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July/August 2012


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Contents VOLUME 14, NO. 4

2

Index to Advertisers

3

In thIs Issue

J U LY / A U G U S T 2 0 1 2

The Future of Physician Payment By Lee H. Beecher, M.D.

4

PresIdent’s Message

In Pursuit of Gigantic—but Hopefully not Titanic By Peter J. Dehnel, M.D.

5 Page 12

tCMs In aCtIon By Sue Schettle, CEO

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MedICal Care organIzatIons

TC Network: A Fictitious Organization...an Interesting Exercise By Roger Kathol, M.D., and Ronnell Hansen, M.D.

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Counterpoint to the TC Network Report on ACOs By Richard J. Morris, M.D.

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Health Maintenance Organizations — Improving Cost, Care or Neither? By Aaron Nathenson, M.D.

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Page 26

Colleague Interview: A Conversation With David Moen, M.D. Hennepin Health: An Integrated Health Care Delivery Network By Jennifer DeCubellis, LPC

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Collaborative Care Cooperative By Douglas Hanson, MPA

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Where do Specialists Fit in Accountable Care? By Thomas P. Flynn, M.D.

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The ACO Paradox By Scott R. Ketover, M.D., AGAF

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Quiet Session: A Welcome Change By Nathan Mussell, J.D.

Page 5

26

The Legacy of Dr. Eduard Boeckmann, East Metro Medical Pioneer

28

Mental Health and Primary Care Task Force Meets/ Senior Physicians Association News

29

Spotlight on Honoring Choices Physician “Stars”/ Honoring Choices Minnesota Conference

Page 32 MetroDoctors

30

In Memoriam/Career Opportunities

32

luMInary of twIn CItIes MedICIne

Mitchell J. Einzig, M.D. The Journal of the Twin Cities Medical Society

On the cover: Like a Unicorn — everyone knows what an ACO is but never seen one. Articles begin on page 6. July/August 2012

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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

July/August Index to Advertisers TCMS Officers

President: Peter J. Dehnel, M.D. President-elect: Edwin N. Bogonko, M.D.

Advanced Dermatology Care........................... 7 Advanced Spine Associates, P.A. ........................ Inside Back Cover

Secretary: Lisa R. Mattson, M.D. Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D., MTS Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS 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 Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. 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 TCMS.

Treasurer: Kenneth N. Kephart, M.D.

Crutchfield Dermatology.................................. 2

Past President: Thomas D. Siefferman, M.D.

ENT Specialty Care ..........................................23

TCMS Executive Staff

Fairview Health Services .................................31

Sue A. Schettle, Chief Executive Officer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Executive Assistant (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Katie R. Snow, Project Coordinator (612) 362-3704 ksnow@metrodoctors.com For a complete list of TCMS Board of Directors go to www.metrodoctors.com.

Healthcare Billing Resources, Inc. ...............25 Lockridge Grindal Nauen P.L.L.P. ...............11 Minnesota Epilepsy Group, P.A....................14 Minnesota Physician Services, Inc. ..............13 MMIC Health IT ........... Outside Back Cover Noran Clinic Sleep Center ............................... 9 Saint Therese......................................................... 7 Stillwater Medical Group................................30 Tinnitus and Hyperacusis Clinic....................... Inside Back Cover Toshiba Business Solutions.................................. Inside Front Cover Uptown Dermatology & SkinSpa................28 U.S. Navy ............................................................31

Crutchfield Dermatology “Remarkable patient satisfaction from quality service, convenience and excellent results”

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: nbauer@metrodoctors.com.

Exceptional Care for All Skin Problems

Charles E. Crutchfield III, M.D.

For advertising rates and space reservations, contact: Betsy Pierre 2318 Eastwood Circle Monticello, MN 55362 phone: (763) 295-5420 fax: (763) 295-2550 e-mail: betsy@pierreproductions.com MetroDoctors reserves the right to reject any article or advertising copy not in accordance with editorial policy. Advertisements published in MetroDoctors do not imply endorsement or sponsorship by TCMS. 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 Katie Snow at (612) 362-3704.

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July/August 2012

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The Journal of the Twin Cities Medical Society


IN THIS ISSUE...

The Future of Physician Payment

DOCTORS ARE REALISTS. The PPACA, now the law of the land and President Obama’s signature health care legislation, is now in the hands of the U.S. Supreme Court which is due to rule on key aspects of its constitutionality this summer. The 2012 elections and political discourse prominently feature health care policy issues which directly affect our professional and economic futures as doctors. Accordingly, the Twin Cities Medical Society wants its members to discuss and debate how we, as physicians, can best serve our patients while also having a viable economic future. In this spirit, this edition of MetroDoctors features the Twin Cities Network, a report from the TCMS Policy Committee. The TC Network is a “fictitious” physician controlled organization which could accept capitation risk contracts with payers (executive summary, Roger Kathol, M.D., and Ron Hansen, M.D., co-chairs (page 6). It is important to note that the TC Network report is not a TCMS endorsement of ACOs and/ or capitation contracting. Richard Morris, M.D., who is a member of the TCMS Policy Committee, offers his counterpoint and caveats for physicians and patients (page 8). These discussions stir emotion in TCMS physicians who remember the Hennepin Medical Society sponsored Physician’s Health Plan (PHP) HMO in the 1970s. PHP was touted to be the physician HMO with the imprimatur of the medical society to compete with Minnesota’s dominant HMOs in order to assure and protect physician interests. There are lessons to be learned from the PHP history. Aaron Nathenson, M.D., with contributions from James Ehlen, M.D. and Doug Shaw, snapshot the development of PHP and give their perspectives (page 10). Accountable Care Organizations (ACOs) are legislated in the PPACA and its administrative rules. ACOs have as their primary goal controlling health care costs by using population-based capitation payments to provider organizations. David Moen, M.D. is on the front line in implementing a Fairview Health System ACO. In the Colleague Interview, he explains how a switch to capitation will require changes in health care delivery as he fields questions from the Editorial Board (page 12).

Twin Cities medical practices are developing integrative care models and/or are considering how to interact with ACOs: The Hennepin Health Network is an innovative pilot project to integrate medical, behavioral health, and human services for the lowest income public sector patients (page 15); The Collaborative Care Cooperative now with 17 members empowers independent specialty medical practices to form Practice Cooperatives (page 17); Thomas Flynn, M.D., reports from Minnesota Oncology, a large independent cancer care organization, which is planning its own specialty ACO (page 19); and Scott Ketover, M.D., of Minnesota Gastroenterology describes issues and challenges of ACOs (page 21). A temporary Minnesota State budget surplus resulted in a somewhat less contentious legislative session this year. Of note: The Minnesota Board of Medical Practice is now required to publicly report physician malpractice judgements (page 24). Finally, Mitch Einzig, M.D, exemplary clinical teacher, is featured as this issue’s Luminary of the Twin Cities Medical Society (page 32). Plan to attend the MMA annual meeting, September 14-15, 2012 and serve as a TCMS delegate to the MMA House of Delegates. Your voice is important! Registration information is available at www. metrodoctors.com. And, if you’re moved to do so, send us a Letter to the Editor.

By Lee H. Beecher, M.D. Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

July/August 2012

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President’s Message

In Pursuit of Gigantic—but Hopefully not Titanic pETEr J. DEHNEL, M.D.

T

his edition of MetroDoctors highlights some of the significant transitions that are occurring in the delivery of health care services both locally as well as nationally. Regardless of the Supreme Court’s decision on the 2010 “Affordable Care Act” legislation, change is going forward in numerous ways. We have a whole new glossary of health care terms — accountable care organizations, clinically integrated networks, the triple aim, bundled payments for episodes of care, and so on. This is all supposed to be new and innovative — real solutions for improving the patient care experience, improving population health and lowering the per capita increase in health care spending — aka “the triple aim.” To some, it is just the next logical iteration in transitioning to a systems approach to delivering consistent quality care. Conversely to some, primarily more senior members of the physician community, this seems like “déjà vu all over again” (Yogi Berra) with it looking much like old-style capitation under a new name. In any case, it seems that consolidation and creating larger organizations is inevitable. In order to serve the needs of our physician community, the members of the Policy Committee of TCMS have diligently worked to create a “guide” or “tool” to aid in the understanding of the new structures that are being created and implemented. The “Twin Cities Network” has been developed with a foundational principle of physician leadership. This principle is seen as a distinct contrast to a number of the proposed ACO-type networks currently in development. The completed report has generated considerable controversy through its development. One of the prime issues is physicians assuming risk for managing a population of patients. Managing financial risk puts physicians in an ethically awkward position of potentially choosing between patients and profits — or even between patients and financial viability. Unfortunately, the risks for groups go far beyond financial, and that makes many of us extremely uneasy. Unrecognized risks can be illustrated through an example from the early twentieth century. One hundred years ago on April 15th, the luxury liner RMS Titanic sank after hitting an iceberg in the north Atlantic. There was the loss of 1,514 lives in this great sea tragedy. There were opportunities to avoid this disaster, of course, but one of the important unrecognized risks was the possibility that this “modern” ship could actually sink. Without that acknowledgement, there was insufficient life boat capacity for all of the 2,200 plus passengers and crew. Where are the risks associated with the accountable care organization concept? At least five are easy to recognize from the outset: 1. Business risk — the risks involved with running any business, in that it may not be successful. 2. Key concepts risk — a business may be based on an inadequate or erroneous foundation, such as capitation with too small of population base. 3. Investment risk — since loss reserves have to be held with any group taking on risk, the choices involved with managing those investments can make or break your business. 4. Care management risk — if an organization spends more managing its high complexity patients, it may fail financially. 5. Insurance risk — depending on the size of a patient population, a disproportionate number of patients with newly diagnosed hepatitis C, advanced multiple sclerosis or refractory Crohn’s disease or AML requiring a tandem (double) stem cell transplant can “break the bank,” even with significant stop loss insurance. This is why “larger” becomes an important principle for business viability. These five, as stated before, are the ones easy to recognize. It is the unrecognized risks inherent within a specific organization that may be the biggest challenge at the end of the day. “Unsinkable” or “too big to fail” should never be assumed. That would be a titanic mistake. Stay engaged, stay informed, be proactive, and continue to focus on providing excellent care to your patients who continue to depend on you for their important health needs. TCMS continues to provide a venue for physicians to work collaboratively on these very important issues. 4

July/August 2012

MetroDoctors

The Journal of the Twin Cities Medical Society


tCMs In aCtIon SUE A. SCHETTLE, CEO

TC Network

The TCMS Policy Committee focused a great deal of time and effort in 2011 and early 2012 to develop a tool for physicians who may be interested in what a physician-led network might look like. This was an exercise and not intended to be a platform for TCMS to actually create a network, but instead, to be used as a way to spark conversation and dialogue about physician-driven health care reform. Our 2nd TCMS Forum will be held on Wednesday, July 11 from 7:00 a.m.– 8:30 a.m. at Broadway Ridge, 3001 Broadway Street NE, Minneapolis, and will be devoted to discussing the TC Network. We will have a panel of physicians discuss the pros and cons of a TC Network-like organization. We are hoping for a great discussion. Please join us! You can register by visiting our website.

released book entitled Having Your Own Say. This book was published in partnership with our colleagues from LaCrosse, Wisconsin who founded the Respecting Choices advance care planning initiative. This book contains chapters from organizations such as Dartmouth Institute for Health Policy and Clinical Practice, National Palliative Care Research Center, Center to Advance Palliative Care, in addition to highlighting activities that are going on in other countries including Australia. We are honored to have been asked to contribute our story to this book. If you are interested in buying the book, visit the www.havingyourownsay.org website.

