 26

this individual. Dr. Beecher is a board certiďŹ ed psychiatrist ofďŹ cing in St. Louis Park. PETER BOOSALIS, M.D. and NICHOLAS MEYER, M.D. were recognized for their Distinguished Service to the Community with an award presented at the Annual Meeting of Lakeview Memorial Hospital Medical Staff. Dr. Boosalis and Dr. Meyer recognized the need to provide support to area military veterans and their families. They organized a non-proďŹ t organization, the Military Family Support League, which offers assistance to families of veterans while their loved one is serving overseas. In addition, they were instrumental in promoting the need to provide returning veterans support upon discharge. Dr. Boosalis is a board certiďŹ ed anesthesiologist with Valley Anesthesiology Consultants, P.A. and Dr. Meyer is a board certified orthopedist with specialization in hand/wrist/elbow surgery at St. Croix Orthopaedics, P.A. This award is given annually by a panel of physician peers to recognize fellow physicians for their overall distinguished service to Lakeview Hospital, its patients and the community. DENIS CLOHISY, M.D., has been named the new head of the Department of Orthopaedic Surgery at the University of Minnesota Medical School. Since 1999, Dr. Clohisy has held the Roby C. Thompson Jr., M.D., Endowed Chair in Musculoskeletal Oncology. He became a full professor in 2001. PETER COLE, M.D. and RALPH BOVARD, M.D. have been selected to serve as the co-medical directors of the 2008 U.S. Figure Skating championships at the Xcel Energy Center in St. Paul, January 20-27, 2008. Dr. Cole is the chief of orthopaedics for Regions and HealthPartners Medical Group, and Dr. Bovard is the lead physician for primary care orthopaedics for the HealthPartners Medical Group. CHARLES HIPP, M.D., president of Stillwater Medical Group, was recently appointed to the Board of Directors of the Institute for Clinical Systems Improvement (ICSI). CHARLES HORWITZ, M.D. and DONALD GLEASON, M.D. were the recipients of the first annual Minnesota Distinguished Pathologist Award from the Minnesota Society of Pathologists at its meeting in November. This award is presented to a practicing (or retired) MetroDoctors

pathologist in Minnesota who has had an impact in a hospital, local community, academic, local, state, national or international environment. Dr. Horwitz works at Abbott Northwestern Hospital for Hospital Pathology Associates, P.A. and Dr. Gleason is retired. LOUIS LING, M.D. was elected to the Governing Council of the Section on Medical Schools (SMS) of the AMA. Dr. Ling is the associate medical director for education at HCMC. RUTH LYNFIELD, M.D. has been named state epidemiologist and medical director for infectious disease. Dr. LynďŹ eld has worked for the Minnesota Department of Health as a medical epidemiologist since 1997. SANNE MAGNAN, M.D. was appointed Minnesota Health Commissioner by Gov. Tim Pawlenty. Dr. Magnan was president of the Institute for Clinical Systems Improvement in Bloomington prior to her appointment. ROBERT C. MORAVEC, M.D. was one of the recipients of the Robert Raszkowski, M.D., Ph.D. ACCME Hero Award. This award was established to recognize volunteers who have provided exemplary and long-term service to the ACCME, through service on the Board, the Accreditation Review Committee, the Committee for Review and Recognition, the Monitoring Committee, as volunteer surveyors and/or as workshop faculty. Dr. Moravec is currently the medical director at St. Josephâ&#x20AC;&#x2122;s Hospital in St. Paul. Childrenâ&#x20AC;&#x2122;s Cancer Research Fund honored BRENDA WEIGEL, M.D., with its prestigious ButterďŹ&#x201A;y Award during its 2007 Annual Meeting. This award celebrates ongoing commitment and dedication to the battle against childhood cancer. It is presented in ďŹ ve categories: corporate, fundraising partners, medical, volunteers, and Care Partners. Dr. Weigel won the award for the medical category. She is an assistant professor in the University of Minnesotaâ&#x20AC;&#x2122;s Department of Pediatric Hematology/Oncology. GREGORY WRIGHT, M.D., FAAP, FACC, is the new chief of the critical care division at Childrenâ&#x20AC;&#x2122;s Hospitals and Clinics of Minnesota. A pediatric cardiologist, Dr. Wright brings 21 years of experience at Childrenâ&#x20AC;&#x2122;s to his new part-time position. He will continue his clinical practice at the Childrenâ&#x20AC;&#x2122;s Heart Clinic. The Journal of the East and West Metro Medical Societies

12/26/07 2:47:00 PM


ICERE INSP

RIBERE

INCIDERE

C INS

PRESIDENT’S MESSAGE V. STUART COX, M.D.

