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MetroDoctors The Journal of the Hennepin and Ramsey Medical Societies March/April 2002 1

V O L U M E 4 , N O . 2 M A R C H / A P R I L 2 0 0 2

C O N T E N T SPhysician Co-editor Thomas B. Dunkel, M.D.Physician Co-editor Richard J. Morris, M.D.Managing Editor Nancy K. BauerAssistant Editor Doreen M. HinesHMS CEO Jack G. DavisRMS CEO Roger K. JohnsonProduction Manager Sheila A. HatcherAdvertising Representative Betsy PierreCover Design by Susan Reed

MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Hennepin and Ramsey MedicalSocieties, 3433 Broadway Street NE, BroadwayPlace East, Suite 325, Minneapolis, MN 55413-1761. Periodical postage paid at Minneapolis,Minnesota. Postmaster: Send address changes toMetroDoctors, Hennepin and Ramsey MedicalSocieties, 3433 Broadway Street NE, BroadwayPlace East, Suite 325, Minneapolis, MN 55413-1761.

To promote their objectives and services, theHennepin and Ramsey Medical Societies printinformation in MetroDoctors regarding activitiesand interests of the societies. Responsibility is notassumed for opinions expressed or implied insigned articles, and because of the freedom givento contributors, opinions may not necessarilyreflect the official position of HMS or RMS.

Send letters and other materials for considerationto MetroDoctors, Hennepin and Ramsey MedicalSocieties, 3433 Broadway Street NE, BroadwayPlace East, Suite 325, Minneapolis, MN 55413-1761. E-mail: [email protected].

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: [email protected].

MetroDoctors reserves the right to reject anyarticle or advertising copy not in accordance witheditorial policy.

Non-members may subscribe to MetroDoctors at acost of $15 per year or $3 per issue, if extra copiesare available.

2 Editor’s MessageIndex to Advertisers

3 SOAPBOXGet Engaged in Public Safety Efforts

4 FEATURESix Sigma: A Tool for Leadership in Health Care

7 Minnesota Medical Association Patient Safety Task Force

8 Safest in America: A Patient Care Initiative

10 Minnesota Alliance for Patient Safety

11 MHHP Taking a Leadership Role in Patient Safety Initiatives

12 ICSI: Collaborating to Improve Minnesota Health Care

14 Intensivists Provide Unique Dimension of ICU Care

16 COLLEAGUE INTERVIEWKathleen D. Brooks, M.D.

19 Highlights of the AMA Code of Medical Ethics

23 Bioterrorism SeminarMentoring Program

RAMSEY MEDICAL SOCIETY

24 President’s Message

25 132nd Annual Meeting

27 New Members/In Memoriam/Call for Delegates and Resolutions

28 RMS Alliance

HENNEPIN MEDICAL SOCIETY

29 Chair’s Report

30 New Members

31 In Memoriam/Call for Delegates and Resolutions

32 HMS Alliance On the cover: Initiatives forpatient safety are gainingmomentum. Related articlesbegin on page 2.

Marc

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Safety


Safety

MetroDoctorsT H E B U L L E T I N O F T H E H E N N E P I N A N D R A M S E Y M E D I C A L S O C I E T I E S

Doctors

2 March/April 2002 MetroDoctors The Journal of the Hennepin and Ramsey Medical Societies

A

Editor’s Message

March/AprilIndex to Advertisers

Allina Education and Research .............. 20Sally Bradford Realtor ........................... 13Brainerd Medical Center ......................... 9Classified Ad ......................................... 22Corporate Express (formerly US Office Products) ................ Inside Front CoverFinancial Network .................................. 2Hamm Clinic ....................................... 23Hazelden .............................................. 26HealthEast Care System ........................ 21Hennepin County Medical Center ........ 15I-Retrieve ...................... Inside Back CoverMethodist Hospital .............................. 11Minnesota Medical Foundation ............. 6MMIC .................................................. 19Multicare Associates .............................. 14RCMS Inc. ............................................. 8Riverway Clinics ................................... 15U of M CME............. Outside Back CoverWally McCarthy Cadillac ........................ 3Wally McCarthy Hummer .................... 18Weber Law Office ................................. 27

AS I FACE THE POSSIBILITY of kneesurgery, I am acutely reminded of the Instituteof Medicine’s 1999 report on errors in healthcare. We know better than anyone that thecoordination of patient care is dauntinglycomplex, dependent on components thatsometimes don’t fit well together, and thaterrors are a frequent occurrence. The Institutereport was a splash of cold water in ourcollective face. We physicians share theresponsibility and must not be defensive. Atthe same time, I am reminded of MarkTwain’s comment about “lies, damn lies, andstatistics;” i.e. you can prove anything you

want with numbers. A few years ago, weheard from a Harvard professor that someone-third of Americans use alternative healthcare—but in the fine print, his definition of“alternative” included the use of vitamins. Amore recent article put the actual use ofalternative health care practitioners at about 4percent. So how broadly or narrowly does theInstitute define “error”?

My point is that the assumptions anddefinitions are all-important to understandingthe magnitude and severity of the problem,and most importantly, to crafting appropriate,proportionate responses. We physicians are

the most ethical and devoted and trainedstakeholders; we must volunteer for thediscussions or risk being politicked or “six-sigma’d” out of decisions. It’s all aboutleadership and keeping the process heading inthe right direction. Please read about theMMA Patient Safety Task Force in this issue.

Now excuse me while I tattoo “this side”on my left knee. ✦

Richard J. Morris, M.D.,Co-Editor

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AAT THE END OF ONE OF MY FAVORITE movies, “Top Gun,” thecharacter played by Tom Cruise hears the call, “Get Engaged!”

This is an appropriate message for physicians.The release of the Institute of Medicine report on medical errors

generated myriad news articles. As a result, the public is acutely aware ofthe issue of patient safety. Troubled by the possibility of medical errors,they look to physicians to assure them that their safety is a high priority.

Various groups are seeking concrete ways to reduce errors. Wephysicians must make sure we are at the table, proposing our own

solutions, and doing our part to bring a culture of safety to health care.This is an issue that cries out for physician leadership and expertise.

How can you become engaged?1) Participate in the Minnesota Medical Association Task Force on

Patient Safety.2) Become a physician participant in the Minnesota Alliance for

Patient Safety (MAPS) through membership on one of itscommittees: Best Practices; its subcommittee, Technology;Communication and Education, or Data: Privacy, Management,and Measurement.To become engaged in patient safety efforts, please contact me at

612-362-3722 or [email protected]. ✦

Get Engaged in Public Safety Efforts

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F E A T U R E S T O R Y

P

S i x S i g m aA Tool for Leadership

in Health Care

…performance

must be managed

on three levels

to produce

long-standing

excellence:

1) organization;

2) process; and

3) job/performer.

“PLEASE, TAKE BACK LEADERSHIP OF YOUR INDUSTRY!”This was the plea I heard recently from a corporate human resources leader of a For-

tune 100 company. He was encouraging a group of leading health care organizations tostep up to the plate and address the important issues in health care. We have all heard thepleas from corporate buyers about the cost of health care many times before. Yet, this man’scomment haunted me for days. Are we not leading already? If not, what would strongleadership look like?

I have to admit that there is a vacuum of leadership in health care today. If strongleadership existed, I do not think we would see the frustration that is evident in everyoneinvolved in health care, from patients, to payers and providers.

With strong leadership, we would see innovation directed at anticipating and meetingthe needs of people regarding safety, service, effectiveness and cost. Instead, health care lagsbehind the expectations of people, payers and providers. Safety is a top-of-mind concernwith employers, as evidenced by the Leapfrog group’s advocacy for specific methods tolower risks. Costs continue at double-digit annual increases, threatening the ability ofcompanies to pay both wage increases and health care premiums. Additionally, clinicianspracticing well-accepted medical treatments are being challenged to demonstrate the effec-tiveness of their treatment. Today’s health care consumer is savvy, and notices where im-provements in process could save them time, money, and worry.