Honoring Choices MN

The 3rd Annual Sharing the Experience conference will be held on Thursday, July 19, 2012 at the Ramada Plaza, 1330 Industrial Boulevard NE, Minneapolis from 9 a.m. – 5:00 p.m. Attendees will learn the progress and findings of featured advance care planning programs, hear updates from Honoring Choices Minnesota partners and insights from guest speakers, and network with others who are passionate about promoting advance care planning conversations in Minnesota. This event is always well attended and there are terrific lessons learned that are shared. To register visit the Honoring Choices Minnesota section of our website, www.metrodoctors.com. Deadline for registration is July 10. The story of Honoring Choices Minnesota is contained within Chapter 4 of a newly

MetroDoctors

healthy eating and active living offerings; investigating additional policies and practices where people live, work, eat and play; identifying efforts to provide access to healthy foods; and encouraging efforts to improve employee wellness among city-operated worksites. We were extremely pleased to be making tangible progress in our efforts to improve public health by advocating for healthy eating active living strategies. Tom Kottke, M.D. and Courtney Jordan Baechler, M.D. are co-chairs of the Twin Cities Obesity Prevention Coalition and are helping to move the resolution concept to other cities. The Eagan resolution idea was highlighted in the May 2012 consumer information guide called Minnesota Health Care News. Be a Delegate

Twin Cities Obesity Prevention Coalition

Have you registered yet to be a Delegate to the MMA Annual Meeting? It’s not too late! The meeting will be held in the Twin Cities this year, at the Minneapolis Marriott City Center Hotel, Friday-Saturday, September 14-15, 2012. Submitted resolutions and registration information can be found on our website: www.metrodoctors. com.

The City of Eagan unanimously passed the state’s first ever Healthy Eating Active Living resolution at its March 20, 2012 meeting. The resolution was brought forward by the TCMS Twin Cities Obesity Prevention Coalition. Among the strategies called for in the resolution are: advocating for the continued sustainability of existing

Correction: In the May/June issue of MetroDoctors, Andrew Litchy, ND was incorrectly identified as Mr. Litchy rather than Dr. Litchy in his article author biography, “What About the Integration of Naturopathic Medicine?” We apologize for the error.

The Journal of the Twin Cities Medical Society

July/August 2012

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Medical Care Organizations

TC Network:

A Fictitious Organization...an Interesting Exercise

T

hrough much of 2011 and early 2012, the TCMS Policy Committee met and eventually developed a report that was presented and recently approved by the TCMS Board of Directors. The report is called “Twin Cities Network” and was intended to be a resource for physicians and others who are exploring what a physician-led network might look like. Executive Summary

In this report, the Policy Committee of the Twin Cities Medical Society (TCMS) presents a physician developed model of care delivery intended to improve patient health, augment access to outcome based medical care, and decrease total health care costs. The model is generally consistent with desired outcomes associated with accountable care organizations (ACOs), though the Policy Committee specifically chose to avoid using the politically charged term “ACO” and to call the product of their deliberation The Twin Cities Network (“TC Network”), a fictitious organization with a mission to create a sustainable network of practitioners that delivers effective, efficient, and affordable care that leads to improved patient health. This report is written with the specific intent to contribute to improved health care in the State of Minnesota. The Policy Committee is not endorsing “ACOs” per se nor would it consider the development of a TC Network uncomplicated or without risk. Rather, the Policy Committee, composed of practicing physicians, chose to enter into an intellectual exercise in hopes that it could provide a framework for what a physician-led network might look like. By roger Kathol, M.D., and ronnell Hansen, M.D., Co-Chairs

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July/August 2012

The Policy Committee recognizes that there are many things that physicians and co-memberowners would need to keep in mind if they would enter into contractual arrangements similar to those described below. Singer and Shortell summarize possible shortcomings of TC-like networks uncovering 10 potential developmental mistakes that we have classified into three categories: 1) the overestimation of organizational capabilities (ability to manage risk, to develop and use EHRs, to measure performance, and to standardize care management protocols), 2) the failure to balance the interests and engage stakeholders (mistakes six to nine — not representing interests of primary care physicians, specialists; not engaging patients; not using cost-effective specialists; ineffectively navigating regulatory and legal issues; and not truly improving the delivery of care), and 3) the failure to recognize that failure in one area could magnify failure in another. In other words, there are upside and downside risks associated with the development of collaborative health systems, such as the TC Network. Nonetheless, the Policy Committee generally agrees that providing creative and proactive physician input is essential for any chance of success in moving to a health system that improves the patient experience, fosters patient and population health, and lowers total health care costs. The purpose of this fictitious TC Network is fourfold: 1) to empower physicians to become active participants in the development of an improved health care system; 2) to provide a “clinical” metropolitan physician-based perspective of a vision for better care delivery and complementary payment procedures; 3) to inform lawmakers, the health care industry, and the public about potential directions that physician envisioned health reform should take; and

4) to stimulate discussion among physicians, their patients, policy makers, politicians, and health care industry stakeholders, including hospitals, health plans, employers, and government agencies, about health care reform alternatives. The TC Network describes a collaborative, clinician-based, and outcome-oriented care team delivery process. Primary and specialty clinician equity member owners create the integrated care delivery vision. They work with TC Network business administrators, non-clinician member owners, and patients in collaboration with clinician and non-clinician contracted providers and industry stakeholders to operationalize an infrastructure of coordinated care that has at its root the patient centered health care home (PCHCH). PCHCH practitioners then coordinate work processes with medical specialists and health facilities using customized TC Network payment procedures that encourage quality-based, rather than volume-based, long term patient-centric and cost reducing integrated care. The TC Network — Clinical

The Policy Committee first discussed and created its vision of a physician-driven delivery system that would promote patient health. The principle clinical components of a “mature” TC Network would include: • A health care home base for patients’ service delivery and care coordination, which includes: 1) preventive care, 2) routine/ acute care, and 3) chronic/complex care components. • TC Network-based medical team contributions (e.g., nutritionists, care managers, pharmacists) to clinical settings (e.g., PCHCHs, specialty clinics) in a way that maximizes patient outcomes.

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The Journal of the Twin Cities Medical Society


Coordination of patient-centered health care homes, specialty medical care, including mental health and substance abuse, and facility care through a TC Network communication, referral, and IT system. Core primary care and specialty physician leadership (member-owners) in collaboration with patients and other health care stakeholders (potential member-owners) willing to commit to a team culture of TC Network-designed integrated care delivery and reimbursement procedures with a patient outcome and population health focus. Contracting with essential “non-member” specialty physicians; health service facilities/organizations (e.g., hospitals, hospice, nursing homes) and/or medical vendors; (e.g., pharmacy manufacturers, medical suppliers) that are not “at risk” but are willing to accept TC Network contract clauses, use TC Network IT documentation, adhere to TC Network care delivery workflows, and/or follow communication expectations as a part of integrated team care. Inclusion of patient incentives for healthy behaviors and outcomes.

the delivery of efficient and effective, nonvolume-based inpatient and outpatient quality care with minimum hassle for clinicians or patients. Gain/loss sharing for “at risk” memberowners. • Predetermined upside limit on TC Network cost savings distribution to member-owners in the form of bonuses before gains are reinvested in new patient care programs or premium reductions. • Purchase of reinsurance to prevent catastrophic downside risk.

Full Report

The full TC Network report can be found on our website: www.metrodoctors.com. A TCMS Forum will be devoted to discussing the TC Network including a discussion about the pros and cons. Please attend on Wednesday, July 11 from 7:00 a.m. – 8:30 a.m. at Broadway Ridge, 3001 Broadway St. NE, Minneapolis, MN. Register on our website: www.metrodoctors.com.

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The TC Network — Administrative

Once delivery system components had been conceptualized, the committee then discussed capitalization options, payment reforms that would foster desired delivery workflows and outcomes within the TC Network as well as gain/loss sharing. The principle administrative components of a “mature” TC Network would include: • An incorporated member-owned company called “The TC Network” which “sells” coordinated care delivery by a network of providers to patients and populations of patients. • Centralized TC Network administration and information technology (IT) owned by equity member-owners and used by all member-owner and contracted partners. • Contracting with third-party administrators to pay TC Network member-owner and non-member-owner practitioners and facilities using TC Network payment procedures designed to facilitate and foster

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The Journal of the Twin Cities Medical Society

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Medical Care Organizations

Counterpoint to the TC Network Report on ACOs Counterpoint to the TC Network Report On ACOs

In the movie about the Watergate scandal “All the President’s Men,” Deep Throat said to investigator Bob Woodward: “Just follow the money.” That would be good advice for investigators of Accountable Care Organizations (ACOs). Few physicians understand the implications of ACOs, born of thousands of pages of legislation and regulation. I believe ACOs threaten our profession and the patientphysician relationship. The Twin Cities Medical Society, recognizing the complexity of the Patient Protection and Accountable Care Act (PPACA), charged its Policy Committee to develop an educational paper for physicians, which emerged as the “TC Network” document (TCN). I, and some other members of that committee, believe the document fails to provide an informative balance of pros and cons of ACOs, unrealistically downplays the financial risks for physicians, and promotes a myth that physicians can control ACO governance. Its vision would practically guarantee the demise of independent practice. Though the TC Network is described as a “fictitious organization,” accepting its assumptions is playing with fire. Payment for “Quality”?

The PPACA created incentives for integrating physicians and hospitals into large health care networks on the premise that integrated care systems will cost less. Despite the fact that the demonstration projects have been failures by and large, the beat goes on. Quoting the TCN document: “TC Network payment procedures (are) designed to facilitate and foster the By richard J. Morris, M.D.

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July/August 2012

delivery of efficient and effective, non-volumebased inpatient and outpatient quality care with minimum hassle for clinicians or patients.” Right. Wanna buy a bridge? Quality is near-impossible to define because of the daunting issues of ever-changing medical evidence, risk adjustment of different patient populations, and patient attribution to providers. Published studies have failed to consistently prove any association between quality measures and cost reduction — a reality overlooked by the TCN fiction. Bob Woodward said: “If you’re gonna hype it, hype it with the facts.” The TCN report presents no evidence that ACOs achieve higher-quality outcomes less expensively because there isn’t any. Their mantra “paying for quality” is a glib euphemism for cutting payments. Hazards of Integration: “Follow the Money”

Integration requires great gobs of money to comply with the law. Therefore the owners of ACOs are necessarily those with big money, i.e. hospitals, insurance companies, government. ACOs turn the health care paradigm upside down. Heretofore patients were at the top, with physicians and hospitals serving them, and payers at the bottom doing the financial transactions. With ACOs, the moneyed interests are at the top, the “health care team” bows at their altar, and patients beg us for service. Our sworn obligation is to the patient. The PPACA puts physicians financially at risk for their performance, which is why we will be under pressure to serve Mammon. The most-discussed payment scheme is “global payment” which is capitation by another name. Capitation creates an irreconcilable conflict for physicians, who stand to make or lose

personal income depending on the care they order. (Some say FFS presents a conflict too, but there’s no moral equivalence to being paid for withholding care.) Capitation was rejected by patients and physicians after the misadventures of the 1990s. It challenged the mutual loyalties of physicians and patients, and divided primary care and subspecialty physicians. Putting an ACO at capitated risk effectively makes the ACO an insurance company. But ACOs don’t have a statutory obligation to maintain financial reserves like those required of insurance companies, leaving physicians and patients vulnerable to financial swings. Medical insurance companies and HMOs, likely to own many ACOs, would be able to pass off their financial risk to ACOs. The TCN report doesn’t acknowledge this risk. The barriers to entry into health care competition are such that there will be fewer, larger organizations. Some wonks think our whole country may consolidate into four or five mega-organizations. Patients will be the big losers, with physicians close behind. The federal government has modified anti-trust rules so competitors can integrate into an ACO. But it is basic economic dogma that competition is necessary to keep prices low. Without competition, government must centrally control prices. That is economically unsustainable. The fictitious TC Network is well-intentioned but is naïve. Why would investors cede control of governance to physicians? That’s not how capital investors work. And why would anyone invest anyway since profits will be unlikely, given the added costs of: hiring care coordinators, navigators and patient coaches; installing and maintaining complex information systems; and hiring many more

MetroDoctors

The Journal of the Twin Cities Medical Society


administrators and technicians. Of course, stinting on physicians’ salaries would be the easy answer. The utopian TCN document proposes ways “excessive profits” (huh?) could be distributed, including rebates to payers and patients, a fable designed to attract the uninformed. Like risky medication, the document should come with a black box warning. The TCN report is said to be an “exercise” to stimulate discussion, but if it has the imprimatur of our TCMS, policy makers, payers and uninformed physicians will think ACOs are approved by our physician society. Ignoring the possibility of that misperception is disingenuous. Take-home Points