SINCE 1870

What We Do Matters

I

to be scared. It was about 2 a.m. and I had been called to the high risk OB floor. At this hour I may not be able to get ahold of an attending, and even if I could, they would never be able to make it to the hospital in time. They were about to start a C-section and I had been called because the prenatal ultrasound had shown a large tumor, probably a lymphangioma, which completely covered the head and neck region. If the baby went into respiratory distress and they were unable to intubate, I would have to do a tracheotomy. I had only assisted in one newborn trach. I had never seen a neonatal tracheotomy through a potentially bloody tumor. It was a big hospital and I initially had a hard time finding the unit. But after I saw a couple of people running I just followed them to the center of the chaos. There were more than 20 people crammed inside the medium sized room. I pushed my way through so that I would be able to see the baby, and then checked the room to see where I would potentially operate and make sure the tracheotomy set was open. Within minutes the baby was delivered. I heard the first cry and then, the first few breaths. I did not hear any stridor. Feeling relieved, I pushed further in to get a better look at the baby. Once I saw him I knew my services would not be needed. There had been a significant miscommunication. While there was a large tumor, it protruded straight off his gluteus; his head and neck were perfectly clear. We all have stories like this, although, many of them have much more somber endings. Accountants and business executives do not get to tell stories like this. What we do matters. One of the negatives of organized medicine is that we tend to focus on the problems of our profession. We are being assailed from all sides. There have been several meetings this year that, when I left, I felt like throwing up my hands and giving up. Even on good days I feel that we are, at best, tilting at windmills. It is easy to forget how blessed we are in this profession. Medical school applications nationally are at an all time high this year. Most physicians I talk to have a hard time understanding this and, in general, would not recommend that their children pursue a career in medicine. I think we forget that, despite all the struggles, there are few, if any, careers that are as fulfilling.

EMMS Elected Board Members

Arthur A. Beisang III, M.D., Director Charles E. Crutchfield, III, MMB, M.D., At-Large Director Laura A. Dean, M.D., Specialty Director, Obstetrics & Gynecology Andrew S. Fink, M.D., At-Large Director Thomas J. Losasso, M.D., At-Large Director Nicholas J. Meyer, M.D., Director Robert C. Moravec, M.D., At-Large Director Jane C. Pederson, M.D., Specialty Director, Internal Medicine Jerome J. Perra, M.D., Director Lon B. Peterson, M.D., Director Thomas D. Siefferman, M.D., Specialty Director, Pediatrics Jacques P. Stassart, M.D., At-Large Director Christina J. Templeton, M.D., Specialty Director, Psychiatry Scott A. Uttley, M.D., Director EMMS Appointed Board Members

Stephanie D. Stanton, M.D., Resident Physician Kimberly C. Viskocil, Medical Student Marie L. Witte, M.D., Young Physician MMA Officers and Board Members

Lyle J. Swenson, M.D., MMA Vice Speaker of House Todd D. Brandt. M.D., --!%AST-ETRO4RUSTEE Charles G. Terzian, M.D., --!%AST-ETRO4RUSTEE David C. Thorson, M.D., --!%AST-ETRO4RUSTEE EMMS Ex-Officio Board Members & Council Chairs

Blanton Bessinger, M.D., AMA Alternate Delegate Peter F. Bornstein, M.D., MPS, Inc. Chair Kenneth W. Crabb, M.D., AMA Delegate Robert W. Geist, M.D., 0ROFESSIONALISM%THICS Council Chair Neal R. Holtan, M.D., Community Health Council Chair Frank J. Indihar, M.D., AMA Delegate, Chair of -.$ELEGATION Carolyn A. Johnson, M.D., Sr. Physicians Association President Mark J. Kleinschmidt, Clinic Administrator Anthony C. Orecchia, M.D. %DUCATION2ESOURCE#OUNCIL#HAIR EMMS Executive Staff

Sue A. Schettle, #HIEF%XECUTIVE/FlCER Katie R. Snow, %XECUTIVE!SSISTANT Doreen M. Hines, Manager, Member Services

MetroDoctors

The Journal of the East and West Metro Medical Societies

Metro Doctors JanFeb08.pdf 27

All the more reason to keep our profession strong. Not only for other physicians, but our community needs us to be involved. I have talked several times to Dr. Ron Hansen (radiologist with St. Paul Radiology) over the last couple of months about a combined Senate and House committee he is on. He takes an enormous amount of time out of his personal and professional life to serve on this committee, but he is glad he has. He is consistently astonished how poorly the practice of medicine is understood, and without an “insider” at the table, how poorly the advice given to the legislators is. If our elected representatives hear only from the insurers and business community we know, not only will our profession suffer, but also the patients we serve. I continue to encourage you to get involved. If you feel you do not have time to serve on a committee — commit to get to know your Senator and Representative. These personal relationships matter. In general, a legislator is much more likely to listen to a physician they know and trust, rather than a well paid lobbyist. We are late to a game that is played well by many others, especially lawyers. We need to take the time and energy to catch up. 2008 will be a big year in health care legislation. Our representatives want to hear from us. All in all, this has been an exciting (exhausting) year for me. Our society has not only a new CEO, but also a new name, East Metro Medical Society. Our Board is turning over and it is great to see new faces of people who want to be more involved. I want to thank Roger Johnson personally for all he has done for organized medicine. I would like to thank Sue Schettle and congratulate her for carrying on a great tradition here at East Metro. She is consistently looking for ways to make us an even better medical society. Thank you to Doreen Hines and Katie Snow for all the work they do that often goes unheralded. And lastly, I want to thank the Board of Directors for their contribution. While the committee process can be slow and occasionally painful, by getting everyone’s input we end up with the best for our Society and our profession. %AST-ETRO-EDICAL3OCIETY ASSISTINGPHYSICIANSIN the practice of the profession of medicine for the benefit of our community. January/February 2008