In health care today, there are problems with performance and the marketplace. Bothmust be improved before the health care industry can assume a leadership position. Forpurposes of this article, we will limit ourselves to an examination of performance issues andleave the more complex issue of the marketplace for a later date.

What does it take to create strong performance in a system? Improving Performance, byRummler and Brache (Jossey-Bass, 1995), presents the theory that I have found to be mostworkable in a health care setting. According to the authors, performance must be managedon three levels to produce long-standing excellence: 1) organization; 2) process; and 3)job/performer.

Organization, in this context, means the way working teams are formed, how they areled, the goals they set, and how the working teams are managed. Process is the extent towhich processes are identified, named, owned and managed. Job/performer is the way anorganization supports its people by creating an environment that offers a high likelihoodof success. Organizations that successfully manage all three levels create a synergism thatallows them to achieve their organizational goals.

Health care services usually have significant gaps when evaluated against this model.

B Y D A V I D K . W E S S N E R


(Continued on page 6)

On a cultural level,

Six Sigma is an

expectation that

work be designed

and managed in a

manner that

creates reliable,

defect-free results

from any process.

The strongest level has been the job/performer level. Intense professional education andsystems of licensure have produced knowledgeable and principled practitioners who canmanage the care of their patients. The other two levels, organization and process, are man-aged more or less depending on each individual situation. While most health care servicestoday are provided within some type of organizational context (hospital, group practice,etc.), the care of any patient or resolution of any problem usually involves many groupswith varying goals and methods. The result is a fractured experience for the patient withredundant data gathering, significant communication costs and a more-than-average chancethat something will fall between the cracks.

The least developed level in health care services is process. For the most part, processesin health care are not identified or named, ownership has not been established and man-agement of process per se does not occur. This situation is attributed in part, I believe, tothe traditional model where strong physicians manage each situation for the benefit oftheir patients. This model is under increasing scrutiny as the complexity of our contempo-rary health care calls for more medical professionals to be involved in each case, and greaterreliance upon technology. It is no longer enough for one strong individual to define andmanage a process. In today’s health care environment, processes require an organizationalcontext in order for them to be managed.

This is where the concept of Six Sigma comes in. The term was coined by MikelHarry, a Motorola statistician in the 1980s. Harry articulated a method to systematicallyand dramatically improve the performance of processes within an organization. The con-cept was soon adopted by Larry Bossidy at Allied Signal and Jack Welch at GE with resultsthat got the attention of Wall Street and corporate America.

Six Sigma can be defined on several levels. On a technical level, Six Sigma is a mea-surement of variation that achieves no more than 3.4 defects per million opportunities forfailure. (A “defect” is defined as any missed target or non-conformance to standard. Ex-amples of Six Sigma performance include fatalities per flights taken in commercial aircraft.)

On a cultural level, Six Sigma is an expectation that work be designed and managed ina manner that creates reliable, defect-free results from any process. Six Sigma has raised anexpectation and belief that work can be engineered to be totally safe and totally reliable.

Six Sigma is also a methodology that uses statistically valid data and analysis to accom-plish breakthrough improvements within an organization. These improvements can be inmany dimensions, including increased capacity, productivity, reliability, effectiveness orefficiency. This method, which is very well known to students of quality improvement, iscalled D-M-A-I-C (Define, Measure, Analyze, Improve and Control).


Six Sigma

(Continued from page 5)

Lastly, Six Sigma is a management sys-tem that is capable of producing cash returnwithin the initial year of implementation,and continued financial returns and com-pounded return on key metrics over mul-tiple years. When implemented well,Six Sigma not only funds itself, but alsothrows off benefits for customers and share-holders alike.

The way Six Sigma delivers these spec-tacular results is by focusing on manage-ment of processes in order to remove thevast waste, redundancy and rework thatexist in most unmanaged processes. Mostwork operates at a sigma or defect level farbelow Six Sigma. In fact, the published lit-erature measuring the reliability of healthcare points to a performance level of some-where between three and four sigma. At thatlevel, a defect can be expected once in ev-ery one hundred opportunities. (In otherwords, greater than 10,000 times more

ment is identified, organizational commit-ment to implement the improvement mustbe made and supported. This way, resourcescan be focused on improvement, and par-ticipants within the process can participatein these improvement efforts. Those in-volved must train in the methodology anddedicate time to the improvement effort.Maintaining performance requires a track-ing system and ownership of the process.

Six Sigma can be applied within anyorganization. In health care organizations,however, it is important to note that com-plex care processes require an organizationallevel that goes beyond the current scope ofmany health care organizations. Chronicdisease management, for example, requireshighly reliable support people, along withphysicians and other resources (educationaland hospital) that are not presently thenorm.

The second condition needed to suc-cessfully apply Six Sigma to health care isleadership commitment. Six Sigma is acomplicated and costly undertaking that re-quires resources and strong internal support.The commitment of resources to Six Sigmawill not be successful unless leadership isconvinced that progress at the process levelis imperative.

At Park Nicollet, we are convinced. Wehave committed eight teams to a first waveof Six Sigma projects designed to vastlyimprove the reliability of processes that pa-tients and staff deal with every day. We arealso committed to implementing a trulyintegrated medical record across the con-tinuum of care. These process improve-ments provide us with the hope thatdramatic improvements in health care ser-vices are not only possible, but they are alsoclose at hand. It is our goal to be part of alarger effort to take back the leadership ofour health care industry. The next few yearsare going to be exciting. ✦

David K. Wessner is President and Chief Ex-ecutive Officer of Park Nicollet Health Ser-vices.

likely than if that process was performingat Six Sigma levels.)

Health care professionals are well awareof the waste and rework that they deal withon an hourly basis in caring for patients. Infact, experience has shown that when theprocesses of a system are performing at athree or four sigma level, 25 to 30 percentof the organization’s costs come from re-working and dealing with defective output.I have discussed this with health care pro-fessionals and have yet to find anyone whotakes issue with that statement.

Can Six Sigma — a movement thathas been focused in large, publicly tradedcorporations — work in health care ser-vices? That has yet to be determined. I be-lieve the answer is yes, but only when keyfactors exist that allow Six Sigma to realizeits full potential.

The first factor is organizational con-text. In order for a process to be success-fully managed, it must exist within anorganizational structure. Once an improve-


A

Minnesota Medical AssociationPatient Safety Task ForceAS THE PATIENT SAFETY EFFORTS gathermomentum, it has been recognized by the Min-nesota Medical Association (MMA) leadershipthat physician-specific issues are not receivingsufficient attention. Despite development ofvarious forums (e.g. Minnesota Alliance for Pa-tient Safety, otherwise known as MAPS), hos-pital committees and executive councils,physicians have not been fully engaged in thediscussions.