There’s nothing inherently wrong with the idealistic concept of integrated care systems as envisioned by the TC Network report. What’s wrong with its vision is that it repeats the rhetoric that physicians are to blame for the high cost of health care, so it rearranges the hierarchy to put the interests of physicians, and in significant measure patients, at the bottom. The TCN

myth ignores insurers’ greed and bureaucratic inefficiency for driving up health care costs. It condones layers and layers of new bureaucracy and investor ownership that will engulf any potential clinical savings, could sacrifice the ideals and incomes of the medical profession, and will put ethically-challenged controls between physicians and patients. All without a consensus of published evidence that ACOs save money. I worked in an integrated system for 10 years and was on its management committee for six. I know the inefficiencies of large integrated organizations. There is a place for them in the landscape as an alternative, not as the only game in town. If independent practices disappear, where will all the disgruntled patients and employed physicians go? Shouldn’t there be more proof of the ACO concept before we turn American health care upside down? Shouldn’t the Board of TCMS have demanded more balance in the TCN document before releasing it to the world? Patients could be the biggest losers in this inchoate new age of medicine. They don’t want Congress (the “Patient Protection…Act,”

mind you) to tell right-thinking physicians how to give efficient care. There are enough costsaving opportunities, like generic medicines, evidence-based care (the TCN reformers made no mention of the billions of dollars spent on unproven alternative care), appropriate use of ERs and hospitals, and market improvements like health savings accounts — we don’t need political and corporate prescriptions for our profession. If physicians become commodities for sale to the financial and political interests, we will lose our ethical and professional souls and alienate the patients we’re sworn to serve. In the movie, Charles Colson, special assistant to President Nixon, had a cartoon on his office wall saying, “When you’ve got ’em by the balls, their hearts and minds will follow.” Take heed. Give your feedback to TCMS c/o sschettle@metrodoctors.com. Richard J. Morris, M.D., member, TCMS Policy Committee, and Board of Directors, Minnesota Physician Patient Alliance.

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The Journal of the Twin Cities Medical Society

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July/August 2012

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Medical Care Organizations

Health Maintenance Organizations — Improving Cost, Care or Neither?

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anaged care has had a long history in the Twin Cities area and one of the most controversial developments has been the health maintenance organization (HMO). Most health insurance companies offer some form of HMO coverage. The popularity of these plans is based on a concept of early and easy access to providers for members. This is coupled with prevention, treatment of medical problems, first dollar coverage and hopefully, reduction of premiums to employers and employees. HealthPartners (Group Health) was one of the first closed panel medical groups that did not use fee-for-service as its means for reimbursement. Rather, it used a preset fee system for financing this plan. This first occurred in 1939. It was not looked upon favorably by many private practice, fee-forservice physicians as they felt that the quality of medical care practiced by the closed panel HMO may be less effective than the care given by fee-for-service physicians. After World War II an increased interest in the HMO occurred. Employers were concerned about the rising costs of medical care. There was an explosion of new medical technology combined with the advancement of medical treatments for many disease conditions. General Mills spearheaded the search for new forms of health care delivery through the Twin City Health Care Development project. A think tank headed by Dr. Paul Ellwood and Dr. Walt McClure began to develop interest in managed care. Dr. Ellwood was the first to popularize the term health maintenance organization (HMO). In

By Aaron Nathenson, M.D.

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1972 both the St. Louis Park Medical Center and the Nicollet Clinic fee-for-service multispecialty groups, formed HMOs (MedCenter Health Plan and the Nicollet-Eitel Health Plan).These initiatives were in response to a growing competition with Group Health in their local area, and viewed as a way to attract new patients by working closely with major employers in the area. In the mid 70s members of the Hennepin County Medical Society (HCMS), particularly those in smaller and single specialty practice settings, became concerned about the competition for patients with the rapidly growing HMOs in the Twin Cities area and, in response, decided to develop an open panel HMO, or Independent Practice Association (IPA). Private physicians and Twin Cities hospitals were included in the plan. Thomas Hoban, who was the CEO of the medical society, was instrumental in developing the new HMO plan, named Physicians Health Plan of Minnesota (PHP). Eventually, the Federal Trade Commission became concerned with potential medical monopoly and restraint of trade issues in the Twin Cities, as well as in other areas of the country, strongly advising that these plans be shut down or their ownership and control transferred to entities not controlled by medical societies or principally dominated by physicians. While not necessarily agreeing with the concerns expressed by the FTC, the cost and commitment of time needed to defend PHP as a medical society venture was simply not sustainable. Accordingly, it was determined that governance of the open panel HMO should immediately become the responsibility of a consumer-majority Board. Physicians

who remained involved in governance would no longer be selected by the medical society.1 Richard Burke, the CEO of Charter Med, a for-profit management company that provided management services for PHP, was then selected as the CEO of PHP. (Charter Med would later become United Health Care.) HMOs grew rapidly during this period of time. By 1984 PHP had grown to be the largest HMO in Minnesota with 50 percent of the metropolitan HMO market and 25 percent of the Medicare subscribers in the Twin Cities area. Medicare patients comprised 30 percent of the private physician’s volume.1 The competition for patients caused various health plans to develop new programs to attract more patients. One of the programs PHP started called SHOP rewarded Medicare patients if they used designated hospitals for care.2 The plan excluded five

MetroDoctors

The Journal of the Twin Cities Medical Society


hospitals in the Twin City area. The purpose was to strengthen PHP’s negotiation power with the contracted hospitals in affecting rates for their Medicare patients. Physicians who utilized these excluded hospitals were concerned that they would lose their Medicare patients. The chiefs of staffs of these five excluded hospitals felt obligated to explore and understand why this course by PHP was necessary. Four of the five chiefs of staffs formed a committee to gain information from the Board of PHP as to how governance and business decisions were being made. Several law firms were interviewed to advise the committee on how to approach the organization. A law firm was selected and the committee was structured to have an executive committee and an advisory group of 20 physicians from throughout the Twin Cities. The group adopted the name of PHP Oversight Committee. All the physicians on the Oversight Committee were physician providers of PHP. Over the next 18 months PHP and the Oversight Committee battled in the press and in court over issues of accessibility to PHP Board information. Additionally, the PHP Oversight Committee identified the role of Richard Burke as CEO of PHP and Charter Med as representing a conflict of interest. Three lawsuits developed during the months of confrontation. The Oversight Committee started a process to recall the Board. At that point Governor Rudy Perpich interceded and had the Attorney General and Commissioner of Health moderate an agreement between the PHP Oversight Committee and the PHP Board. Negotiations were completed with compromises from both sides. A new PHP Board was formed and PHP remained a strong HMO in the community. Many years have passed since the dispute between the Oversight Committee and the Board of PHP. PHP merged with Share Health Plan to form Medica, which remains a strong HMO in the Twin Cities today. Although managed care has become an accepted fact in today’s health care environment, concerns remain about the cost of medicine to employers and individuals and is one of the leading issues in current health MetroDoctors

care policy debates. The HMO model has been a disappointment as a means to control health care utilization and cost. Lack of health insurance to 40 million Americans is a burden that both local and federal officials must deal with. Americans now spend 17 percent of gross domestic product on health care and as a country we rank 32nd in the wellness measures globally.3 A single payer system and a national health insurance plan are on the horizon. The present health care delivery system needs to be changed and new ideas and systems need to be implemented to protect the health of all citizens. The most significant lesson learned, in my opinion, from watching the development of managed care systems is the need to be aware of conflicts of interest. Medicine is big business and there will always be conflict between management and providers. It is my observation that restricting utilization and limiting care is a means to keep costs controlled and bottom lines in the black.

The Journal of the Twin Cities Medical Society

The health and care of patients should not be just a business decision, but needs to include a medical decision that uses evidence-based studies, appropriate technology and diagnostic testing, and sound judgment by physicians. Aaron Nathenson, M.D. is former chief of Ophthalmology at Hennepin County Medical Center and is an associate professor of Ophthalmology at the University of Minnesota. He served as one of the chiefs of staffs on the PHP Oversight Committee. K. James Ehlen, M.D., member of the PHP Oversight Committee (eventually serving as chairman and CEO of PHP) and Doug Shaw, former associate director, Hennepin County Medical Society, contributed to this article. References 1. City Business, Wayne Nelson, circa 1985. 2. Minneapolis Star Tribune, Tuesday, June 3, 1986, Gordon Slovut, page 6D. 3. Minneapolis Star Tribune, Tuesday, May 1, 2012, Paul Olson, Opinion Page A9.

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July/August 2012

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Medical Care Organizations

Colleague Interview: A Conversation With David Moen, M.D.

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avid Moen, M.D. is currently president and CEO of Fairview Physician Associates, a non-profit physician hospital organization. He also serves as chief medical officer of NetClinic, Inc., a webbased program that serves as an interactive personal health portal to allow virtual care delivery involving patients and clinics. Prior to his role in health care innovation, Dr. Moen led emergency services in two Fairview outstate locations. Dr. Moen earned his medical degree from the University of Wisconsin School of Medicine and completed his residency training at the University of Minnesota Family Medicine and Community Health. He is board certified in family medicine.

We have heard of the promise of the ACO. What are possible perils to the providers and the patients?

What crucial and/or unique operational capabilities must be in place for a clinic to succeed in an ACO?

I think the biggest possible peril is if we as clinicians and our patients as community members don’t embrace this time as an opportunity to really change the system. We can’t wait for others to fix the problem. If we make a payment switch to capitation without changing the care model and engaging the community in helping us establish appropriate incentives and expectations for patients/community we will have a repeat of the 1990’s managed care era. So in short, our biggest peril would be lack of engagement and leadership of clinicians, patients and our community in creating a sustainable approach to improving all of our health.

Critical capabilities include: • effective patient engagement approaches and relationship management • access to care at the right time in the right place when needed • clinical leadership aligned to engage clinicians and manage performance to Triple Aim • access to health data for risk stratification of population • proactive outreach and care planning for high risk patients • team-based approaches and care models adapted for unique needs of complex patients • reactive outreach for patients who experience an acute change in health status • partnerships that facilitate care transitions across the entire continuum • contracts that align incentives to help achieve aims

Is there a core set of contract attributes physicians should be aware of? Contracts at this stage of the game must be framed in meaningful metrics that help us achieve high quality experiences and health outcomes at an affordable cost. We are early in really understanding how best to measure this and translate that into our contracts. It will be critical to discover better ways of measuring meaningful outcomes in less burdensome and costly ways and translating that to aligned incentives designed to achieve the right goals.

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Required guidelines-measures: who has vetted these and are they accepted on our behalf? By whom? This is a great and complicated question. Multiple people have vetted different aspects of these capabilities but we are early in really understanding which ones are most meaningful and effective. For example, we know that patients are more likely to engage with care management staff connected to and trusted by their care giver. We still don’t have as MetroDoctors

The Journal of the Twin Cities Medical Society


accurate of predictive models as we need. Therefore, we are still learning more about who to engage with and which interventions truly help us drive value to the patient and the population. Part of our struggle is that all of these capabilities cost money. Figuring out which to invest in and how to pace that investment is difficult. I do believe that the only way to learn is to get started, measure, and learn from and share our mistakes and successes.

Can a physician participate in more than one ACO? (A single specialty group for instance.) Specialty physicians can participate in more than one ACO as they are designed today. The current model is more challenging for primary care physicians, however. Most independent physician groups desire to maintain choice for their patients. I believe it is very important to maintain as much choice as possible in the system.

Could you provide more detail and intent regarding independent physicians as partners in Fairview’s and other ACOs? What risks do physicians and practices enter into with an ACO program?

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We are all at risk for our ability to adapt and perform. Groups unwilling to have conversations with each other and their partnering organizations about what is working and not working and adapt going forward will likely have problems. Mutual commitment and trust are essential here.

The government or other third party payers will be defining expected or average anticipated costs for a population. Must we accept their calculations? Do we have any mechanism to challenge assumptions such as severity indexing accuracy? Do we have the capability to internally predict population expense on an annual basis? Tough to provide a blanket answer to this one. Smart people in dialogue willing to adapt as we move forward is the only approach that makes sense. There are many unknowns and much to learn. This is not business as usual and if it is, it will not work; collaboration and ongoing dialogue are essential with mutual commitment to achieving intended results. Sound aspirational? Yes. Achievable? Yes.