12/26/07 2:47:00 PM

25

Metro Medical Society

I WAS A 4TH YEAR resident, so I knew enough

President V. Stuart Cox, M.D. President-Elect Peter B. Wilton, M.D. Past President James J. Jordan, M.D. Treasurer Ronnell A. Hansen, M.D.

East

EMMS Officers


EMMS IN ACTION SUE A. SCHETTLE, CEO

RMS Foundation Update

The Ramsey Medical Society Foundation has elected a new chairman who will serve a two year term beginning in 2008. Dr. Kent Wilson, retired otolaryngologist from Midwest ENT assumed his chairmanship of the foundation board beginning January 2008. Also newly elected to the RMS Foundation board is Dr. Mark Destache who is an anesthesiologist from Associated Anesthesiologists, PA based in St. Paul. We would like to offer our thanks to Dr. Robert Moravec who has served as the RMS Foundation board chair for the past six years. His dedication and commitment to the foundation has been appreciated. Our thanks also go out to the three other outgoing board members including Dr. Lyle Swenson, Dr. Brent Asplin and Dr. Barclay Cram for their longstanding commitment and service to the foundation. Smoke-free Projects

Since the Freedom to Breathe Act went into effect October 1, Cynthia Piette, working in

Washington County, and Diane Tran, working in Dakota County, have done terrific work in continuing to grow their grassroots networks and engaging their respective communities by hosting community events. Across the country, when smoke-free laws go into effect there is generally a concerted effort by those who are against the smoke-free law to try and overturn it, or to add exemptions. That’s why having the grassroots network continually connected into the project is so crucial so that when they are needed to get involved, they’ll be ready to mobilize. Medical Student Lunch ‘n Learn Lecture Dr. Stuart Cox presented to a group of 1st

and 2nd year medical students on October 25. The lecture was well attended. RMS and HMS have co-sponsored Medical Student Lunch ’n Learn sessions for many years. RMS/HMS Joint Public Policy Council

The RMS/HMS joint public policy committee had its third meeting in early November and discussed a number of legislative issues that will likely come forward in the 2008 legislative session. This group was formed with the purpose of being the policy arm/vehicle of RMS and HMS. Current co-chairs of the

group include Peter Boosalis, M.D. and Art Beisang, M.D. Meetings with Legislators Representative Mindy Greiling (DFL) 54-A met with physicians at the Hamm Clinic on Friday, November 30. Dr. James Jordan and Dr. Robert Nesheim provided Rep-

resentative Greiling with a tour of the Hamm Clinic and spent time talking with her about issues affecting mental health. Representative Greiling serves as the Co-Chair of the Mental Health Caucus, which is a bipartisan effort and includes members from the House of Representatives and the Senate. AMA Meeting

The Interim Meeting of the American Medical Association was held November 9 through November 14. Dr. Cox and Sue Schettle attended the meeting in addition to some RMS members who serve in various roles in the AMA. Those include Drs. Gonzalez-Campoy, Jacott, Crabb, Bessinger, Stanton and Indihar, among others.

Help us Celebrate... Installation of Peter B. Wilton, M.D., as the 138th President of Ramsey Medical Society and the 1st President of East Metro Medical Society at the 2008 RMS Winter Gala and Annual Meeting Friday, January 25, 2008 Town & Country Club 300 Mississippi River Blvd. N., St. Paul — Mark your calendars and plan to attend (families are welcome)— Social Hour — 5:30 p.m. – 6:30 p.m. Dinner — 6:30 p.m. – 7:30 p.m. Program and Award Presentations — 7:30 p.m. – 8:00 p.m. Entertainment — 8:00 p.m. – 8:45 p.m. Watch your mail for your invitation, visit www.metrodoctors.com or call (612) 362-3704 for more information.

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January/February 2008

Metro Doctors JanFeb08.pdf 28

MetroDoctors

The Journal of the East and West Metro Medical Societies

12/26/07 2:47:01 PM


EMMS UPDATE

2008 EMMS Election Results Congratulations to the newly elected EMMS leaders

East

PRESIDENT-ELECT Ronnell A. Hansen, M.D. Diagnostic Radiology 3T0AUL2ADIOLOGY 0!

SECRETARY/TREASURER Thomas D. Siefferman, M.D. Pediatrics Pediatric & Young Adult Medicine, P.A.

DIRECTOR Peter J. Boosalis, M.D. Anesthesiology Valley Anesthesiology Consultants, P.A.

DIRECTOR Peter F. Bornstein, M.D. Infectious Diseases St. Paul Infectious Disease Associates, Ltd.