In 2000, the MMA House of Delegatespassed a resolution, 408, on patient safety:

“Resolved, that the Minnesota Medical As-sociation continue to work with local andnational efforts to reduce medical errorsand improve patient safety; and be it furtherResolved, that particular attention be paidto the issues of: 1) need for and methodsto identify root causes of errors; 2) dataprivacy and confidentiality; 3) mechanismsto reduce the culture of blame in thehealthcare industry; and 4) mechanisms forthe equitable distribution of associatedcosts.”In response to the need for physician in-

put, the MMA formed its Patient Safety TaskForce during the spring of 2001. The charge ofthe task force is fourfold:• Identify those physician-specific issues in

which physicians play a key role in patientsafety;

• Identify key policy issues that physiciansneed to incorporate into practice;

• Assure the voice of physicians is heard inthe appropriate patient safety efforts (Min-nesota Alliance for Patient Safety, NationalPatient Safety Foundation, the publicarena, etc.); and

• Develop strategies to approach safety anddemonstrate a willingness to lead.Over the course of the first three task force

meetings, material regarding malpractice, riskmanagement, doctor-patient communication,and key current efforts were reviewed. The taskforce has identified its key initiatives for the nearfuture. These initiatives are designed to coordi-nate with community-wide efforts and assurephysician input. The initial efforts of the MMAPatient Safety Task Force will focus on:• Disclosure of medical errors that directly

affect patients and the physician responsi-bilities for participating in facility disclo-sure policies;

• Reductions in medication errors and sup-port of other efforts to improve medica-tion safety;

• Medical school and residency education ofpatient safety issues, medical harm reduc-tion and physician communication skills;

• Clarity and legibility of medical orders andthe elimination of confusing and illegibleorders; and

• Identification and dissemination of “best”patient safety-focused practice parameters.The task force has also expressed signifi-

cant interest in the regulatory environment andis showing that the Minnesota Board of Medi-cal Practice and other regulatory agencies createa culture that encourages the identification andcorrection of medical errors and harmful epi-sodes instead of one that suppresses reportingof errors for fear of punitive review.

Members of the MMA Task Force for Pa-tient Safety include:

Robert Moravec, M.D., ChairCharles Rich, M.D.Scott Tongen, M.D. (representing the Minnesota Board of Medical Practice)David Larson, M.D.Robert Beck, M.D.Ken Dedeker, M.D.Eric Knox, M.D.Sam Levine, M.D.Steve Rousey, M.D.Margaret MacRae, M.D.Richard Carlson, M.D.Tom Arneson, M.D.Ray Bonnabeau, M.D.Each of these physicians has demonstrated

a significant interest in patient safety and is par-ticipating both through organized medicine andat their local facilities to significantly improvethe delivery of care for all patients. Through thistask force and through other collaborative ef-forts, the MMA will take a leadership role tofacilitate the roles of physicians in promotingpatient safety. You may feel free to contact anymembers of the task force to forward ideas andstate what patient safety issues may be of par-ticular interest to you. ✦

Robert C. Moravec, M.D., serves as chair of theMMA Patient Safety Task Force, and is medicaldirector of HealthEast Care, Inc.B Y R O B E R T C . M O R A V E C , M . D .


S

Safest in AmericaA Patient Care Initiative

SETTING COMPETITION ASIDE, healthsystem participants of a unique new collabora-tion have forged a powerful vision to improvelocal health care. Called Safest in America, thisgroup of local hospitals has set out to make ourcommunities the safest place in America forpatients to receive hospital care.

The initiative is exciting because cross-sys-tem collaboration on patient safety at a seniorlevel, and in such specific detail, hasn’t existedbefore in this part of the country.

“While there is much good work occur-ring in the community with regard to patientsafety, this collaborative is unique in that it pro-vides the venue for member hospitals to sharesensitive information confidentially,” said TomSchmidt, M.D., medical director, inpatient care,Park Nicollet Health Services.

The chief executive officers of nine Min-nesota hospitals and health care organizationssigned a memorandum of understanding in2001, agreeing to collaborate on process im-provements to enhance patient safety. Partici-pating organizations include Allina Hospitals

and Clinics, Children’s Hospital and Clinics,Fairview Health Services, HealthEast,HealthPartners, Hennepin County MedicalCenter, Mayo Clinic Rochester, Park NicolletHealth Services and North Memorial MedicalCenter.

“This effort marks the beginning of a newrelationship between health care systems in thecommunity, said George Halvorson, CEO ofHealthPartners, and chair of the CEO groupsponsoring the initiative. “Although we competein many ways, we have agreed to set competi-tion aside and work collaboratively to improveand standardize high risk processes in our sys-tems.”

Participating CEOs have agreed to set acollective vision for hospital patient safety; pro-vide broad direction and oversight; learn jointlyabout safety issues, barriers and solutions; sharelearning and to hold each other accountable foraction. A task force of chief operating officers,chief medical officers and safety officers frommember hospitals lead a task force of ground-work activity. The CEOs will continue to meetregularly to provide oversight and support tothe operations group.

“We have intentionally not sought public-ity for this initiative,” Halvorson added. Anycelebration will follow results from our work.”

The Institute for Clinical Systems Im-provement (ICSI) is providing staff support forthe collaborative. ICSI is facilitating topic-spe-cific work groups for Safest in America. Accord-ing to Gordon Mosser, M.D., executive director,“ICSI is pleased to have the opportunity to con-tribute its expertise in managing cross-organi-zational collaboration. Hospital safety is an idealtopic for collaborative improvement work. Theeffort will be strengthened and accelerated bythe synergy that we have gained from joiningtogether.”

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Clinical and operational leaders frommember organizations have met to identify po-tential projects. Ideas selected for initial workrelate to such high-risk processes as operatingroom procedures and medication administra-tion—efforts that would make the region saferif standardized across organizations. The opera-tions group will continue to meet monthly tooversee the work of the teams and guide thedevelopment of future projects.

The first project will focus on reduction ofharm from medication errors. The secondproject will focus on the elimination of wrongsite surgeries. The group has identified poten-tial future projects as well.

The medication error reduction projectlaunched January 24. Mark Thomas, M.S.,R.Ph., Children’s Hospital and Clinics phar-macy director, will lead the collaborative. Teamsfrom each organization include a cross sectionof clinicians and hospital staff who will developcommon outcome measures.

“We hope to identify and implement ini-tial changes very quickly,” says Thomas. Thegroup plans to reduce harm related to medica-tion errors by working collaboratively to stan-dardize protocols and processes related to:• The use of high-risk drugs (one or two will

be selected to start);• The use of medication ordering abbrevia-

tions;• And, the use of pediatric medications fre-

quently associated with dosing errors.In addition, the group plans to establish a

mechanism to use local expertise among col-laborating hospitals to conduct a peer-reviewedassessment of an identified list of practice rec-ommendations at participating hospitals.

Plans are underway to roll out the surgicalsite marking collaborative this spring. Goals in-clude eliminating harm to surgical patients re-sulting from clinicians performing the wrongprocedure, performing the procedure on thewrong surgical site or on the wrong person.Toward that end, the group will seek to createand implement standard processes to:• Identify the correct surgical site;• Identify the correct level or body part; and• Identify the intended procedure.

In addition, each hospital will define a pa-tient identification process that is consistent withthe needs of their organization.

Since the publication of the Institute of

Medicine’s reports, To Err is Human in 1999and Crossing the Quality Chasm in 2001, pa-tient safety has become a high priority for thepublic and within the health care industry. Theorganizations involved in Safest in America arecommitted to working together for the benefitof all patients. As Hugh Smith, M.D., chair ofMayo Clinic’s Board of Governors put it, “We

all believe patient safety is a critical issue. Weare rolling up our sleeves and doing somethingabout it in a coordinated way.” ✦

Alison Page is Fairview Vice President, PatientSafety, and Chair, Operations Group, Safest inAmerica.

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IIN JUNE 2000 the Minnesota Hospital andHealthcare Partnership, the Minnesota Medi-cal Association, and the Minnesota Departmentof Health joined forces to create the MinnesotaAlliance for Patient Safety (MAPS), a statewideforum of key patient safety stakeholders to co-ordinate and further advance patient safety inMinnesota. MAPS is a public-private initiative,which includes more than 50 Minnesota healthcare organizations representing academia, healthplans, provider networks, accrediting organiza-tions, regulators, peer review organizations,professional associations, pharmacy, license agen-cies, and other organizations that work togetherin a noncompetitive fashion to improve patientsafety practices in the delivery of health care.

MAPS was created to promote optimumpatient safety through collaborative and support-ive efforts among all participants of the healthcare system in Minnesota.