How does “Meaningful Use” fit into the ACO structure/ function? I am certainly not an expert in meaningful use but I will share my perspective as it relates to building infrastructure in our current environment. Requirements to achieve meaningful use funding were designed to enable us to establish key parts of infrastructure that hopefully are meaningful! There is a hint of sarcasm there in that I am not always sure that what we have decided is meaningful is really going to make a difference in the long run. What I hope is that we continue to achieve meaningful

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(Continued on page 14)

MetroDoctors

The Journal of the Twin Cities Medical Society

July/August 2012

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Medical Care Organizations Colleague Interview (Continued from page 13)

standardization where it produces value and allow variation where that produces value. This is a journey in my mind.

Please address the necessary process(es) involved to: arrive at a capitation contract with a group of providers; make provisions for “secondary” insurance to cover cost overruns; and provide financial incentives for employed physicians and for network contractors. This is also a very complicated question to answer in a paragraph. Said simply (and probably inadequately), it is critical to have an understanding of the scope of the population in the contract and an understanding of the care delivery assets required to serve that population. It then requires smart financial/actuarial people to figure out how to manage risk unrelated to performance and align incentives and management to improve performance. In this area, too, there is a lot of work to be done.

How is the partnership between Fairview and Medica going? How is “success” in containing costs being measured? Fairview is partnering differently with all health plans. What is most satisfying to me is that we are talking more about how we work more effectively together to serve our community. All our mission statements

say that in one form or another and it feels like we are acting more that way than we have in the past. Our conversations with Medica started earlier as we both were willing to lead a change for the benefit of all our community. We are farther along with Medica and PreferredOne in developing products for the market but all health plans want to do this work with provider partners. Success in containing costs in all our contracts with health plans is being measured based on projected cost trends based on risk of population served and market inflation vs. our performance against that trend. All contracts assure that quality and experience are rewarded and aligned as well.

In your opinion, will independent medical practices in the Twin Cities of necessity affiliate with a health plan network or ACO similar to those offered by the Fairview system in order to survive financially? I am not sure about this one. I do believe an affiliation has advantages in sharing some of the costs of necessary infrastructure to better serve populations of patients. I also know the independent physicians really value their ability to adapt and adjust their practices to meet their business needs. From what I have seen, the independent practices that are around today have done a great job of adapting to changing environments in this market. I would like to see the system continue to evolve so that independent practice remains a vital component of our system.

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July/August 2012

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What might the metro health system ACOs do collectively to aid the provider community and the general population? Across all health systems we are having this very conversation. One of our biggest frustrations as providers in this community is the complexity of the payment system for patients and clinicians. Interestingly, one of the biggest frustrations for payers is the complexity of the provider system for their members. As our health care system has gotten more complex (increased treatment options, products, etc.) we have not effectively reduced complexity for the users (patients and clinicians) of the system. Emerging Themes: Today’s model is too complex and cumbersome for patient and clinician users. We need to identify those things that have been created to benefit or make easy for non-patient and clinician stakeholders in the system that increase complexity for the ultimate users. Single-payer systems will have to emerge if we can’t identify common elements in a payer and data sharing framework that we all embrace in today’s system. Common attribution model is a good example. MetroDoctors

The Journal of the Twin Cities Medical Society


Hennepin Health An Integrated Health Care Delivery Network

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magine being worried about where you were going to sleep tonight and how you were going to get your next meal. Checking your blood pressure and medication compliance pales in comparison to a life in crisis. For our lowest income Medicaid recipients this is often the failure of health care. Hennepin County, in partnership with the Minnesota Department of Human Services (DHS) are working together to turn the system around with a Medicaid Demonstration project, Hennepin Health. Hennepin County’s integrated health care delivery network is designed to serve the unique needs of one of the most challenging and costly segments of the county’s safety net population. By integrating medical, behavioral health, and human services in a patient-centered model of care, the project seeks to improve health outcomes dramatically and lower the total cost of providing care and services to this population. As a safety net provider, Hennepin County is uniquely motivated to reduce costs, improve outcomes, impact lives/communities, and ensure that cost shifting does not occur. This social disparities approach to health care is based on the premise that treating a safety net patient’s medical problems without addressing underlying social, behavioral, and human services barriers and needs, produces costly, unsatisfactory results — both for the patient and the programs providing and paying for care. Providing services to help individuals meet their basic needs (food, housing, financial assistance, transportation, etc.) is critical to engaging this population successfully into health care services. Education on resources, assistance linking to

these resources, as well as general education is critical to improving individual investment in health. Identifying where the system has failed to meet individual needs is imperative. Individuals do not seek crisis care because it is what they value, they do so because the system does not meet their needs. We have engaged patients to discuss the “why” behind crisis care being the primary mode for engagement in health care and have learned everything from: same day access (we have hence created walk-in capacity at community clinics); open 24 hrs. (we have extended clinic hours, 24/7 nurseline, and are working on expanding access further to address this need); lack of reliable transportation (we have ensured bus passes are available where needed, prescheduling of rides, connected to services in shelters, are delivering medications to some venues vs. individuals not taking them due to transportation concerns). The common thread missing in crisis services that individuals want and is our “link” to primary care is the relationship — building a system with easy access where in addition,

the staff know the individual and there is a relationship which is critical to changing crisis behaviors, improving health outcomes, and reducing costs for this population. As of January 1, 2012, Hennepin County implemented a health reform initiative in partnership with the Minnesota Department of Human Services, targeted at ~10,000 individuals per month. The initial focus population is 21- to 64-year-old adults, with no dependent children in the home, living in Hennepin County, with incomes at or below 75 percent of the Federal Poverty Guidelines ($677/month or $8,124/year for one person) who qualify for Medical Assistance (MA). This population often receives minimal preventive care, is at high risk for acute care needs, and has poor health outcomes and health status. Lack of data sharing supports, the lack of policy and payer supports, and general system buy-in has prevented the County from launching a program such as this in the past. The current health care reform environment has heightened awareness, urgency and a path to pursue such changes. In addition, economic downturns have further forced health care to look at systemic issues as a means of survival. Hennepin County entered into a full risk contract with DHS and is receiving the same rate as the area health plans to manage this population differently. The hope is that the project will demonstrate overall cost reductions while increasing preventive care and positive patient outcomes. It is a one year contract with a one year renewable option. One critical component for success is

By Jennifer DeCubellis, LpC

(Continued on page 16)

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The Journal of the Twin Cities Medical Society

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Medical Care Organizations Hennepin Health (Continued from page 15)

an integrated system of providers. Hennepin Health has four internal partners and a growing list of external partners; however, in comparison to traditional networks, this is a smaller defined network focused on outcomes. Internal partners consist of: • Hennepin County Medical Center (HCMC): a 477-bed safety net Level 1 Adult trauma center with a robust network of primary and specialty care clinics throughout Hennepin County. • NorthPoint Health & Wellness Center: a Hennepin County full-service outpatient primary care clinic and Federally Qualified Health Center (FQHC), certified as a health care home. • Human Services and Public Health Department (HSPHD): social service functions for Hennepin County. • Metropolitan Health Plan (MHP): The County’s HMO which provides the administrative services for Hennepin Health (network management, claims payment, member services, etc.). Though Hennepin Health has four core partners, the population has expansive needs, such as dental care, transportation, mental health care, vision, housing, home care, and rehabilitation services, and the treatment model must address such needs. Hennepin Health is working with over 50 community providers to define outcome driven collaborations. The extended partners are critical for ensuring service provision in the enrollee’s community, ensuring continuity of care with changes in benefits and/or health status, and ensuring sustainability of the system. The extended partnerships form the foundation of a larger state-wide care system that allows for replication of the model to additional payer sources and communities and ensures scalability to additional populations. Early learnings have been many and continue to evolve monthly. An initial focus on the top 5 percent who are utilizing >64 percent of total funds has been critical. These patients are utilizing high levels of crisis services, as well as often moving between multiple providers and multiple pharmacies with a result of fragmented care and poor outcomes. Interventions focused on linking 16

July/August 2012

these individuals to a health care home and coordinating service needs have been crucial as a means to get better outcomes. Initial internal measures are focused on reductions in crisis levels of care (ED, Inpatient, Corrections, etc.) and increases in preventive services such as engagement in health care homes/primary care settings. We also utilize community measures to look at specific disease management outcomes utilizing a patient registry. Another critical measure is “churn.” Individuals on Medicaid typically stay on benefits for eight months before they fall off; >15 percent of this population is dropping monthly due to not completing renewal paperwork. We are working with DHS to impact this through provider supports for onsite renewals at the time of care. We are tracking drop rates in hopes of keeping more individuals engaged in care as a means to reduce health disparities over time. We have captured baseline data on member’s utilization of health care and social services when they enrolled and will re-test these baselines each quarter to determine impacts. Another initiative focuses on the ideal of one patient record. The importance of sharing information across systems to unduplicate care is critical to bending the cost curve and improving outcomes. One example is a patient in our shelter who was identified as having five caseworkers at one time across various systems — none of whom knew the others existed and whose unaligned work was often contradictory. Hennepin Health is working to create one record so services are coordinated in a seamless manner. Hennepin Health is looking at effective Medical spends — this often means using health care dollars to avert medical complications. With 32 percent of our population in “unstable housing” health care at area shelters is critical to ensure patient access. Medication delivery to shelters is being tested to improve adherence and reduce transportation barriers, which may further reduce ambulance runs to the emergency department. Average hospital lengths of stays are often doubled due to placement challenges for persons with behavioral needs, brain injuries, forensic history, to name a few. Housing supports help place individuals and keep them housed and out of hospitals and EDs.

One of the top non-emergent ED visits is for dental pain. Instead of prescribing pain meds, Hennepin Health is attaching dental care near the ED and ensuring same day access. Persons presenting in the ED for dental pain no longer get an ED charge and pain medications, they are walked to the dental clinic for care. By doing so, we reduce ED costs and avoid pain medications which often exacerbate chemical dependency issues. In addition, dental care needs are assessed by providers at all points of service. Once a need is identified, HCMC and NorthPoint both provide dental care onsite and we have contracted with Delta Dental for expanded service capacity and location. Challenges exist around this new territory specifically around defining data sharing parameters. There exists data sharing regulations around health care data and welfare data, but there are not clearly defined rules when you cross these two worlds. Hennepin Health’s success is highly dependent upon quick data access to drive system changes and inform providers. Hennepin Health is working with DHS to better define these parameters within integrated systems. Knowing who is utilizing high levels of care and why is imperative for health care improvement plans and cost reductions. We cannot change what we don’t understand. With data, we can turn the system around. Hennepin Health is working on real time provider and patient dashboards to guide health and outcomes. As a safety net provider, Hennepin County is excited to be a part of health care reform. This is a great opportunity for innovations to reduce costs and improve outcomes for our patients and our communities! Jennifer DeCubellis, LPC is an area director in Human Services and Public Health for Hennepin County in Minneapolis, Minnesota with responsibility for health care reform. Jennifer leads Hennepin Health, an initiative to improve system efficiencies between multiple public sector agencies as a means to improve patient experiences and reduce costs. Jennifer has spent the last 18 years in health care administration with an emphasis on program redesign, system efficiencies, and quality improvements.