DIRECTOR Katherine M. Clinch, M.D. Anesthesiology Associated Anesthesiologists, P.A,

The Following Have Been Appointed to a Position on the RMS Board by an MMA Section.

Delegates to MMA Elected to Serve With EMMS Board Members

Richard L. Baron, M.D. Blanton Bessinger, M.D. Amy L. Gilbert, M.D. DIRECTOR Andrew S. Fink, M.D. General Surgery/ Vascular Surgery 2ADIATION/NCOLOGY

J. Michael GonzalezCampoy, M.D., Ph.D.

DIRECTOR Marie L. Witte, M.D. Internal Medicine Stillwater Medical Group

Jo Ann Wood, M.D. Appointed by the MMA Young Physician Section Internal Medicine University of Minnesota

Frank J. Indihar, M.D.

Stephanie D. Stanton, M.D. Appointed by the MMA 2ESIDENT0HYSICIAN3ECTION Family Medicine United Family Practice Health Center

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

Active Niladri Aichbhaumik, M.D. Wayne State University School of Medicine Allergy & Immunology St. Paul Allergy & Asthma Clinic, P.A. Romaine B. Bayless, M.D. Ohio State University College of Medicine Obstetrics & Gynecology Reproductive Medicine Infertility Assoc. Gena M. Bonitatibus, M.D. University of Alabama School of Medicine Allergy & Immunology/Pediatrics Aspen Medical Group â&#x20AC;&#x201C; Bandana Square MetroDoctors

Erin K. Micallef, M.D. University of Minnesota Medical School Family Medicine Fairview Lakes North Branch Clinic Majken A. Schwartz, M.D. University of Illinois College of Medicine Family Medicine Allina Medical Clinic Shoreview Steven T. Silver, M.D. University of Minnesota Medical School Psychiatry Hennepin Faculty Associates

The Journal of the East and West Metro Medical Societies

Metro Doctors JanFeb08.pdf 29

Christopher J. Stadtherr, M.D. University of Minnesota Medical School Family Medicine East Metro Family Practice â&#x20AC;&#x201C; Inver Grove Heights Resident Physicians Jaemi R. Keith, M.D. University of California School of Medicine Anesthesiology U of MN Graduate School Medical Students (University of Minnesota)

Ruben J. Macias January/February 2008

12/26/07 2:47:02 PM

27

Metro Medical Society

PRESIDENT Peter B. Wilton, M.D. General Surgery St. Paul Surgeons, Ltd.


“Ethical Issues in Pay for Performance”— A Presentation by Dr. David Satin

D

r. David Satin spoke at the open public meeting of the RMS Council on Professionalism and Ethics co-sponsored with the medical staffs of United and HealthEast hospitals on November 16, 2007. Dr. Satin first described how a pay-for-performance (P4P) model of physician reimbursement functions. The charitable interpretation is: P4P reimburses physicians for providing quality care, and finances quality improvement innovations. The skeptical is: P4P enables third party payers to control costs by bribing physicians to follow prescribed practice patterns.The taking-it-too-personally is: Do they really think that the existing moral and social incentives for providing excellent care are insufficient — that financial incentives will succeed where my professional character failed?

He discussed: the goals of goal setters; withholds to fund P4P “rewards;” the potential economic, social, and moral results of P4P; the benefits claimed for P4P (enforcing quality, standardized care, and cost savings); and the burdens of P4P (expense of data collection and threat of an altered doctor-patient relationship). In summary he said, “it is unclear whether P4P will improve overall morbidity and all cause mortality.” This was a brilliant and balanced appraisal of P4P. A lively question and answer session followed the presentation.

Meet One of the New EMMS Board Members

J

o Ann Wood, M.D., MSEd is serving as the Young Physician representative on the EMMS Board of Directors. She is an associate professor of medicine at the University of Minnesota, board certified in both pediatrics and internal medicine, a Fellow of the American Academy of Pediatrics and the American College of Physicians. She earned her medical degree and completed her residency both at the

University of Louisville. Dr. Wood completed a Faculty Development Fellowship in General Medicine at the University of North Carolina, Chapel Hill. She received her Master’s Degree in Education from the University of Southern California in 2005. At the University she is leading the “Ambulatory Care Experience” Steering Committee for the MED 2010 Educational Reform and she serves as the Medicine Firms Medical Director, as well as the Director of the 7A Medical Unit at the University of Minnesota Medical Center, Fairview.

RMS Senior Physicians

R

MS senior physicians had lunch at Regions Hospital in late October and enjoyed hearing from The Honorable Al Quie, former Minnesota Governor, U.S. Congressman, and State Senator, about his horseback trips along the entire Continental Divide over multiple summers. Mr. Quie accompanied his talk with a slideshow of trip photos for the 20 attendees, and his adventurous spirit shown through as he retold stories of close calls on the trail. The RMS Senior Physicians Association meets 28

January/February 2008

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quarterly at local hospitals. Carolyn Johnson, M.D. will be turning over the presidential title to J. Richard Burton, M.D. at the next meeting on January 24, 2008.