MAPS serves as a network of organizationsfor gathering and disseminating patient safetyinformation relevant and pertinent to Minne-sota. MAPS members share patient safety in-formation about the work within theirorganization. The key to MAPS success is itsability to serve as a leadership forum to encour-age dialogue and discussion among such a di-verse group of stakeholders about issues andsolutions that affect patient safety.

MAPS identifies and coordinates specificprojects that significantly impact patient safety.The following are some of MAPS accomplish-ments:• Developed and disseminated the brochure

Redefining the Culture for Patient Safety,which explains the key concepts in thestudy of patient safety and offers changes

to our language regarding patient safety.The patient safety brochure, now beingused in 15 states, is available on MHHP’swebsite at www.mhhp.com.

• Developed MAPS website to disseminatepatient safety resources and tools through-out Minnesota (www.mnpatientsafety.org).

• Supported amendments to the peer reviewstatute, which was instrumental in gettingthe revisions signed into law during the2001 Legislative Session, which will pre-vent medical accidents by allowing orga-nizations to learn from one another.

• Successfully assisted national organizationswith planning the Annenberg III confer-ence Let’s Talk-Communicating Risk andSafety in Healthcare held May 16-18, 2001.

• Successfully convenes key patient safetystakeholders to focus on changing and im-proving the culture for patient safety of itsrepresentative organizations.It is encouraging to reflect on the successes

of MAPS, but the work is just beginning. Asthe coalition looks ahead it will begin focusing

on future projects that will impact patient safety.Some of these projects include:• Commission an expert panel task force to

review the Vulnerable Adult Act and rec-ommend revisions as appropriate to enhancethe culture of patient safety and reporting.

• Develop a patient/consumer educationalbrochure to fully inform patients and en-courage full participation with health caredecisions.

• Collaborate with Midwest Medical Insur-ance Company and National Patient SafetyFoundation to disseminate Annenberg IIIlearnings through an educational video toassist caregivers in communicating with pa-tients and families after unanticipated out-comes.

• Develop a white paper with recommenda-tions on a data reporting and measurementstrategy for patient safety in Minnesota.

• Enhance MAPS website to be a primarypatient safety resource for Minnesotahealth care organizations.

• Identify and disseminate proven safe prac-tices statewide.

• Identify and disseminate principles for pro-curement and use of technology as it re-lates to patient safety.MAPS recognizes that there are many spe-

cific patient safety initiatives underway locallyand nationally as well as specific hospital pro-grams. MAPS role is to coordinate and collabo-rate with these efforts and offer its uniquefeatures, such as the benefits of a public-privatepartnership and its broad-based membershipand expertise, in order to facilitate patient safetyefforts throughout Minnesota. ✦

Tania Krueger is coordinator for the MinnesotaAlliance for Patient Safety.

Minnesota Alliance for Patient Safety

B Y T A N I A K R U E G E R , M . B . A . , P . T .


MHHP Taking a Leadership Rolein Patient Safety Initiatives

PPATIENT SAFETY IS A MAJOR priority forMinnesota hospitals. The publication of theInstitute of Medicine report, “To Err is Human:Building a Safer Health System” released No-vember 1999, strengthened the mandate toimprove patient safety and reduce the numberof preventable events. Minnesota hospitals’ com-mitment to safety and quality was demonstratedwhen Minnesota ranked fourth in the nationfor providing quality care to Medicare patients.1

The Minnesota Hospital and HealthcarePartnership (MHHP) has committed to im-prove patient safety through efforts such asimplementing a Patient Safety Committee andparticipating in the Minnesota Alliance for Pa-tient Safety (MAPS).

The MHHP Patient Safety committee,chaired by Steven Kleinglass, acting director andchief operating officer at the Veterans AffairMedical Center, include key patient safety stake-holders from MHHP facilities. The committeewill effect change by developing public policyto advise and advance policies, taking a leader-ship role in Minnesota and championing lead-ership to improve the culture in MHHPmember facilities, and collaborating with MAPSto disseminate successful practices and patientsafety resources.

Some successful activities to date include:• Developed a standardized model commu-

nication policy to guide care providers withcommunicating unanticipated outcomesto the patient and family.

• Supported revisions to the Minnesota PeerReview Statute that were signed into lawMay 17, 2001. This law paves the way forMHHP’s web-based patient safety regis-

try. This registry will allow hospitals to learnfrom one another with complete confiden-tiality. Aggregate data will be analyzed andtrends identified in order to learn and pre-vent patient harm.

• Developed and disseminated patient safetytool kits for leaders, management, and staffthat includes valuable resources to createand sustain safety within health care insti-tutions.

• Established statements of belief on report-ing systems for medical accidents.

• Commissioned a task force to make rec-ommendations on public reports to engageconsumers with health care decisions. ✦

Tania Krueger is a director of health policy for theMinnesota Hospital and Healthcare Partnership.

MHHP is a trade organization representingMinnesota’s 142 hospitals and 20 health systems.

1 Stratis Health study, published in the Journalof American Medical Association October 4,2000.

B Y TA N I A K R U E G E R , M.B.A., P.T.

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I

ICSI: Collaborating to ImproveMinnesota Health Care

B Y G O R D O N M O S S E R , M . D .

IN 1992 HEALTHPARTNERS (then GroupHealth), Mayo Clinic, and Park Nicollet Clinicjoined together to plan a new approach to im-proving health care in our state. HealthPartnersand the Buyers Health Care Action Group sup-ported the project financially. Within a fewmonths, they inaugurated the Institute for Clini-cal Systems Improvement (ICSI), embodyingtheir commitment to collaborate in the use ofevidence-based medicine and continuous im-provement methods to improve health care.

Over the past nine years, ICSI has grown.Twenty-eight medical groups and 18 hospitalsare now members. Half of Minnesota’s physi-cians practice in member organizations, whichrange in size from Family Practice Medical Cen-ter in Willmar—with seven physicians—toMayo Clinic in Rochester. Metro area membersinclude Park Nicollet Health Services,HealthPartners Medical Group, FamilyHealthServices Minnesota, Allina MedicalClinic, Quello Clinic, North Clinic, and manyothers. Recent joiners include St. Mary’s/DuluthClinic Health System, Grand Rapids Clinic, andMeritCare in Fargo.

ICSI’s sponsorship has also expanded. LastMarch four additional health plans joined withHealthPartners to support the program. ICSInow has three principal sponsors—HealthPartners, Blue Cross Blue Shield of Min-nesota, and Medica—and two associatesponsors—PreferredOne and UCare.

ICSI is governed by a board dominated byrepresentatives from the member medical groupsand hospitals. Eleven of the 17 board membersrepresent organizations that provide health caredirectly. One board member represents patients,one represents an employer, and three represent

The continuous improvement methodstaught and fostered by ICSI are those pioneeredby Walter Shewhart, W. Edwards Deming, andJ. M. Juran in arenas other than health care.These methods emphasize the use of improve-ments to systems and processes, and not at-tempts to change individual physician behavior,as the most effective route to better health out-comes. Within the past 15 years these methodshave been introduced into health care by PaulBatalden, M.D., who hails from Minnesota andnow works at Dartmouth Medical School—along with Donald Berwick, M.D., of the In-stitute for Healthcare Improvement in Boston,Brent James, M.D., of InterMountain HealthCare in Salt Lake City, and others. Within thepast two years, the systems approach to healthcare improvement has received widespread at-tention in health care and in the general pressin response to the Institute of Medicine’s tworeports on the quality of health care in America,To Err is Human: Building a Safer Health Systemand Crossing the Quality Chasm.