MetroDoctors

The Journal of the Twin Cities Medical Society


Collaborative Care Cooperative

In

2011 a group of leading independent specialist practice leaders began to meet on a regular basis to discuss what our future role would be in a “reformed” health care market. We all shared a concern not to repeat some of the past mistakes of older managed care designs and we were committed to embracing the new possibilities. Our first challenge was to establish a legal organizational structure that would allow independent practices the ability to work in collaboration toward managing cost, improving quality and providing excellent service. A Provider Cooperative gave us the shared ownership and organizational structure we were looking for. Provider cooperatives are covered by a separate Minnesota Statute (62R). The state recognizes the value of physicians collaborating in this way so regulatory prohibitions on working together are significantly lessened. There are both common and preferred shareholders with one vote per common share. Common shares are held by the group practice and provide equal voting rights. The governance structure includes an elected Executive Committee and a 13 member Board of Directors. With the rapid pace of changes happening in health care, we were acutely aware of the importance of developing a communication and messaging plan to clarify our purpose, goals and strategies. The Co-op provides patients, purchasers and payers with easy access to over 500 medical specialist providers. The Co-op focus is on how medical specialists interface with primary care, hospitals, purchasers and payers. Co-op specialists will “wrap around” medical homes assisting them in meeting their quality standards, cost of care targets and coordination

By Douglas Hanson, MpA MetroDoctors

of patient care. For larger integrated delivery networks, the Co-op can provide a plug-in model which can be customized/scaled to the need of each specific system. Specialists can operate most efficiently within their own scope of practice and are very responsive to everchanging patient needs and treatment options. Payers, including both public and commercial, have delivered the first round of performance-based contracts into our health care market. They tend to lean heavily on primary care. There is considerably less focus on specialty care. We certainly support the emphasis on primary care and using a medical home model of care is certainly appropriate for measuring larger attributed populations. There is, however, a missed opportunity when the specialist is not fully engaged. When patients are faced with the need for acute or trauma care or care for a chronic disease their utilization of services increases and they are typically seeing a specialist. Specialists can have a profound effect on the cost of care and quality of care. The site of service alone can have a huge affect on the cost procedures and diagnostic tests. In addition, the development and adoption of clinical guidelines, alternative pricing formulas including “bundling” of care can result in more predictable costs. We are engaging with ACOs and similar Integrated Delivery Networks (large and small) to work in these areas. While all of our shareholders work individually with most networks, our interest is to move the relationship to the Co-op level where additional value can be achieved for these networks and our shareholders alike. We have recently entered into our first partner agreement with Integrity Health Network in Greater Minnesota with over 250 physicians. We have also begun working with some health plans to develop our own analytics surrounding utilization and total

The Journal of the Twin Cities Medical Society

cost of care. These health plans have expressed interest to feature Co-op network specialists within their insurance products. Shareholders are now using the Co-op to develop large scale quality outcome measurements. For example, our orthopedic shareholder practices are collaborating to create meaningful outcome data from patients who have undergone total knee replacement procedures. This is consistent with Minnesota Community Measurement and the Minnesota DHS mandate. We have consensus on the survey instruments, survey time intervals, patient demographics, software and analytics. By using the Co-op shareholder members can create efficiencies, standardize patient demographics/profiles and significantly increase the pool of patients under study. Conducting post procedural/surgical outcome studies requires periodic surveying of the same patients over time. The expense is significant and the state mandate unfunded. While shareholders still individually absorb these costs, the Co-op has become a valuable resource creating efficiencies and standardization. We will continue to produce more specialty care quality studies. (Continued on page 18)

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Medical Care Organizations Collaborative Care Cooperative (Continued from page 17)

Future plans also include improving integration and care coordination with primary care. Advancements in information technology is a significant and a differentiating factor in the delivery of health care today. We have very sophisticated electronic medical record (EMR) technology in most practices. We clearly are in an improved position to capture data, apply analytics and create meaningful information. There remains, however, a significant missing piece of infrastructure and that is full interoperability. The ability to move data easily from one EMR to the next is still largely missing. To many of us it appears the technology industry which we depend on has become the obstacle in getting us to full interoperability. As competing vendors jockey for market share there is little interest to spend resources or extend service that may advantage a competitor. It would be good to see more collaboration within the information technology industry on this front. In the meantime the Co-op has invested in a physician-to-physician communication application called the Care Team Conferencing (CTC) Tool. The goal of the CTC Tool is to simply and effectively improve on communication and coordination of care with primary and specialist physicians. Providing direct communication with specialists offers primary care a resource to help them with effectively managing care. In some cases, patients may be managed without a need for formal referral or by receiving timely specialist care and avoiding an unnecessary trip to the ER. It is interesting that when we are out talking to physicians about this application, it is common to hear of curbside chats that used to occur when physicians gathered more and interacted within the walls of hospitals. The CTC provides a structured, easy to use and secure communication. Physicians can use the application from a smart phone, tablet or lap top. We are currently in a pilot phase of development. In Greater Minnesota the effects of health reform is just as significant. From the early formation of the Co-op we have had interest to create a state-wide specialty representation. We have made frequent trips to northern, central and southern Minnesota. A broad geographic representation can support independent 18

July/August 2012

Vision: Delivering extraordinary patient care through effective physician collaboration across organizational boundaries, allowing patients and their primary care team the freedom to select the specialty physicians of their choice. Mission: The Collaborative Care Cooperative offers a patientcentered alternative to coordinate care, in a cost-effective setting. Our mission will be enhanced through the delivery of an exceptional patient experience with each care team interaction. We will achieve our mission by deploying innovative electronic tools and collaborative practices which remove communication barriers, and through a continuous drive to customize care for each, individual patient.

practices across the state and improve community health. The future of the Collaborative Care Cooperative is wide open. Not being tied to bricks or mortar certainly provides for a nimble and adaptable organization. We have very ambitious plans, relying on our collaborative interests to preserve patient choice and to continually tap into the knowledge and innovation of the independent specialist and our primary care colleagues. Staying focused on the Triple Aim of managing cost, quality improvement and the patient experience will continue to be our guide.

For more information please contact Douglas Hanson, chief administrative officer (612) 229-4801. Douglas Hanson, MPA is a senior health care executive with extensive experience in hospital and clinic management, operations, and marketing. Hanson currently serves as chief administrative officer for the Collaborative Care Cooperative, a network with over 500 independent specialists serving Minnesota. Prior to the Co-op, he was President/CEO of Integrated Medical Rehabilitation of MN, LLC a multi-site rehabilitation company.

Collaborative Care Cooperative Shareholders Allergy and Asthma Care, pA Center for Diagnostic Imaging Colon and rectal Surgery, pA Edina Eye physicians, pA Metro Urology, pA Midwest Ear, Nose & Throat Specialists, pA Minnesota Eye Consultants, pA Minnesota Oncology/Hematology, pA Noran Neurological Clinic, pA Oakdale Ear, Nose & Throat, pA St. Croix Orthopaedics, pA St. paul Eye, pA St. paul radiology, pA Summit Orthopedics, Ltd. Therapy partners Twin Cities Orthopedics, pA West Metro Ophthalmology, pA

MetroDoctors

The Journal of the Twin Cities Medical Society


Where do Specialists Fit in Accountable Care?

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n late 2011, the Centers for Medicare and Medicaid Services (CMS) released its final rule for the implementation of the Medicare Shared Services Program (MSSP) and the Advanced Payment Model under which Accountable Care Organizations (ACOs) would function. The final rule confirms that the agency’s focus will be to achieve cost effectiveness in populations that are large but relatively low cost, and specialties that manage smaller but higher cost patient populations will be involved more peripherally. Patients will be assigned to the ACO based on the primary care physician (PCP) who provides the most primary care services. Although often misunderstood by specialists, the rule does allow for the assignment of patients who receive no services from a PCP to a specialist who provides the greatest number of primary services. For patients with conditions such as cancer, advanced renal failure or complex cardiac disease, a specialist may provide most if not all of their care in a given time frame such that the patient could be assigned to no ACO, the ACO in which the specialist participates, or the ACO of a PCP who sees the patient infrequently and belongs to an ACO different than that of the specialist. Such ACO assignments could make coordination of care and access to the specialist more difficult and reduce opportunities to realize cost savings. Another feature of the final CMS rule that could impact specialists is the exclusion of patients in the 99th percentile of costs from per capita spending targets and

By Thomas p. Flynn, M.D. MetroDoctors

the analysis of how the ACO is performing relative to those targets. For oncologists this will mean that many cancer patients undergoing active treatment will be excluded from assignment to an ACO given the expense of modern cancer care. Beyond these components of the final CMS rule, another aspect that may affect specialists is the approach to spending targets. Per capita spending targets will be based initially on three years of historical spending weighted more heavily on the third year. Then in the three performance years there is an upward adjustment using a minimal index of inflation. This represents a major challenge in oncology, for example, given the number of new cancer drugs and technologies being developed and rapidly becoming available for use in patient care. So-called targeted therapies, which are often more effective and less toxic, are very expensive, and it will be difficult, perhaps impossible, to provide state-of-the-art cancer care to Medicare beneficiaries with cancer at a stable or lower cost over even just a three-year period. Similar challenges are likely in other specialties that deliver care to complex patients who require costly drugs or medical devices. Finally, many patients demand that oncologists provide the latest cancer drugs based on their personal research — often conducted on the internet. It will be key for physicians to delicately manage patient expectations with the reality of these new approaches to health care reimbursement. Under an ACO, the eventual reimbursement scheme would require a “better, faster, cheaper” approach to health care. In other words, our group will need to find better ways to provide care (total cost, P4P, etc.). Generic equivalent cancer

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drugs would need to be utilized instead of more expensive (yet equivalent) brand name drugs. This would result in meeting quality and clinical objectives, yet save the patient and the government (Medicare) unnecessary drug expense. The key to the success of the ACO is the ability to deliver multi-lateral, effective and timely information so patient care can be managed in an effective manner. The size of Minnesota Oncology and its partnership with US Oncology should allow our practice to be able to intelligently manage patient care and to control, or at least moderate, increases in health care costs. The key challenge to all of these efforts is to find a way to link (interface) all of the different practice management systems and EHRs among the

(Continued on page 20)

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Medical Care Organizations Where do Specialists Fit? (Continued from page 19)

various parties (hospitals, physician practices, other care providers) — hopefully, health data interchanges will develop and evolve to manage these complex data streams. Without these data interchange capabilities, ACOs will not be able to carry out their expected missions. For independent specialty practices particularly, we believe it is important that ACOs are governed and clinically managed by physicians, who have an obvious stake in the physician-patient relationship. If the ACOs are deemed to be skewed in favor of the health systems (or hospitals), this would be potentially corrosive for the long-term stability of ACOs. If however, health systems are willing to truly engage with their employed physicians AND to partner with independent physician practices, this would result in ACOs becoming potentially enduring organizations. The commercial health insurance sector is, of course, also interested in greater value and controlling costs. We expect to see a continued trend among commercial payers to develop non-traditional payment methodologies as an approach to control costs. Although cancer patients represent only 1 percent of commercial patients, cancer services represent 10 percent of all health care costs, which would be an attractive focus for cost savings. A shift away from volume-based, fee-for-service payments toward episode of care based, bundled payment, and shared savings models are being actively pursued by a number of payers. At Minnesota Oncology, we employ evidence-based clinical pathways which have been associated with lower costs without compromising outcomes. Patients with lung and colon cancer treated with chemotherapy on these pathways had costs that were over 30 percent less than those treated off-pathway and experienced the same survival outcomes.1,2 Opportunities are being pursued with payers to qualify for reimbursement based on compliance with these pathways as well as fee schedule adjustments that provide appropriate incentives for the use of lower cost generic chemotherapy agents. Nationally, United Health Care and 20