In Memoriam MARGARET M. ANDERSON, M.D. passed away on October 3 at her home in Sun Lakes, AZ. She was 93. Dr. Anderson graduated from the University of Manitoba, Canada and practiced as an anesthesiologist in St. Paul. She joined RMS in 1950. ROY L. PETERSON, M.D. died on October 9 at the age of 88. Dr. Peterson graduated from the University of Minnesota Medical School and completed his internship at the U.S. Marine Hospital in Detroit, MI. He then served the next four years at U.S. Marine Hospitals in Boston, MA and Mobile, AL. Dr. Peterson began a family medicine practice in White Bear Lake and remained there until his retirement. In 1969 he developed and patented a pocket tracheotomy instrument designed to enable physicians to perform emergency tracheotomies as safely and rapidly as possible. Dr. Peterson joined RMS in 1953. NEIL TROTMAN, M.D. died at the age of 76 on November 5 in Scottsdale, AZ. He graduated from the University of Illinois College of Medicine. Dr. Trotman practiced general and thoracic surgery in St. Paul until retiring in 1991. He joined RMS in 1965.

Logo Extend your Heart to the Homeless February 1 to February 29, 2008 We ask that you and your clinic staff donate personal hygiene supplies and over-the-counter medications that will be distributed to Health Care for the Homeless, Listening House and SafeZone. Call Doreen at (612) 362-3705 to learn more about how your clinic can participate.

MetroDoctors

The Journal of the East and West Metro Medical Societies

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CHAIR’S REPORT ANNE M. MURRAY, M.D.

The Death of Primary Care in Minnesota

P

PRIMARY CARE is being hung out to dry in

Chair Anne M. Murray, M.D. President Richard D. Schmidt, M.D. President-elect Edward P. Ehlinger, M.D. Secretary Peter J. Dehnel, M.D. Treasurer Eric G. Christianson, M.D. Immediate Past Chair Paul A. Kettler, M.D.

Minnesota. Poor reimbursement at both ends of the life spectrum is already endangering the survival of pediatrics and geriatrics, but now threatens to get worse. Recent proposals for expansion of MinnesotaCare to cover a greater proportion of children without an increase in physician payments, and a 10.1 percent Medicare reimbursement cut by Congress would force many Minnesota practitioners to close their doors to these patient populations. Dr. Peter Dehnel, a pediatrician at Children’s Health Network, serves with me on the West Metro Board of Directors. He will provide insights re: proposed expansion of MinnesotaCare. I will address reimbursement levels at the other end of the life spectrum — geriatrics.

WMMS Board Members

Lauren Baker, M.D. Alan L. Beal, M.D. Carl E. Burkland, M.D. Laurie Drill-Mellum, M.D. Kenneth N. Kephart, M.D. Stephen MacLeod, M.D. J. Riley McCarten, M.D. Frank S. Rhame, M.D. Janette H. Strathy, M.D. Thomas C. Tunberg, M.D. David J. Walcher, M.D. David A. Willey, M.D. WMMS Ex-Officio Board Members

Michael B. Ainslie, M.D., MMA Trustee Martha Arneson, Co-Presiding Chair, HMS Alliance Beth A. Baker, M.D., MMA Trustee Christian L. Ball, M.D., 2ESIDENT2EPRESENTATIVE David L. Estrin, M.D., AMA Alternate Delegate Melanie Fearing, -EDICAL3TUDENT2EPRESENTATIVE Donald M. Jacobs, M.D., MMA Trustee Roger G. Kathol, M.D., MMA Trustee Candace S. Simerson, --'-!2EPRESENTATIVE Richard E. Streu, M.D., Sr. Physicians Association 2EPRESENTATIVE Karin M. Tansek, M.D., MMA Trustee Trish Vaurio, Co-Presiding Chair, HMS Alliance Benjamin H. Whitten, M.D., AMA Alternate Delegate James A. Young, II, M.D., MMA Trustee WMMS Executive Staff

Jack G. Davis, #HIEF%XECUTIVE/FlCER Jennifer Anderson, Smoke-Free Project Coordinator Nancy K. Bauer, Assistant Director, and -ANAGING%DITOR -ETRO$OCTORS Kathy R. Dittmer, %XECUTIVE!SSISTANT

MetroDoctors

Pediatric Primary Care and an Expanded MinnesotaCare Program

On the surface, expanding state-based health care insurance to cover all children is very attractive to most of us in medicine. Who would deny that making sure that children have insurance coverage for their health care needs is good for the state? The irony is that by expanding state-based insurance programs at their current reimbursement rates to cover more children we will likely reduce children’s access to health care services. This is an extremely important distinction, but one that frequently gets confused by legislators and the public. An insurance card is simply that — a piece of paper that is only as good as the program behind it. It is not a guarantee that there will be a preferred clinic in an accessible location that will accept that card to provide services. The family may be forced to obtain all of their care at an Emergency Department, urgent care or MinuteClinic. Pediatric primary care clinics are under financial stress as are all primary care clinics in Minnesota. Their operating margins are now very small, due to years of relatively flat reimbursement rates while their employee and operating costs are rising. MinnesotaCare programs and Medicaid both reimburse at rates far below commercial insurers, generally