As the ICSI members pursue care improve-ments, they often join together in topic-specificcollaboratives, called “action groups.” The mostpopular action groups have been those aimedat achieving same-day access for physician ap-pointments, and twelve member medical groupshave achieved this goal in some or all of theirclinics. ICSI has also conducted action groupson care for diabetes, hypertension, asthma, lipiddisorders, and other diseases—as well as actiongroups on patient safety, preventive services, andmanagement of change in organizations. Eachaction group follows a sequence of meetings,telephone conference calls, progress reports, andexchanges of information on improvementmethods that have been successful. ICSI staffarrange for experts from around the country tomeet with the participants.

the three principle health plan sponsors. Theboard hires the executive director, who is theseventeenth board member.

The primary purpose of ICSI is to acceler-ate improvement of the health care that its mem-bers provide to their patients. This is achievedthrough an annual cycle of commitment andaction, required of all members as a conditionof continued membership. Typical targets for

intensive improvement work are diabetes, coro-nary artery disease, preventive services, and wait-ing time to get appointments. Members thatare not able to mount an organized programand make progress are asked to depart.

In their improvement efforts, the membersare supported by each other and by the staff atICSI. This support takes several forms. All newentrants participate in an 18-24 month orien-tation and training program that includes 32classroom hours for physician leaders and qual-ity improvement staff members. In accordancewith each medical group’s and hospital’s wishes,this training may be followed up indefinitelywith coaching by ICSI staff. ICSI also producesvideotapes, audiotapes, and written materials foruse by members. Many of the written materialsare available on ICSI’s website at www.icsi.org.

The primary purpose of

ICSI is to accelerate

improvement of the

health care that its

members provide to

their patients.


The centerpiece of ICSI’s work on evi-dence-based medicine is the guideline program.ICSI is best known for its guidelines, and manyphysicians have the impression that the guide-line program is the whole ICSI program. Guide-line production was, in fact, the whole of ICSI’sprogram in the early 1990s, but the balance ofeffort since 1997 has shifted from producingguidelines to using them for system-orientedimprovement work. About two-thirds of ICSIstaff time is now spent on using the guidelinesas opposed to creating and maintaining them.However, despite this shift, the guidelines con-tinue to be the foundation for the rest of theprogram.

The collaboration has produced 50 clini-cal practice guidelines, which are publicly avail-able on ICSI’s website. Topics include breastcancer treatment, atrial fibrillation, simple cys-titis, and other commonly encountered clinicalconditions. They are written by physicians,nurses, and other professionals in the ICSI mem-ber organizations. ICSI staff provides projectmanagement, document preparation, and otherforms of support. All guidelines are updated atleast every 18 months. All sponsoring healthplans have endorsed the ICSI guidelines andceased production of separate guidelines on top-ics covered by ICSI. The ICSI guidelines serveas reliable scientific statements of best health carepractice, providing the basis for setting the aimsto be pursued through systems improvement.

ICSI also provides clinicians with technol-ogy assessments, that is, syntheses of the medi-cal evidence on given items of technology suchas CT scanning for lung cancer screening, elec-tron-beam CT for diagnosis of coronary arterydisease, and genetic testing for breast cancer risk.Ordinarily the topics of these reports are emerg-ing items of technology about which cliniciansin member organizations have requested system-atic reviews of the literature in order to deter-mine whether the items are effective and safe.

ICSI provides a venue for sharing and col-laboration for improvement across all interestedmedical groups and hospitals in Minnesota andimmediately adjacent areas. It is no longer anexperiment. The success of ICSI members inimproving care is demonstrated in over 20 ar-ticles published in peer-reviewed journals. ICSIcontinues to grow and to provide a model forhow to improve care in other parts of the UnitedStates. Programs in Pittsburgh, upstate New

York, Denver, and Seattle have been patternedin part after ICSI.

In a time of commercially motivated com-petition and fragmentation, the effective col-laboration realized through ICSI is a refreshingreminder of the collegiality and mutual supportthat used to be more common in medicine. Thehealth care landscape has changed substantiallyover the past two or three decades, but we areregaining some of what was lost. There remainsa great deal more to do and a great deal more toregain. ✦

Gordon Mosser, M.D., is Executive Director of theInstitute for Clinical Systems Improvement.

Editor’s Note: Results of improvement effortsin ICSI medical groups can be found in thearticles listed below. In all cases, the work wasdone using ICSI guidelines and methods ofimprovement taught by ICSI. However, thework was done by the medical groups and hos-pitals and not by ICSI or ICSI staff. The suc-cesses noted should be attributed to the mem-ber organizations of ICSI and not to ICSI itself.

Anderson RS, Healey ML. Immunizationrates in children receiving diphtheria-tetanus-pertussis and measles-mumps-rubella vaccines simultaneously. Journalof Clinical Outcomes Management2000; 7(1):27-30. Park Nicollet Clinic.

Nyman MA, Murphy ME, Schryver PG,Naessens JM, Smith SA. Improvingperformance in diabetes care: a multi-component intervention. EffectiveClinical Practice 2000; 3(5):205-12.Mayo Clinic.

O’Connor PJ, Quiter ES, Rush WA, WiestM, Meland JT, Ryu S. Impact ofhypertension guideline implementationon blood pressure control and drug usein primary care clinics. Joint Commis-sion Journal on Quality Improvement1999; 25(2):68-76. MinnHealth (St.Paul) and Northfield Family Physicians.

O’Connor PJ, Solberg LI, Christianson J,Amundson G, Mosser G. Mechanism ofaction and impact of a cystitis clinical

practice guideline on outcomes and costsof care in an HMO. Joint CommissionJournal on Quality Improvement 1996;22(10):673-82. HealthPartners MedicalGroup Clinics.

Rolnick SJ, Hyer B, Jackson J, Loes L.Implementation of an active manage-ment of labor guideline in a managedcare setting. Quality Management inHealth Care 1998; 6(3):35-42.

Sperl-Hillen J, O’Connor PJ, Carlson RR,Lawson TB, Halstenson C, Crowson T,Wuorenma J. Improving diabetes care ina large system: an enhanced primary careapproach. Joint Commission Journal onQuality Improvement 2000; 26(11):615-22. HealthPartners Medical Group.

Stroebel RJ, Broers JK, Houle SK, Scott CG,Naessens JM. Improving hypertensioncontrol: a team approach in a primarycare setting. Joint Commission Journalon Quality Improvement 2000;26(11):623-32. Mayo Clinic.

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Intensivists Provide UniqueDimension of ICU Care

B Y R O B E R T J . B E C K , M . D .

OVER THE LAST 50 YEARS, intensive careunits (ICUs) have dramatically improved carefor critically ill patients. In 1958, only about aquarter of larger community hospitals in theUnited States had an ICU. By 1997, more than5,000 ICUs were in operation across the coun-try, according to the Society of Critical CareMedicine. More recently, ICUs have begun

implementing intensivist programs to providemore consistent, specialized care teams in thecomplex area of acute care.

HealthEast Care System, along with Pul-monary & Critical Care Associates (PCCA),recently rolled out an ICU Service Line, com-monly referred to as an intensivist program. Itoffers a higher level of patient care, with board-certified critical care physicians, or intensivists,managing and staffing the ICUs at St. John’sHospital in Maplewood and Woodwinds HealthCampus in Woodbury. These intensivists areboard certified in internal medicine, pulmonarydisease and critical care medicine. At Wood-winds, the care provided by intensivists iscomplemented by acute care nurse practitioners(ACNP) staffing the ICU 24 hours per day.ACNPs specialize in critical care, and have ex-tensive experience in critical care nursing. Theintensivists also help establish a cohesive ICUteam that, in addition to ACNPs, includes so-cial workers, pharmacists, nutritionists, nurses,respiratory therapists, and chaplains.