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Aetna are piloting oncology-specific episodes of care payment models with large oncology practices. Beyond ACOs and the approaches with payers outlined above, there are other opportunities for specialists to be accountable for the care they provide. The Congressional Budget Office estimates that up to 30 percent of medical care delivered in the United States is for tests, provider visits, procedures, hospital stays and other services that are unnecessary and do not provide a health benefit to patients. In 2010, Howard Brody, M.D. published a piece in the New England Journal of Medicine titled “Medicine’s Ethical Responsibility for Health Care Reform – the Top Five List.”3 Dr. Brody challenged the medical community to address waste and inefficiency in health care delivery by suggesting that each specialty identify the top five practices that are widely utilized, costly and yet for which there is no evidence to indicate they add value to the care that is provided. The American Society of Clinical Oncology (ASCO), which established a Cost of Cancer Care Task Force in 2007 that developed a policy statement on the high cost of cancer care, encourages oncologists to discuss the cost of care with patients. More recently, in response to Dr. Brody’s challenge, ASCO developed a “Top Five List” for oncology as opportunities to improve care and reduce costs.4 Minnesota Oncology, which has already embraced some of these items, is exploring ways to incorporate these approaches into everyday practice, ultimately utilizing our electronic health record. We would view the employment of such top five lists as a strategy to make care more accountable, reduce wasteful expenditures, and thereby lower the cost of care while maintaining and arguably improving quality. Comparative outcome studies will be needed to define how we can achieve cost savings while maintaining the highest quality of care and the best outcomes. Large groups such as ours should participate in contributing to this body of evidence. All parties should welcome comparative studies when measuring quality and outcomes. Competition, by nature, drives organizations to constantly improve and innovate — which

should benefit the patients and society at large, while contributing value to an ACO. Specialists may be on the periphery in ACOs as developed by CMS, but they still have opportunities to collaborate with PCPs under that model and contribute to the realization of cost savings, potentially participating in more than one ACO. Beyond involvement in ACOs under CMS, specialists will be able to partake in nontraditional payment methodologies either independently or as part of ACO responder organizations employing episode of care reimbursement, bundled payment structures, shared savings arrangements or other methodologies as health care transforms from a volume-based, fee-for-service reimbursement system to a model that is value based. To further enhance value by eliminating waste, specialists are perhaps in the best position to develop and employ approaches such as the “Top Five Lists,” which in our view are worthy of significant attention and further efforts to implement. Thomas P. Flynn, M.D. has been in private practice since 1987 as a partner in Minnesota Oncology with a clinical practice based in Minneapolis. He has served as the group’s president from 2001 to the present. Dr. Flynn was awarded a medical degree by the University of Minnesota Medical School. He completed an internship and residency in internal medicine at Washington University/Barnes Hospital in St Louis, and a fellowship in hematology/oncology at the University of Minnesota. Prior to joining Minnesota Oncology, he was on staff in the Hematology-Oncology section at St. Paul Ramsey Medical Center and a member of the University of Minnesota Medical School faculty. References: 1. Neubauer, MA, et. al. Cost Effectiveness of EvidenceBased Treatment Guidelines for the Treatment of Non-Small-Cell Lung Cancer in the Community Setting. JOP 2010; 6:12-18. 2. Hoverman, JR, et.al. Pathways, Outcomes and Costs in Colon Cancer: Retrospective Evaluation in Two Distinct Data Bases. JOP 2011; 7:52s-58s. 3. Brody, H. Medicine’s Ethical Responsibility for Health Care Reform – The Top Five List. N Engl J Med 2010; 362:283-285. 4. Schnipper LE, et.al. American Society of Clinical Oncology Identifies Five Key Opportunities to Improve Care and Reduce Costs: The Top Five List for Oncology. JCO published online April 3, 2012; DOI:10.1200/JCO.2012.42.8375.

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The ACO Paradox

T

he passage of the federal Accountable Care Act in the spring of 2010 provided the legislative framework for many changes to occur in health care financing. While the initial discussion and debate around federal health-care legislation focused on improving access for the underinsured, improving quality for patients, and helping to control health care costs, the major impact of the federal legislation will be focused upon cost control. Most physicians are now familiar with the term Accountable Care Organization (ACO). The federal legislation resulted in the Center for Medicare and Medicaid Services (CMS) establishing a Medicare Shared Savings Program. This program is designed to incentivize health care providers to help control health care costs and, as a result of doing so, to share in the financial benefits. CMS has used the acronym ACO to name the outcome of these efforts. This has led to some confusion in the use of the term ACO in the marketplace. Does ACO Mean ACO?

We need to think of ACOs from two perspectives. The first is as a noun and the second is as an adjective. When discussing the Federal or CMS ACOs we need to think of the term as a noun or as a destination. The U.S. government finalized the rules in November 2011 in the Federal Register, which define exactly what is an ACO. These rules narrowly establish which providers and health care organizations, and under what circumstances, can perform as an ACO for Medicare beneficiaries. On the other hand, the use of the term ACO for programs being developed outside By Scott r. Ketover, M.D. AGAF MetroDoctors

of Medicare refers to more of a process or a journey. This implies that the non-CMS ACO actually refers to a clinically integrated network of providers and/or systems and can be defined in many different ways across non-CMS patients. Most importantly both structures, the CMS and non-CMS ACO, are designed to meet the goals of the “Triple Aim�: 1. Reduce per capita cost of care 2. Improve the patient experience and quality of care 3. Improve population health And to further add to the confusion, CMS has recently defined a category of Pioneer ACOs. These are designed to follow the same cost control format of the other shared savings programs, and if they are successful in their first two years they can then change in year three to move to a population-based payment arrangement with full risk and capitation. Common Features in all ACOs

All of the ACO programs are designed such that health care providers assume the financial

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responsibility and risk for meeting the goals of the Triple Aim. In the CMS ACOs the patients retain full freedom of choice. That is, Medicare beneficiaries may continue to choose the providers and the institutions where they receive their care, without regard to a particular ACO. The non-CMS ACOs will individually determine whether or not patients are restricted to a narrowly defined network of providers and institutions or have open access and wide choice. As each accountable care organization determines its structure this will in turn have a major impact upon the ability of the ACO to help meet the Triple Aim and determine the overall cost of the product to the patients, employers and other subscribers. Providers will have significant incentives to help control appropriate utilization of health care services and to help minimize the use of services that are of unproven benefit. As physicians, we greatly impact utilization via the orders that we create for office visits, hospitalizations, testing, procedures, labs, radiology, prescriptions, and therapies. However, demand for health care services is often initiated by a patient’s need or desire. Thus, many patients enter the system of care and consume services before providers can help to control utilization. Triple Aim vs. Single Aim

There is almost no debate among health care providers that the Triple Aim is a worthy target. However, what we have seen so far in the development of CMS ACOs is emphasis on the shared savings program. The economic realities around the enormous cost of delivery of care throughout the nation are driving the changes in both form and function of health care organizations. The (Continued on page 22)

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Medical Care Organizations The ACO Paradox (Continued from page 21)

incentives to reduce the per capita cost of care will dwarf those designed to enhance quality of care and improve population health. In the past two years, these economic incentives have resulted in a rapid increase in consolidation of health care providers. Mergers and acquisitions among hospitals, hospitals and medical providers, and provider groups are happening at an ever-increasing rate. This consolidation is often being called clinical integration, and it is hoped that these changes result in less expensive delivery of care. Clinical Integration

It is believed that by combining the strengths of the various provider groups and organizations along clinical service lines that major cost controls can be achieved. Implementation of guidelines and pathways will help to decrease unnecessary utilization. The combined application of the intellectual capital of many providers will hopefully lead to improved health care delivery at a lower cost. However, the process of successful clinical integration is very expensive. This will demand very robust information technology platforms. This IT infrastructure has yet to be developed. Most medical clinics and hospitals are still trying to purchase and implement electronic health records. There are numerous EHRs available in the marketplace and the conversion from a paper-based medical record to that of an electronic one is quite cumbersome, time-consuming and costly. The clinical interoperability of the various EHRs is in its infancy. Regional, state and national health information exchanges do not yet exist for the overwhelming majority of the U.S. population. So the adoption and implementation of EHRs is certainly necessary but clearly insufficient for promoting the process of widespread clinical integration. The ACO Paradox

Will ACOs provide the correct incentives to achieve the Triple Aim? While most experts agree that clinical integration is essential to meet the goals of an improved system, it remains unclear as to how to execute the integration. There are many

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single specialty provider groups, which have developed the focused factories necessary to minimize inappropriate utilization of health care resources. The methodology to bring these independent provider groups together to achieve an even larger goal is unknown. There will be quite a lot of trial and error in shaping these new relationships. Independent medical provider groups have previously viewed both hospital organizations and third-party payers as competitors. And in many circumstances these relationships were somewhat adversarial. Future success depends upon restructuring these relationships. Current market realities are helping to move this process along. In general, thirdparty reimbursement to independent specialty practice is less than that of the reimbursement received by multispecialty practice and health systems. This fact promotes the movement of single specialty providers into larger organizations. It remains to be seen if the utilization, overhead and cost control advantage of the focused factory is lost when the single specialty provider becomes part of a large clinically integrated multispecialty network/ACO. How has Minnesota Gastroenterology Engaged this Environment? Minnesota Gastroenterology, PA is a large single specialty independent practice. We are composed of 60 gastroenterology physicians and 20 mid-level providers. Our organization has continually assessed how we deliver GI care with the goal of providing the best possible clinical outcomes at the lowest possible cost. This requires an internal organizational dedication to creating a governance and operational structure focused upon patient care. This is always a “work in progress.” In addition to a strong internal emphasis there is also external engagement from the practice members to our larger GI community. We accomplish this by: • Active participation and leadership in regional and national gastroenterology organizations. This includes: the American Gastroenterological Association, the American Society for Gastrointestinal Endoscopy, the American Association for the Study of Liver Diseases, the Twin Cities Medical Society, the Institute for

Clinical Systems Improvement, the national GI Practice Management Group, the Get Your Rear in Gear colon cancer awareness events, and the MN Labor Care Health Fair. Engagement with other local provider groups via hospital system organizations. This includes participation in local hospital medical staff committees and positions on the boards of several of the health systems.

Recommendations for Independent Groups

1.

2.

3.

4.

Every Independent practice should create its seat at the table. Independent providers need to assess their geography and identify their current allies and competitors. Practices need to seriously consider which of their current competitors can actually be turned into allies. Physicians, and other health care providers, hospitals and health systems must continue to seek out each other to define the advantages of clinical integration. Independent practices cannot afford to wait on the sidelines. Implement an electronic health record. For many years I have said, “if there was ever an industry ripe for digitalization, it is health care. There are billions of pieces of patient information, which are only valuable to the health care provider at the moment of care delivery.” The federal Meaningful Use dollars will help defray the cost, and it is inevitable that all of health care will be documented in an electronic format in the not-too-distant future. ACOs must be designed to give the individual patients their personal responsibility for their own health. Today, CMS defined ACOs allow Medicare beneficiaries to sidestep this responsibility. I believe this will greatly limit the success of the CMS model. Non-CMS ACOs have the opportunity to engage the recipient of care in achieving the Triple Aim.

Editor’s Note:

Following the submission of this article, the editorial board requested further comments from Dr. Ketover. His responses are below:

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The impetus for ACOs is cost containment as you state, and this poses dilemmas for physician organizations.

to the bottom” as plan cost will dominate and issues around quality and outcomes will receive more “lip service.”

• How would you envision patients being active and effective in directing cost controls? Patients will not have the tools to be active and effective in directing cost controls until full transparency of cost is supported: this means all providers, payers, hospitals, facilities, etc. need to be free to “publish” and discuss the contracted rates/payments they receive for services (currently a Stark and payer contract violation).

• If care coordination is key to cost reductions in an ACO, what will this entail practically — i.e. who will do it? Care coordination as currently envisioned by CMS and private payers is a “gatekeeper” concept and will only serve to add administrative cost to care, and may actually cause total cost of care to increase. Real ACO care coordination will require robust IT platforms (not available today) with full transparency of costs and the health care community, politicians and insurers will not support this.

• How would patients (or would they) be able to direct to whom the money goes for their care? Very soon many patients will participate in private insurance exchanges (starting 1/1/13 for some) as their employers convert to defined contribution benefit plans. Patients/employees will choose their “plan” based upon their personal monthly cash contribution. This will be done via the web during open enrollment each fall. Choice will be guided by cost in the same way as most people purchase auto insurance (as a commodity). Plan design will create a “race

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• What role will medical specialists vs. primary care gatekeepers have in evaluating a given patient’s need for their services? Specialists and primary care doctors will not provide the gatekeeper role unless their compensation is directly tied to benchmarks and this would create a moral dilemma around denial of care.

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• Can a group like yours participate in more than one ACO? For CMS: primary care can only participate in one ACO. For non-CMS both primary care and specialty care can participate in multiple ACOs as permitted by each non-CMS ACO design. Scott Ketover, M.D., president and CEO of Minnesota Gastroenterology, P.A. Dr. Ketover is a native of New York City. He earned his undergraduate degree in Communication Studies from Northwestern University, attended business school at New York University and completed his premedical training at Columbia University. Dr. Ketover received his medical degree from the University of Minnesota. He completed his residency in internal medicine and his Fellowship in gastroenterology at the University of Minnesota Hospital and Clinics. He has been a member of Minnesota Gastroenterology’s Board of Directors since 1998 and has served as the chairman of the Board since 2007.