The Journal of the East and West Metro Medical Societies

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in the neighborhood of 25 to 30 percent of the median commercial insurance rates. The commercial rate, itself, is generally well below most clinics’ posted fee schedule. Prepaid Medical Insurance Plan (PMAP) programs, which are state public programs administered through the insurers, have received yearly increases from the legislature. What is not known by most legislators and the general public is that those increases have generally not been passed on to clinicians. Instead, the PMAPs conveniently keep the yearly rate increases for themselves. If clinics are now confronted with seeing an increasing percentage of children covered through MinnesotaCare and related state-based programs, this will quickly become a financially non-viable situation — clinics will literally have to stop seeing these patients to avoid bankruptcy and clinic closure. Just as any well-intended grocery store can’t afford to sell a $4.00 gallon of milk for $1.50, caring and dedicated pediatric clinicians can’t afford to see patients when the reimbursement rates are substantially below the cost of delivering that care. The obvious solution is for the state to raise the physician reimbursement rates to a level on par with commercial insurers. Although that solution is not likely to be palatable from a political sense — it would wreak havoc on the state’s budget, and few legislators are willing to raise taxes sufficiently high to pay for this “fair market” level of reimbursement to clinicians — it is really the only viable solution. A mechanism is also needed to ensure that the rate increases go directly to the physicians; not retained by the PMAPs. Another Proposed Cut in Medicare Rates

Physicians caring for geriatric patients have been writing our annual letter to our Congressmen requesting a vote “no” to another proposed Medicare cut. Once again this bill (Continued on page 31)

January/February 2008

12/26/07 2:47:03 PM

29

W e st M e t r o M e d i c a l S o c i e t y

WMMS Officers


WMMS IN ACTION JACK G. DAVIS, CEO

WMMS 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.

You will read elsewhere in the journal about the Board decision to change the name of the Hennepin Medical Society to the West Metro Medical Society. This change took effect on January 1, 2008. The Hoban Scholarship Selection Committee awarded four scholarships this fall to students who are pursuing advanced degrees in medical administration or nutrition. These scholarships are awarded in the name of Thomas and Mary Kay Hoban. Tom was the Executive Director of the Hennepin Medical Society from 1969 through 1994.

The Hoban Scholars are (from left): Azza Zarroug, Kara Mitterholzer, Christina Servetas, and Barbara Jacobs. H. Thomas Blum, M.D., is Chair, Hoban Scholarship Committee.

The Hennepin Medical Foundation Board of Directors met in October to award grants for 2007. Organizations receiving grants include: the Center for Cross-Cultural Health, the Greater Minneapolis Crisis Nursery, HCMC-Newborn Intensive Care Unit, Hennepin Medical Society Alliance, Minnesota Visiting Nurse Agency, Sub-Saharan African Youth and Family Services in Minnesota, the Thomas P. Cook Scholarship and the University of Minnesota AHC CLARION Student Group. Edward Spenny, M.D. is the current President of the HMF. 30

January/February 2008

Metro Doctors JanFeb08.pdf 32

The Joint RMS/HMS Public Policy Council recently met to review the upcoming legislative issues for the 2008 legislative session. Considerable discussion took place regarding the potential Constitutional Amendment for a “right to health care,” the health care reform efforts of the Legislative Commission and the Governor’s Task Force, and the probability of an Interpreter Bill. Other issues to be monitored include no-fault auto and workers compensation reimbursement issues, potential non-physician scope of practice initiatives, medical facilities construction control, transparency/cost disclosure, and Health Care Access Fund oversight. Edward Ehlinger, M.D. and Jack Davis joined about 12 other health care constituents in a Congressional “meet and greet” with Representative Keith Ellison of the 5thMinnesota Congressional District. Discussion took place regarding the medical community’s support of SCHIP and the concern of the pending Medicare cuts due to take place on January 1, 2008. Representative Ellison was supportive of Medicine’s position on both these issues.

HMS past chair James Rohde, M.D. and incoming RMS president Peter Wilton, M.D. presented 185 first year medical students with an engraved reflux hammer at the University of Minnesota Medical School’s White Coat Ceremony on November 16, 2007.

Director of Hazelden enlightened us about “Addiction Treatment: It’s a lot more than 28 days.” As Richard Burman, M.D. steps down as President of the Senior Physicians Association, Robert E. Doan, M.D. begins his term as President in 2008. Our dates for meetings are Tuesdays, April 22, June 10, September 16, and November 11 at 11:30 a.m. at the Zuhrah Shrine Center.

Brenda Iliff, Clinical Director of Hazelden, stands with Richard Burman, M.D., president of Sr. Physicians Association.

Career Exploration for High School Students Two HMS member physicians were invited to participate in “career exploration” classes at area high schools.