In numerous studies, intensivist care in theICU has been proven to enhance patient out-comes, according to Linda Funk, M.D., presi-dent of PCCA. “Most ICUs don’t haveintensivists managing care. When they do, thedata is clear that patients have fewer complica-tions, spend less time in the ICU, and have lowermortality rates.” Due to positive results ofintensivist programs across the country, a na-tional patient safety initiative, led by Fortune500 companies, recommends the intensivistmodel as a standard for ICU patient care.

“Studies have shown that around 500,000patients die in ICUs every year,” says Dr. Funk.“By implementing intensivist models in citiesaround the country, around 50,000 lives couldbe saved each year.”

With the increasing complexity of care be-ing delivered in our ICUs, along with the lim-ited number of beds, we need to make sure weare utilizing them as effectively as possible. Thisis the goal of the intensivist program.

By providing care only in the ICU,intensivists help save valuable time for ill pa-tients. In a traditional ICU, nursing staff wouldhave to call the attending physician, and thenwait for a return call before treatment changescould be made. Intensivists at HealthEast havecommitted to returning stat pages within fiveminutes during off-hours, reducing lag timebefore patients are able to receive evaluation andtreatment.

The role of the intensivist is to enhancethe care of the patient, not replace the role ofthe primary physician. The intensivist programoperates under a “mandatory consult model ofcare,” which allows critical care physicians todetermine patient placement and care priori-ties. Primary care physicians are encouraged toparticipate in the co-management of the pa-tients’ critical needs, while the intensivists con-tinue to collaborate with other specialists.

“We won’t infringe on the primary carephysician’s role, and the degree of our involve-ment will be determined on a case-by-case ba-sis. Primary care physicians will continue to havethe input they desire. They also have the optionof handing off care while their patient is in theICU as it is difficult to make multiple dailyrounds necessary on the critically ill. We will beinvolved with each patient throughout theirICU stay and manage multidiscipline teamrounds, conducting family conferences, etc. Wewill have some level of involvement in the careof all non-cardiac patients at St. John’s andWoodwinds,” explains Dr. Funk.

Two areas of focus for intensivists include

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continuity of care and improved communica-tion with primary care physicians. Throughouta patient’s stay and at the time of discharge fromthe ICU, there is continued communicationwith the primary care physician, whether or notthe physician has been involved in the ICU care.Also, the intensivist gives the primary care phy-sician an assessment when each patient leavesthe ICU.

The intensivist model supports frequentfamily conferences, which improve communi-cation between the health care team, the pa-tient and the family. Rebecca Wong, ClinicalDirector at St. John’s ICU says, “The modelprovides an environment for continuous learn-ing, by using research-based practice, ongoingteamwork, and quarterly critical care confer-ences, with case studies. The intensivist modelis based on best practice. Improving patientoutcomes is why we are all here.” ✦

Robert J. Beck, M.D., is the vice president of medi-cal affairs at HealthEast Care System.

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AQWhat are any real chances for correction of the geographi-cal disparity between states in regard to Medicare pay-ments?

This has been a major issue for Minnesota providers since the program’sinception. The AAPCC payments were established based on historicalmedical costs that were considerably less in Minnesota than in other statessuch as Florida. In simplest terms, in order to correct the geographicaldisparity, either the total pot of money available for Medicare paymentsincreases, or the existing pot is reallocated.

If the formula were changed to reallocate money in a manor morefavorable to Minnesota, other states would lose money. The formula changewould require Congressional action, and would logically be vigorouslyresisted by states such as New York, Florida and California, that have largeCongressional delegations. Therefore, Minnesota has been unable to af-fect change.

In this time of economic downturn, the pot of money available forMedicare is limited. Short of a large infusion of money into Medicare byCongress, the pot will not be increasing. With all the competing demandson federal dollars, it is unlikely that Congress at this time would choose toinfuse large amounts of cash into the program specifically to correct thedisparity. Therefore, I don’t see this correction happening soon.

What are your insights into how Medicare will look infive to ten years?

In 2001, Medicare spent approximately $238 billion. This accounted forapproximately 13 percent of the federal budget, and about 19 percent ofthe total national spending for personal health services. Currently the pro-gram involves 40 million beneficiaries. In the next decade, due to the

baby boomers, there will be a substantial acceleration in the number ofMedicare beneficiaries. The first wave will become eligible in 2010. There-after, increasing numbers of seniors will become eligible.

Actuarially, we can calculate the increased costs to the program forthe entrance of the baby boomers. However, another significant pressureis the development and dissemination of new medical technology. Thefinancial impact on the Medicare program of evolving technology is sub-stantial, but not easily calculable. The American public has a prodigiousappetite for this technology.

This will create enormous financial pressures on the program. It ap-pears that we will be operating with deficit federal funding for close to thenext decade, according to economists today. Therefore, it is extremelyunlikely that the Medicare program will receive any substantial increase infunding, and the money available will have to be spent across a muchlarger population.

Given these financial realities, it is unlikely we will see any kind ofsubstantial expansion of benefits. It is questionable whether Medicare willbe able to cover the range of services currently covered. Despite itsunpalatability, Congress will need to consider instituting cost controlmeasures such as stringent utilization review, case management, and pro-tocol-driven medicine. Instead of fairly automatic incorporation of newtechnology into the benefit set, the Medicare program will have to insti-tute more careful evaluation of such technologies, including much moreemphasis on cost-benefit analyses than exist today. New technologies willalso be compared to existing less expensive modalities.

In the next five to 10 years, the Medicare program will likely phaseout local contractors, and contract with a few large companies to admin-ister the program across the country. The original premise of administer-ing Medicare locally to ensure that the program reflects local standards ofpractice will no longer apply. National Coverage Decisions will replacethe current Local Medical Review Policies developed in individual states.This will be necessary to exert financial order and control on the program.

Instead of a program where medical practice drives the finances, itappears we will move to a program where finances will heavily influencethe medical services offered.

Kathleen D. Brooks, M.D.

Editor’s Note: Kathleen Brooks, M.D., is the Minnesota Carrier Medi-cal Director for Part B Medicare, Wisconsin Physician Services. Shecontinues to do part-time clinical work for HealthPartners MedicalGroup. Dr. Brooks teaches at the University of St. Thomas in the Phy-sician Leadership College, and is a Clinical Associate Professor in theDepartment of Family Practice at the University of Minnesota.

The questions for this interview were provided by Drs. ThomasDunkel, Carl Burkland, Blanton Bessinger, Robert Moravec, and LeeBeecher.

C O L L E A G U E I N T E R V I E W


The 2nd IOM Report “Crossing the quality Chasm”recommends changing our methods of health care deliv-ery—especially for the top 20 chronic conditions. Thisincludes coverage for group care, e-mail or phone care, etc.I would like to know what you think of this recommenda-tion and what role the government programs like Medicarecan play in this change. What is your influence as apracticing physician representative and medical director?Can you speak out on the recommendations or are yousomewhat restricted?

Medicare, as a defined benefit plan, established payment structures forphysician services based on prevailing patterns of care delivery at the time.The model was one of acute illness management based on direct face-to-face contact with the patient. It operated on the premise that the physi-cian personally performed the billable services. Medicare payments weremade for illness management, not preventive service.

As medicine has evolved, Congress has attempted to “retrofit” theMedicare payment system to encompass modern practice patterns. In-creasing types of preventive services have become benefits. Payments forindependent services of midlevel providers, including physician assistants,nurse practitioners, and certified nurse specialists have been incorporatedinto the program. The use of “incident to” provisions has been expandedto allow payments for auxiliary personnel performing services within cer-tain rules. Telemedicine payment rules have been developed.

The medical community can certainly argue that the Medicare pro-gram has moved very slowly and cautiously in these areas, and has notshown great flexibility in allowing latitude for the rapid development ofcreative care models. However, perhaps health care providers have some-times had unrealistic expectations of a large government program thatpays 900 million claims per year for 40 million patients. It must operatein a deliberative fashion.