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Quiet Session A Welcome Change

L

ooking back, it was a relatively quiet session from a health care perspective. A budget surplus paired with the political realities of redistricting and the upcoming election resulted in only a handful of significant health care policy bills being passed in the 2012 session. Although the session did not start until the end of January, the table was largely set following the release of the November budget forecast in early December. Much to the surprise of everyone involved, the forecast showed an $876 million surplus, a number many had expected to be around a $500 million deficit. Once the session began much of the legislative work did not start until after the revised February forecast came out the last day of the month. Again, the February forecast showed an additional $323 million surplus. Statutorily most of the surplus dollars were already spent the moment they were realized leaving little leftover to repair some of the difficult health care cuts from 2011. The first part of the surplus was used to backfill the budget reserve account and the state’s cash flow account. The remaining dollars from the surplus went to begin repayment on the school aid payment shift used as a budget balancing mechanism the last couple legislative sessions. The surplus is not expected to extend beyond this session as the next biennium is currently projected to have a deficit of $1.1 billion. However, as was evidenced last year, this number could shift based on changing economic conditions.

By Nathan Mussell, J.D.

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HHS Omnibus Budget Bill

Unlike in years past, the HHS omnibus budget bill proved to be relatively non-controversial and moved through the process with relative ease this session. In large part due to the surplus, the total bill was only around $23 million — much of which came from monies being repaid to the state by the HMOs participating in the Prepaid Medical Assistance Program. Dating back to last year, the state mandated that any profits above 1 percent by the HMOs in PMAP (Prepaid Medical Assistance Program) had to be paid back to the state. The final numbers released in early April amounted to a total payback of $73 million, $31 million from Medica, $25 million from HealthPartners, $9 million from Blue Cross, and $8 million from UCare. After returning just over half the funds to the federal government, and allocating a portion back to the Health Care Access Fund, the legislature was left with around $27 million. After much frustration in the negotiating

process, only around $11 million of those funds were allocated toward the HHS budget, leaving the additional funds to be used toward a tax relief package, which in the end was vetoed twice. With the addition of the $11 million, Rep. Abeler and Sen. Hann were able to restore a few of the cuts made in the 2011 budget that had been priorities of the Governor’s supplemental budget including $5.9 million for a delay in the cut for personal care attendants who were relatives of the patient, $4.6 million for restoration of cancer and dialysis treatment coverage in Emergency Medical Assistance. The House and Senate did not include any funding restoration for the Medical Education and Research Costs program which had also been a priority in the Governor’s budget. In addition to the above budget items, a few policy items were included, most of which proved noncontroversial or had been worked out during the conference committee including language around PMAP transparency to conduct audits in conjunction with the legislative auditor, a study of the effectiveness of managed care in public programs, a study of for-profit HMOs in Minnesota, a study of the Emergency Medical Assistance Program, and a study of access to patient health care records. One item of significance that was not included in the final bill included a full repeal of Rule 101. Currently Rule 101, as it is known, requires that a provider accept public program patients in order to also be able to accept state employee, workers compensation and other public employees. The Senate had added an amendment during the

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floor discussion before conference committee that would have repealed the Rule 101 requirements in statute. Ultimately, DHS had significant opposition to the repeal so it was taken out of the bill that came out of conference committee. Managed Care Transparency

Outside of the budget discussions the other issue that drew considerable discussion this session was transparency in the state’s managed care programs. The issue of transparency in the state’s PMAP program has been gaining greater notoriety on both sides of the aisle over the past couple legislative sessions. This session the issue came forward in a bill calling for independent third party audits of the health plans and the rate setting in PMAP done by the Department of Human Services. As it has been reported, the federal government appears to be investigating whether the state intentionally inflated the rates in Medical Assistance (which receives federal matching funds) in order to make up for losses being sustained in GAMC. The issue has gained increased attention in Washington D.C. in Congressional hearings as well. This will likely be an issue to continue watching over the coming months, both to see if any adverse action is taken against the state and DHS and whether any reforms are made at the federal level that may impact the state budget going forward.

Provider Peer Grouping

The Provider Peer Grouping program was a major piece of the Health Care Reform bill passed by the legislature in 2008. Over the past two years there has been concerns raised with the effectiveness and accuracy of the reporting data in the program as it was intended. Earlier last fall, hospitals around the state were the first set of providers to have their peer grouping data released. The release of the data to hospitals brought the concerns of the past two years to light as there were considerable questions about the data’s accuracy and the ability of hospitals to review the data. Legislation was passed this session making a number of changes to the program through creation of an advisory committee, extending the timeline on review of the data, and how the data would be disseminated to the public. The changes in the bill had been worked on by members of the provider community, the health plans and the Department of Health.

Health Insurance Exchange and the ACA

Outside of some initial discussions in the House and Senate HHS committees on the activities of the Governor’s Health Insurance Exchange Task Force, the only legislative activity on the exchange came when Sen. Hann gave the insurance exchange bill a hearing in his committee late on a Monday evening only to vote the bill down along party lines. Beyond that brief show the issue largely remained on the sidelines with eyes on the Supreme Court oral arguments on the constitutionality of the overarching Accountable Care Act. Now that the session is finished, the activity in both the Exchange and larger Health Reform Task Forces will likely begin again in earnest as the groups put together a potentially significant piece of legislation for the 2013 legislative session. Nathan Mussell, J.D., Government Affairs, Lockridge Grindal Nauen.

Board of Medical Practice and the Sunset Commission

One of the most contentious issues that arose in this session that didn’t deal with budget or transparency dealt with a bill coming out of the Sunset Commission requiring certain information regarding any provider’s malpractice settlements, judgments, adverse privileging actions and felony conviction be posted on a public Board of Medical Practice website for notification for consumers. The issue of posting malpractice settlements drew considerable opposition from providers, clinics and malpractice insurers. Ultimately after being in the bill, then out of the bill, then back in, settlements were taken out leaving only the posting of judgments in the final bill signed into law. MetroDoctors

The Journal of the Twin Cities Medical Society

July/August 2012

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The Legacy of Dr. Eduard Boeckmann, East Metro Medical Pioneer Due to the efforts of Boeckmann and others, the Ramsey County Medical Library was established in 1897; however, this was only the first step. Once the collection was started, the Medical Society required ongoing funding to run and house the library.

A Country Doctor Practicing in the City

In 1887, Dr. Eduard Boeckmann (18491927), then a 38-year-old Norwegian immigrant, arrived in Saint Paul, Minnesota with his wife Anna and their four children. Boeckmann would live in the Twin Cities area for the rest of his life and would become a well-known physician and active member and future president of the Ramsey County Medical Society, now the Twin Cities Medical Society. As a doctor, Boeckmann was attentive to his patients and well respected by his colleagues. Dr. William J. Mayo once said that it was to those such as Dr. Boeckmann “that the profession owes a great debt.” An active researcher, practitioner, and philanthropist, Boeckmann’s presence in the Twin Cities continues to influence medical practice in Minnesota in an age far removed from his own. Dr. Boeckmann was a concerned advocate for the well-being of his patients and dedicated himself to providing them with personal, dutiful care; he often referred to himself as a country doctor who practiced in the city. He spent many late nights at the office, working until he had seen every patient, as was his personal policy. Dr. Boeckmann was also generous with his time and expertise and mentored several of his younger, less experienced colleagues. He graciously offered his professional advice and counsel free of charge. To his friends and colleagues, Boeckmann was known for his honesty, sincerity and kindness.

By Kristin roberts

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Dr. Boeckmann the Enterprising Philanthropist

Creation of the Medical Library

In today’s technology-saturated world, it is easy to take accessible information for granted, but for doctors in the 1890s, finding medical information at all, let alone relevant information, could be laborious. Even before Boeckmann’s arrival in Minnesota, the Ramsey County Medical Society had recognized the need to provide access to medical information and research to member physicians, but it took the initiative of Boeckmann and a few of his colleagues to make the possibility of a medical library a reality. Boeckmann understood the importance of the library’s establishment for Twin Cities physicians and their patients, and he gave sacrificially of his time and resources to see that many would benefit from the use of a medical library. For Boeckmann, this meant donating many of his own books to the collection and making door-to-door buggy rides to ask for book donations from other doctors.

Although Boeckmann was not personally responsible for the operation of the medical library, his sense of duty and devotion to the medical profession compelled him to ensure the library’s survival. In one effort to support the upkeep of the library, Boeckmann co-founded the Saint Paul Medical Journal. The Journal provided the library an income through advertising, but it was not substantial enough to support it completely. Yet, Boeckmann’s greatest contribution to the medical library, the Twin Cities medical community, and medical practice across the country was his medical breakthrough: the development of a process for making sterile pyoktanin surgical catgut. Then the primary material for surgical sutures, catgut, made from the gut of sheep, was not always sterile when doctors received it, and it frequently caused infection. Prior to Boeckmann’s research, the only producers of surgical catgut were located in Germany. Dr. Boeckmann, with the help of bacteriologist Dr. Gustav Renz, sought to create a method to prepare an improved catgut suture. In 1899, the year he was president of Ramsey County Medical Society, Boeckmann, aided by the input of his colleagues, finished his development of surgical catgut treated with pyoktanin. This antibacterial dye made sutures sterile, antiseptic, and decidedly preferable to horsehair

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or silver wire — the only other alternatives of the time. Shortly after perfecting his catgut preparation process, in a far-reaching act of philanthropy, Boeckmann donated its manufacture and proceeds to the Ramsey County Medical Society to cover the expenses of the library. Boeckmann’s catgut was manufactured until 1959 when the process was sold, and the remaining money was used to sustain library operation through what is now called the Boeckmann Fund. Boeckmann’s work to support the library and his fellow physicians is still seen as an important part in the development of Minnesota’s medical community. Dr. Frank Indihar, EMMS Foundation Board member, reflects, “Dr. Boeckmann’s significant contribution to the Ramsey County Medical Society (now TCMS) insured the education of his colleagues for generations.” In honor of Dr. Boeckmann’s efforts and commitment to education, the library was renamed The Boeckmann Library in 1971; today, the library is no longer run by the

Previous Award Recipients 2008 George F. Smith, Jr., MD 2007 Walter L. Bailey, MD 2006 Richard W. Anderson, MD 2005 Vernon L. Sommerdorf, MD 2004 Rene W. Pelletier, MD 2003 Mary Lou Ezzo, MD 2002 Deborah L. Wexler, MD 2001 Joseph H. Tashjian, MD 2000 Wayne H. Thalbuber, MD 1999 Neal R. Holtan, MD 1998 Frederick M. Owens, Jr., MD 1997 Stephen P. England, MD 1996 Budd Appleton, MD 1995 No Award Given 1994 Timothy J. Rumsey, MD 1993 Charles E. Crutchfield, Sr., MD 1992 Laura Edwards, MD

medical society, but the collection, now located in United Hospital, is available for the use of Twin Cities physicians and medical researchers. Dr. Boeckmann’s Legacy

Boeckmann’s generosity and the genuine passion for medical practice that drove it was rare then and is still an inspiring story today. Even after more than 100 years, Boeckmann is remembered for his charitable contributions to medicine and unimpeachable character in practice. “Dr. Boeckmann exemplified the best physician traits: medical research curiosity, clinical excellence, and generosity,” says Dr. Kent Wilson, EMMS Foundation president. “The generous gift of his sterile absorbable suture proceeds to the medical society supported the society and its library for decades and now is a major funding source for the EMMS Foundation. The Foundation provides support and leadership in addressing health issues given its unique position in the medical community. Recently, Dr.

Boeckmann’s legacy gift catalyzed the Honoring Choices Minnesota initiative. We may not all be able to donate a business enterprise, but we all can add to Dr. Boeckmann’s initial gift for the benefit of east metro physicians and community.” Recognizing the philanthropic spirit of Dr. Boeckmann, the East Metro Medical Society Foundation plans to continue to sustain the Boeckmann fund in service to the physicians in the east metro. In honor of Dr. Boeckmann, the East Metro Medical Society Foundation will yearly recognize a recipient of the Boeckmann Community Service and Leadership Award. The Boeckmann Award will be given to an east metro physician and unsung hero who, like Dr. Boeckmann, gives sacrificially of him or herself for the good of the community. Dr. Boeckmann’s legacy recognizes outstanding physicians, continues to support the community and serve as an example for future citizen physicians.