Sr. Physicians Association

Membership: Are you a physician who is retired or contemplating retirement? Attained the age of 62? Is a member in good standing of HMS or another medical society? If yes, you are eligible to join the Senior Physicians Association. Go to our Web site at www.metrodoctors.com, click Hennepin Medical Society, click HMS Senior Physicians Association, click on “application” and print a copy. Or call Kathy Dittmer at (612) 623-2885. November 13 was our last meeting for 2007. Brenda Iliff, MA, LADC, Clinical MetroDoctors

(Above) Lee Beecher, M.D. answered questions about psychiatry as a profession at Osseo High School. (Not pictured): Scott Benson, M.D., Ph.D. showcased family medicine to students at Lakeville North High School.

The Journal of the East and West Metro Medical Societies

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Annual Board Meeting— Anne Murray, M.D. is New Chair Nicholas Legeros, sculptor, was the guest speaker discussing the topic, “Can Art Heal?” Mr. Legeros was commissioned by the Hennepin Medical Society and Abbott Northwestern Hospital in 2006 to create a new Shotwell Award. The original Sprites sculpture, created by Paul Grandlund, is located in the courtyard of the old Metropolitan-Mount Sinai Medical Center. A smaller version was created for the Shotwell Award and has been presented to the Shotwell Award recipients since 1971.

Chair’s Report (Continued from page 29)

Paul A. Kettler, M.D. receives the outgoing Chair’s sculpture from Anne Murray, M.D., incoming HMS Chair.

Lee Beecher, M.D., is First Recipient of “First A Physician” Award Lee Beecher, M.D. was presented with the First A Physician Award by the Hennepin Medical Society at their annual Board of Directors meeting on October 10, 2007. In the inaugural presentation of this award, outgoing HMS Board Chair Paul A. Kettler, M.D., stated “Dr. Beecher truly embodies the spirit of the award. He has participated locally in Hennepin Medical Society leadership and governance as well as with the Minnesota Medical Association. He truly advocates for patients and his profession and has been a major contributor and leader in his work on public policy issues. Dr. Beecher has devoted countless hours to his patients, the profession of medicine, and is well respected by his peers.” The “First A Physician” award recognizes a member of the Hennepin Medical Society who exemplifies the profession of medicine. The work of this “unsung hero” has resulted in an outstanding contribution to community and/or the governance and success of MetroDoctors

the Hennepin Medical Society. Community service, work on public policy issues, or other noteworthy volunteer service contributing to improving the health of the population defines the leadership and commitment to medicine by this individual. Lee Beecher, M.D. is a board certified psychiatrist with an office in St. Louis Park, MN and is the immediate past chair of the Minnesota Patient Physician Alliance.

Lee Beecher, M.D. is recognized with the First a Physician Award by Anne Murray, M.D.

The Journal of the East and West Metro Medical Societies

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Mr. Grandlund passed away in 2003 at which time there were only a few sculptures remaining in the HMS inventory. At his request, upon his death, his molds were destroyed. In addition, Lee Beecher, M.D. was presented with the first annual, First A Physician Award (see related article) and James, Dehen, M.D., President of the Minnesota Medical Association, offered a few remarks on behalf of the MMA.

was written to conform to the (everyone- recognizes- clearly- flawed) Sustainable Growth Formula, which is not likely to be revised under the current administration. A recent AMA survey found that 60 percent of physicians would limit the number of Medicare patients they see and half would reduce their staff if the cut takes effect. Multiple primary care practices in Minnesota already refuse to see new Medicare patients. It is already demoralizing for physicians in family practice, internal medicine, geriatrics, neurology, and any specialty caring for a large proportion of geriatric patients to have to annually justify our low Minnesota Medicare reimbursement for cognitive services without a further rate cut. However, reimbursement is also needed for extensive nurse telephone management, coordination of care across settings, and communicating with family caregivers and with other health agencies. As Dr. Jane Potter, recent President of the American Geriatrics Society states: “Too much of what is important for care of especially frail older people occurs outside of face-to-face contacts with those patients…Unless physicians and other health care providers are reimbursed for providing these essential services, there will be too few providers willing to perform these services.” (J Am Geriatr Soc. 2006;54:1453-1462). For now, we can only hope that Congress will see the proposed Medicare cut as a recipe for disaster, and that our country’s new administration in 2009 will create a new formula for successful funding of geriatric care. January/February 2008

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31

W e st M e t r o M e d i c a l S o c i e t y

The annual meeting of the Hennepin Medical Society Board of Directors was held on October 10, 2007 at which time Anne Murray, M.D., internal medicine/geriatrics, was installed as the new Chair of the Board, succeeding Paul A. Kettler, M.D. The annual meeting provides an opportunity for incoming and outgoing Board members along with their spouse/guests, to be recognized and appreciated for their commitment to their professional association. As a thank you for his years of leadership of the HMS Board, Dr. Kettler was presented with the chair’s award, a specially commissioned sculpture by Jeff Barber. 98.6° stands as the norm for health. This sculpture symbolically interprets the degrees for temperature as degrees in angles. Variations in dimension further the notion that people are not exactly 98.6 degrees at all times. The adult figures balance with the angles — and are directly symbolic of those who intercede to maintain the critical balance of 98.6 degrees; those who have chosen medicine as their life’s interest.