Looking forward, health care delivery continues to evolve, focusingnow on issues such as quality of care, chronic care delivery, patient safetyand new technology development. The Medicare program continues toassess how to incorporate new models of care delivery into the paymentstructure. Currently CMS is evaluating group visits, as there is no readypayment structure for such care, and it has been shown to be effective inchronic care management.

My role as Carrier Medical Director allows me to influence this pro-cess in several ways. First, as a practicing physician and representative ofMedicare in this community, I am expected to keep current on evolvingcare delivery patterns. I give input to CMS directly and through nationalCarrier Medical Director meetings and workgroups. I respond to draftregulatory changes before they are finalized. I inform CMS of programrestrictions that may affect access to care. Conversely, my job involvesinterpreting Medicare regulations for the medical community and apply-ing them in coverage and policy decisions. As the Medical Director forthe contracted Medicare carrier, I make decisions about coverage in am-biguous areas where CMS has not issued definitive rulings. This gives methe opportunity to engage in the process of setting and administeringpolicy for evolving health care issues.

Do you think there is a too strict interpretation of thedefinition of home bound? In that a client will not beconsidered home bound and therefore eligible for Medicareservices if they leave their apartment for any reason—i.e.to go downstairs in their apartment to eat at a congregatedining site or just walk around the block for exercise.

This benefit was designed for Medicare beneficiaries who are truly unableto leave their homes. It was not designed for a larger, less restrictive defini-tion, which would include patients able to walk around the block. Thatwould be a different benefit, requiring a very significant increase in alloca-tion of overall dollars to Medicare spending. At this time, the public andCongress do not appear interested in allocating substantially more moneyto the Medicare program. Alternatively, decreasing spending in other ar-eas of the Medicare program could fund that broader benefit.

Why doesn’t Medicare Part B cover home making services,which are essential for home bound client’s well-being andrecovery? (i.e. doing the laundry, changing the bed, goingto the grocery store or pharmacy?)

Medicare Part B benefit covers skilled nursing care and home health aideservices for help with personal care. The other services outlined in thequestion are not covered under this medical benefit. Medicare is a definedbenefit plan. If the program’s benefits were expanded to cover a broaderrange of services, the same alternatives discussed in the above questionwould have to be considered – either expansion of funding or reallocationof resources.

Why aren’t home bound blood draws covered by Medicareespecially in northern climates during the winter months?

If the Medicare beneficiary is eligible for skilled nursing care visits, thenurse may draw blood. However, if the patient simply needs blood drawsand not any other skilled nursing service, this implies that the patient hasa higher level of function and the program does not include this benefit.

We have seen a delay in receiving payments from secondarypayers—with Medicare primary—stating delay inreceiving information from Medicare, is this true?

Wisconsin Physicians Service was implementing a new process with theCoordination of Benefits Contractor for Medicare. Service provided bythe Coordinator of Benefits Contractor was affected by the disaster to theWorld Trade Center on September 11, 2001. They were located in lowerManhattan and required to evacuate and move operations to a differentlocation. As of 10/22/01, all COB activities have returned to normal attheir Manhattan facility, so we anticipate the problem to be resolved.



Having been on both sides of medicine, as a practicingphysician and now as a medical director, how has yourmedical background and experiences contributed to yourcurrent position?

My experiences both past and present as a family physician help groundme in this job. I understand the frustrations of providers trying to do theirbest to be their Medicare patients’ advocates. I value that role. I have beenan owner of a six-doctor practice and remember regulatory burden. I knowthe frustration of trying to understand the expectations of a myriad ofpayers.

I’ve also had the privilege to spend time during a Bush Fellowshipwith a group of very impressive government colleagues. They helped meunderstand the constraints and ethical obligations inherent in managinglarge government programs with significant Congressional oversight. Thatknowledge helps me as an employee of a government contractor.

I sit on the edge, representing and defining the Medicare program tomy medical colleagues. Conversely, I represent a medical perspective tomy government colleagues. In this middle ground, I am called upon tointerpret and provide coverage and policy decisions. I believe my back-ground and previous work experience helps me to define issues and betterunderstand the impact of my decisions.

I am fortunate to collaborate with three other physicians who serve

as the Part B Medical Directors for Wisconsin, Illinois and Michigan. Wehave very active Carrier Advisory Committees composed of physiciansfrom most of the specialties. We try to use that combined medical knowl-edge to make rational medical decisions within the boundaries of theMedicare program.

Closing Comments:

I’ve enjoyed the opportunity to address these questions. They have rangedfrom broad philosophical concerns to specific Medicare coverage issues.Originally, when I began to venture away from regular family practice, itintrigued me to do a combination of work. Some of my days would befilled with patient care. Some would involve administrative duties wherethe goal involved creating a better system and infrastructure for deliveringcare. From that vantage point, I became fascinated by the role of govern-ment in the delivery of healthcare, and that led to my Bush Fellowship.Now the main thrust of my work is to operationalize health policy. Thisposition allows me to be an insider into the workings of a huge publicprogram, and to try to provide a solid medical perspective to the decisionsmade. In order to be competent at this job, I need to collaborate with themedical community and to retain my grounding and roots in medicine. Ineed to be able to call on my medical colleagues for advice. I will continueto ask for this help as we address payment issues for evolving healthcaresystems and technologies. ✦

Colleague Interview


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Highlights of the Code of Medical Ethicsof the American Medical Association

B Y F R A N K A . R I D D I C K , J R . , M . D .A N D A M Y M . B O V I , M . A .

Section E-5.00:Opinions on Confidentiality,Advertising, and Communica-tions Media RelationsIn this article on the AMA’s Code of MedicalEthics, we turn to the section of the Code thatencompasses a wide array of issues related tocommunication between physicians and pa-tients, colleagues, and the public. Specifically,Section 5.00 includes guidelines on confidenti-ality, advertising, and media relations. For each

of these three topics, we will trace a brief his-torical evolution of ethical guidelines and dis-cuss their current application.

Confidentiality and the CodeCentral to communication involving physiciansis the concept of confidentiality, which is oftenheld to be the basis of patient trust in the medi-cal profession. It is not surprising that the Codediscusses the obligation to protect the confiden-tiality of patient information in considerable

detail, along with an exploration of instanceswhen a breach of confidentiality may be per-missible. The legal issues surrounding confi-dentiality and privacy are of great concern tomany physicians, particularly since the releaseof the Health Insurance Portability and Ac-countability Act (HIPAA) regulations. Althoughthese legal issues warrant further discussions, thefocus of the Code is to specifically provide guid-ance for physicians from an ethical perspective.

Confidentiality had a prominent place inthe 1847 Code of Ethics where it was identified


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as an important duty physicians owed to theirpatients: “Secrecy and delicacy, when requiredby peculiar circumstances, should be strictly ob-served; and the familiar and confidential inter-course to which physicians are admitted in theirprofessional visits, should be used with the mostscrupulous regard to fidelity and honor.” Givenits roots in the Hippocratic tradition, confiden-tiality is a concept with a rich history unlikeany other ethical principle in the Code. In fact,looking at the Hippocratic Oath, the similarityto the 1847 Code is striking: “And whatsoever Ishall see or hear in the course of my profession,as well as outside my profession in my inter-course with men, it is be what should not bepublished abroad, I will never divulge, holdingsuch things to be holy secrets.”

In the early development of medicine as aprofession, physicians also were greatly con-cerned with their interaction with colleagues andthe original Code provided detailed guidelineson consultations. Confidentiality also played animportant role in this context, such that “Alldiscussions in consultation should be held assecret and confidential” and the presence of an-other physician should never compromise theconfidential nature of the patient-physician con-versations.