Boeckmann Community Service & Leadership Award The annual Community Service Award recognizes “unsung physician heroes” who have made positive contributions to our local community. When the East and West Metro Medical Societies merged to create the Twin Cities Medical Society, the management of the Community Service Award reverted to the East Metro Medical Society Foundation. In 2011, the Foundation Board of Directors renamed the award to The EMMS Foundation Boeckmann Community Service and Leadership Award. Eduard Boeckmann, MD (1849-1927) was an enterprising physician who developed a preparation process for sterile sutures and later donated his business and proceeds to the Ramsey County Medical Society. Dr. Boeckmann’s legacy gift is still a funding source and he is remembered for his passion and generosity for the good of medicine in the east metro area.

Criteria

Must be an active or retired physician from the East Metro. Service must be voluntary in nature and should include one or more of the following elements: • leadership and development of special community projects or programs; • participation in civic or service organizations/ groups; • participation in educational, charitable, church, or other projects; or • public offices held

Nominate a Colleague

Send a description of the physician you are nominating, including specific community activities above and beyond his/her professional medical work. Send your nominations to: Katie Snow KSnow@metrodoctors.com Ph: 612.362.3704 Fx: 612.623.2888

Nominations due by July 31, 2012 MetroDoctors

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Mental Health and Primary Care Task Force Meets As a follow-up to the TCMS and Minnesota Psychiatric Society co-sponsored Forum on Mental Health: Improving Access and Quality, held last December, a task force of mental health and primary care providers, including other stakeholders, has been convened and met on two occasions. The following goals have been established: • Improve access to mental health/behavioral health services encompassing all age groups through collaborative, integrated services; • Provide educational opportunities to primary care physicians and staff to increase ability to serve patients with mental health/behavioral health issues; Uptn. Group ad GRO11 6/4/12 10:45

Senior Physicians Association News The spring meeting of the Senior Physicians Association was held on Tuesday, May 1, 2012 with Claus Pierach, M.D., professor, University of Minnesota, providing an entertaining presentation on his collection of signed art prints, “Cover Art on JAMA and Other Journals,” complete with personal knowledge of many of the artists. Please mark your calendar and plan to join your colleagues at these upcoming luncheons and the Annual Event: • July 10, 2012 — Aaron Friedman, M.D., “Vision for the Medical School” • October 9, 2012 — Doug Jensen, “Great Lakes and Threats to Minnesota Waters” • Annual Event — Tuesday, September 4, 2012 — Weismann Art Museum — Tour and Luncheon. Guests are welcome! Watch your email for announcements and meeting notices. Please contact Andrea Farina for more information: afarina@ metrodoctors.com; (612) 623-2885.

Increase opportunities for active collaboration between primary care and behavioral health clinicians through expanded partnerships; and • Develop care delivery model(s) that are financially viable. Strategies include supporting the Fast Tracker Program (Minnesota Psych Society), exploring telemedicine opportunities for education and consultation, and payment system reform. If you are interested in participating in the task force and/or learning more about its work, please contact Nancy Bauer at nbauer@ metrodoctors.com; (612) 623-2893. AM

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MetroDoctors

The Journal of the Twin Cities Medical Society


Spotlight on Honoring Choices Physician “Stars” J. Milo Meland, M.D. is co-chair of the Honoring Choices Ambassador training group. Dr. Meland and Ross Anderson, M.D. work closely together with Barbara Greene, MPH, director of Community Engagement, to ensure that community Ambassadors are well-equipped to lead community-wide advance care planning sessions. Ross Anderson, M.D. is co-chair of the Honoring Choices Ambassador training group. Dr. Anderson joins J. Milo Meland, M.D. in convening the 24-person Ambassador group. Dr. Anderson led an Advance Care Planning (ACP) presentation with medical assistants at the Minnesota Medical Assistants state conference.

June 2. Dr. Wilson has also given advance care planning presentations at the Minnesota Network of Hospice & Palliative Care annual conference; to congregation members of House of Hope Presbyterian Church, Saint Paul; and to representatives of United Theological Seminary.

Stefan Pomrenke and Kent Wilson discuss strategies for C. Dwight Townes, M.D. is Drs. encouraging Ambassadors to engage with the community. an Ambassador who has led ACP sessions at Park Ridge facility in Hastings Kenneth Kephart, M.D. conducted an ACP and to members of his local Rotary Club. one-hour webinar for long-term care providers hosted by Care Providers of MinneKent Wilson, M.D. spoke at the 3rd InternaGary Hanovich, M.D. is an Ambassador who sota, a Minnesota long-term care membership tional Society of Advance Care Planning and introduced ACP to residents at Elim Shores organization. End-of-Life Care Conference in Chicago on in Eden Prairie. Stefan Pomrenke, M.D. is an Ambassador who conducted brown-bag lunch-n-learn sessions at the United Theological Seminary as well as ACP concurrent session at Bethel University’s Nursing Research and Practice Symposium Sharing the Experience: “Ending Life Well.” Dr. Pomrenke will take Honoring Choices Minnesota Conference an active role in Bethel University’s upcoming Date: Thursday, July 19, 2012 October 12 Conference on ACP and EOL care. Time: 9:00 a.m.—5:00 p.m. Kusum Saxena, M.D. organized and led an Location: Ramada Plaza, 1330 Industrial Blvd. NE, ACP workshop at the Hindu Mandir (Temple) Minneapolis 55413 of Minnesota. Dr. Saxena is also hosting an Cost: $75 ACP session at Applewood Pointe at Lengthen Lake in Roseville later this summer. Attendees will:

◆ ◆ ◆ ◆

Share the progress and findings of local advance care planning programs Identify best practices for advance care planning through reports from clinics, hospitals, community and other sites Discover new perspectives from guest speakers, faith communities and multi-cultural leaders Network with others who are skilled in implementing advance care planning conversations in Minnesota

Craig Bowron, M.D. conducted an ACP Ambassador Continuing Education session that included sharing his personal experiences with patients at Abbott Northwestern hospital. Dr. Bowron will serve as a keynote presenter at this summer’s “Sharing the Experience” community-wide advance care planning conference on July 19 at the Ramada Plaza, Minneapolis.

Registration deadline: July 10 Questions?

Contact Katie Snow, Coordinator, at (612) 362-3704 or KSnow@metrodoctors.com

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In Memoriam HARRY S. FRIEDMAN, M.D. passed away on April 5, 2012 at the age of 96. Dr. Friedman attended the University of Minnesota Medical School and completed his residency in ophthalmology in 1948. He started a practice in Minneapolis, and served in many leadership roles including president of the medical staff at Mount Sinai Hospital, where he was one of the founders. Dr. Friedman became a member in 1994. ELIZABETH O. JOHNSON, M.D. passed away at the age of 56 on March 18, 2012. Dr. Johnson attended the University of Minnesota Medical School, and completed a pediatric residency at the Children’s Hospital of Philadelphia and the University of Minnesota. Dr. Johnson became a member in 1989. ARTHUR K. LARSON, M.D., age 87, passed away on April 7, 2012. Dr. Larson practiced pediatrics and was a founding physician of the Oxboro Clinic in Bloomington. Dr. Larson became a member in 1957. PALMER PETERSON, M.D., age 95, passed away on May 6, 2012. Dr. Peterson attended the University of Marquette Medical School in Milwaukee, WI and completed his surgical fellowship at the University of Minnesota in 1952. Dr. Peterson practiced for 50 years receiving the 50 Year Medical Practice Award given by the Minnesota Medical Association. HERB POLESKY, M.D., passed away on December 19, 2011 at the age of 78. Dr. Polesky attended Stanford University and completed a fellowship in pathology and laboratory medicine at Yale University. He spent 35 years as director of what is now known as the Memorial Blood Centers of Minnesota. Dr. Polesky was also a professor of laboratory medicine at the University of Minnesota. Dr. Polesky became a member in 1965.

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family medicine at HCMC for 25 years. Dr. Racer became a member in 1952.

HARLEY RACER, M.D., age 87, passed away March 20, 2012. Dr. Racer attended the University of Minnesota Medical School. He was a leader in developing a Family Practice Residency program at Methodist Hospital in St. Louis Park, and he taught and practiced

Career oPPortunItIes

CORRECTION: Our sincere apologies to the family of Joseph M. Tambornino, M.D. for misspelling his name in the May/June In Memoriam. see additional Career opportunities on page 31.

Internal Medicine? Family Medicine?

Yup.

NEW clinic in Mahtomedi, MN? Internal and Family Medicine Opportunities Stillwater Medical Group is an 90+ provider multi-specialty group practice affiliated with Lakeview Hospital. For more than 50 years we have been providing comprehensive healthcare services with locations in the St. Croix Valley, just east of the Twin Cities metro area.

Internal and Family Medicine Physician Opportunities: Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education. For further information please contact: Patti Lewis, Director Human Resources 1500 Curve Crest Blvd, Stillwater MN (651) 275-3304, plewis@lakeview.org stillwatermedicalgroup.com

We’ll make it all better.

MetroDoctors

The Journal of the Twin Cities Medical Society


Career oPPortunItIes

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MetroDoctors

The Journal of the Twin Cities Medical Society

July/August 2012

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luMInary of Twin Cities Medicine By Marvin S. Segal, M.D.

MITCHell j. eINzIg, M.D. Little did the bright young lad growing up in McKeesport, PA realize that he would one day become an iconic beloved teacher of medicine in a clinical academic community half way across the country. Well… that is exactly what happened with our newest Luminary, Dr. Mitchell Einzig. Mitch’s circuitous route to the Twin Cities began near his Pennsylvania roots, obtaining a B.A. at Washington and Jefferson College and moved westward to the University of Chicago Medical School where he graduated in 1964. His internship, residency and military service were accomplished at UCLA, Chicago’s Michael Reese Hospital and the Navy in San Diego. After a short period of private practice in Los Angeles, he settled in Minnesota where he was co-founder of the Wayzata Children’s Clinic — practicing there for 10 years. His long association with Minneapolis Children’s began as a medical staff member during those private practice days. As pleasant and gratifying as pediatric practice was, he realized that his true calling was teaching in a hospital setting. There were many disappointed patients and parents when Mitch began his long tenure at what was to become The Children’s Hospital and Clinics of Minnesota. First as Director of Ambulatory Care and later becoming Director of Medical Education, Vice President for Medical Affairs, the Director of Graduate Medical Education and since his formal retirement in 2003, the co-Medical Director of Outreach, he’s played a major role in transforming his hospital into the premier educational institution that it is today. As a complementary partner with the U of M, the Children’s/Einzig site became a highly sought after rotation for third and fourth year students and residents alike. Dr. Einzig’s teaching venues varied from Grand Rounds to regular lunchtime conferences and especially to his favorite — bedside rounds. In the discussions during those rounds, he utilized the iterative hypothesis testing strategy for diagnostic decision making where he deftly challenged his students to think in a low stress cooperative learning environment. He emphasized clinical 32

July/August 2012

information gathering by listening, viewing and palpating — prior to the rational utilization of appropriate laboratory and imaging studies. He engaged the best and the brightest of his specialty and subspecialty colleagues in our community to aid with lectures and less formal presentations in his quest to create the ideal learning environment. Those expert physicians were always pleased and honored to have participated in Mitch’s curriculum. The appreciation of his diligent efforts by his legions of students was demonstrated by as impressive an array of teaching awards as one could imagine — beginning with the Annual Intern Teaching Award at the San Diego Naval Hospital and repeatedly continuing for decades as the Faculty Teacher of the Year, with the Distinguished Teacher Award and as a Master Teacher. Less formal acknowledgements are evidenced by words of the pupils themselves: “dedicated, enthusiastic, knowledgeable, modest, ultimate role model and … awesome.” Dr. Mitch, Clinical Professor of Pediatrics and Family Practice, has other interests and talented accomplishments: basketball star of yesteryear, golfer, State handball champion, long distance biker, prodigious reader — and perhaps best of all … a caring family man to his two children and Corky, his wife of 40+ years. It was once stated (Henry Brooks Adams, 19th century), “A teacher affects eternity; he can never tell where his influence stops.” That certainly is the case with our Dr. Einzig…as his legacy continues.

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society


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MetroDoctors: Accountable Care Networks Fact or Fantasy?