Welcome New WMMS Members Active Jennifer H. Ambur, M.D. John A. Haugen Associates, P.A. /"'9. Stephanie L. Anderson, M.D. France Avenue Family Physicians, P.A. Family Medicine Sachin S. Bhardwaj, M.D. Dermatology Specialists, P.A. Dermatology Jonathan M. Cooper, DO, M.D. TRIA Orthopaedic Center Orthopedic Surgery Brian R. Drew, M.D. Minneapolis Otolaryngology Head & Neck Surgery, P.A. Otolaryngology Kirsten B. Dummer, M.D. Childrenâ&#x20AC;&#x2122;s Heart Clinic, P.A. Pediatrics, Pediatric Cardiology Maria Gomes, M.D. Minnesota Diagnostic Imaging Partners LLC 2ADIOLOGY Chantel N. Hile, M.D. Minneapolis Vascular Clinic General Surgery Matthew D. Layman, M.D. Twin Cities Anesthesia Associates, P.A. Anesthesiology William D. McMillian, M.D. Minneapolis Radiology Associates Vascular Surgery

Corrine N. Moll, M.D. John A. Haugen Associates, P.A. /"'9.

In Memoriam

Donald A. Pine, M.D. Park Nicollet Clinic, Minnetonka Family Medicine Polly A. Quiram, M.D., Ph.D. VitreoRetinal Surgery, P.A. Ophthalmology Adnan I. Qureshi, M.B.B.S. University of Minnesota Department of Neurology .EUROLOGY Pamela A. Sakkinen, M.D. Twin Cities Dermatopathology Pathology, Dermatopathology Timothy G. Schaefer, M.D. Midwest Plastic Surgery Plastic Surgery Shannon P. Sheedy, M.D. Suburban Radiologic Consultants, Ltd. $IAGNOSTIC2ADIOLOGY Meskath Uddin, M.D. HealthPartners, Riverside Clinic Internal Medicine Bernarda M. Zenker, M.D. Quello Clinic-Burnsville Family Medicine Resident Physician Emmanuel U. Agoh, M.D. Hennepin County Medical Center Family Medicine Medical Students (University of Minnesota)

Visit us at www.metrodoctors.com

January/February 2008

Metro Doctors JanFeb08.pdf 34

JOHN (JACK) E. VERBY, JR., M.D., 84, died on October 23, 2007. While attending medical school at the University of Minnesota, he was a Navy V-12 ofďŹ cer and played semi-pro baseball. He was drafted to serve in Korea as a doctor in 1951. Upon return from the service, he moved to Rochester and helped start the Olmstead Medical Group. After 19 years of practice, he was asked to join the faculty at the University of Minnesota Medical School in 1968. In 1970 he became one of the ďŹ rst family physicians to be certiďŹ ed by the National Board for Family Physicians. During the same year, Dr. Verby created the Rural Physicians Associate Program (RPAP) as an answer to a state mandate to redistribute physicians into rural Minnesota. In 1972, Dr. Verby became a Charter Fellow of the American Academy of Family Physicians (AAFP). Dr. Verby also wrote four editions of the Family Practice Specialty Board Review books, and collaborated with his wife, Jane, on the book How to Talk to Doctors. He joined HMS in 1950. WILLIAM A. â&#x20AC;&#x153;BILLâ&#x20AC;? WILCOX, M.D., LTC (Ret.) died peacefully on November 7, 2007 at the age of 86. During WWII, he was commissioned in the U.S. Army Air Corps and served as Weather OfďŹ cer in the 55th Reconnaissance Squadron, Long Range (Weather). He earned his medical degree from Northwestern University Medical School in Chicago and was board certiďŹ ed in radiology and nuclear medicine. Dr. Wilcox practiced radiology at North Memorial Medical Center and was a clinical instructor with the University of Minnesota and the University of Arizona. He served with Volunteer Doctors for Vietnam in 1969 and also did volunteer medical service in Okinawa, Thailand and Taiwan. Dr. Wilcox joined HMS in 1961.

Luke T. Hafdahl Eric K. Moeker Justin C. Peltola

Joseph S. Micallef, M.D. Fairview Lakes Regional Medical Center Family Medicine

32

HENRY W. QUIST, M.D., age 89, died November 2, 2007 after a long illness. He attended the University of Minnesota for both his undergraduate degree and medical school. He graduated in 1943 and completed his internship at Minneapolis General Hospital. He entered the Army and served as a medical ofďŹ cer in the 101st Airborne Division in France and Germany. In 1948 he entered into medical practice in Minneapolis. He practiced family medicine until his retirement in 1991 at age 73. Dr. Quist joined HMS in 1986.

MetroDoctors

The Journal of the East and West Metro Medical Societies

12/26/07 2:47:05 PM




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