When the Code was re-structured in 1957such that ten basic Principles were identifiedfrom which all other guidelines flowed, Prin-ciple 9 contained a statement very similar tothe 1847 language: “Confidences concerningindividual or domestic life entrusted by patientsto a physician…should never be revealed un-less their revelation is required by the laws ofthe state.” However, it is important to note thatunlike the 1847 version, circumstances in whicha physician could disclose information also wereidentified: “Sometimes…a physician must de-termine whether his duty to society requires himto employ knowledge obtained through confi-dences entrusted to him as a physician, to pro-tect a healthy person against a communicabledisease to which he is about to be exposed.” Thisparticular exception to confidentiality marks aclear concern for public health that was not soexpressed in the original Code.

Also, the 1957 edition advised physiciansthat, in determining the extent to which confi-dentiality should be protected, they should con-

AMA Code of Ethics


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sult the laws governing the jurisdiction in whichthey practiced. This statement illustrates anotherconsiderable change since the 1847 Code—when medical ethics does not yield clear guid-ance, physicians should defer to the law.

In the current edition of the Code, confi-dentiality continues to be at the basis of thepatient-physician relationship. Principle IVstates in part that “A physician shall… safeguardpatient confidences and privacy within the con-straints of the law.” This statement highlightsthe importance of confidentiality but also ac-knowledges the existence of legal limitations.This balance between ethics and law is reiter-ated in Opinion 10.01, “Fundamental Elementsof the Patient-Physician Relationship,” whichgenerally highlights what a patient should ex-pect when seeking treatment from a physician,and specifically states that “The patient has theright to confidentiality. The physician shouldnot reveal confidential communications or in-formation without the consent of the patient…”In some situations, the patient should be awarethat the law or welfare of the patient or publicinterest may require the physician to divulgeconfidential patient information.

Finally, Opinion 5.05 “Confidentiality”echoes previous editions of the Code: “The in-formation disclosed to a physician during thecourse of the relationship between physician andpatient is confidential to the greatest possibledegree.” Similar to 1957 edition, the currentCode also identifies circumstances in which aphysician may have to breach confidentiality,namely when the patient presents a probablethreat of serious harm to him or herself or oth-ers, or when the condition being treated is acommunicable disease or results from gun shotor knife wounds. The specific examples that aregiven remind us of the general public healthexception and again recognize the importanceof law and its enforcement. Seven other Opin-ions in Section 5.00 address more specific as-pects of confidentiality, from confidential carefor minors to HIV status on autopsy reports, aswell as the protection of health informationwhen using electronic means of communication.

It is interesting to note that, until recently,the Code was silent on privacy. Yet, privacy andconfidentiality are commonly interchanged.Generally, a distinction can be drawn betweenprivacy as a legal right that protects a personagainst unwanted intrusions and confidential-

ity as an ethical concept that protects the spe-cial nature of information that is shared betweena patient and a physician. Recently, however,the concept of privacy was included in the 2001revision of the Principles of Medical Ethics andlast December the AMA adopted a Report ofthe Council on Ethical and Judicial Affairs on“Privacy in the Context of Health Care.” Thesenew developments are another manifestation ofthe interplay between ethics and law.

Advertising and the CodeSection 5.00 also includes guidelines regardingadvertising as a means by which physicians re-lay information to the public. Although theCode contains only three policies on this mat-ter, ethical guidelines on physician advertisementhave a long and tumultuous history.


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In 1847, the Code was unambiguous andstated that many public advertisements were “de-rogatory to the dignity of the profession” whendirected toward patients with specific diseases,offering free advice and medicine to the poor,inviting laymen to be present at operations,boasting cures and remedies, or flaunting cer-tificates of skill or success. Such advertisementswere viewed as highly reprehensible or onlyworthy of practitioners without scientific train-ing — or “empirics.”

By 1957, there was a different stance onadvertising, which became viewed as the act ofmaking information known to the public andwas not in itself unethical. Telephone listings,office signs, or professional cards were all iden-tified as means that physicians could use. How-ever, the 1957 Code considered solicitation tobe unethical and barred physicians from usingpersuasion or influence to obtain patients, apractice that was viewed as commercializing thenature of medical services and, therefore, un-dermining physicians’ professionalism.

Of the three current policies related to ad-vertisement, Opinion 5.02, “Advertising andPublicity,” has the most notable history as itstemmed from a 1980 order from the FederalTrade Commission (FTC) to the AMA to stopimposing restraints which were considered a vio-lation of anti-trust laws. Another concern thatcontinues to be expressed in the Code relates tothe direct advertisement of drugs to consum-ers. In fact, this issue may be reminiscent ofphysicians’ suspicion of non-medically trainedproviders seeking to make a profit at the expenseof patients in need of medical attention.

Media Relations and the CodeFinally, section 5.00 includes some guidance onthe dissemination of information to the media.

In the 1957 edition of the Code, there werestrict guidelines against patient solicitation butalso an acknowledgement of the value of accu-rate health and medical information. This ten-sion led to a resolution from the Judicial Councilurging local societies to establish a “publicitycommittee” that would give to the press accuratemedical information of interest to the public.

Opinion 5.04 in the current edition of theCode considers a much narrower aspect of me-

dia relations, namely the dissemination of pa-tient information to the media. The Opinionemphasizes that before any personal informa-tion can be released, the patient’s consent gen-erally must be obtained.

ConclusionThis brief historical review of ethical guidelinesapplicable to various means of communicationand the analysis of current Opinions includedin Section 5.00 once again illustrate that manyof the ethical concerns confronting the medicalprofession have a long history, none more sothan confidentiality with its roots in Hippocraticmedicine. However, it is also interesting to seehow social or economic changes in the practiceenvironment affect ethical standards. For ex-ample, the medical profession cannot afford tooverlook its responsibility toward public healthor its need to adapt to new technological meansof communication. Such evolution makes clearthat a code of conduct is a living document thatneeds to be revisited from time to time. Finally,our exploration of the various sections of theCode of Medical Ethics continues to reveal acareful balance between ethical principles andlegal standards, which together guide physicians’conduct in meeting the expectations of theirpatients as well as those of the public at large.

The full content of the AMA’s Code ofMedical Ethics is accessible online at www.ama-assn.org/go/ceja. ✦

Frank A. Riddick, Jr., M.D., is Chair, Councilon Ethical and Judicial Affairs. Amy M. Bovi,M.A., is Staff Associate, Council on Ethical andJudicial Affairs.

AMA Code of Ethics


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3rd Bioterrorism Seminar Held

“Connections” Mentoring Program

“BIOTERRORISM AND THE New Triage:Ethical, Operational, and Policy Issues in Com-munity Preparedness” was held on Tuesday,January 15, the third in a series of seminars onbioterrorism co-sponsored by the Hennepin andRamsey Medical Societies, Minnesota MedicalAssociation and Hennepin County Medical Cen-ter since the September 11 attack on America.Additional sponsors of this seminar included theMinnesota Center for HealthCare Ethics, Min-nesota Department of Health, Minnesota Pub-lic Health Association, and the MinnesotaEmergency Medical Services Regulatory Board.

Kenneth Kipnis, Ph.D., Professor of Phi-

losophy, University of Hawaii at Manoa, wasthe keynote speaker, calling on the professionsto “think differently” about how to handle thewounded in the event of a bioterroristic attack.A panel discussion followed his thought-pro-voking presentation; the panel was comprisedof Aggie Letheiser, MPH, Assistant Commis-sioner, Minnesota Department of Health; LindaHart, RN, MPH, Director of Quality Improve-ment, Fremont Community Clinic; and JohnHick, M.D., Chair, MDH Terrorism ClinicalCare Workgroup and Emergency Medicinephysician at HCMC. Karen Gervais, Ph.D.,Director, Minnesota Center for HealthCare

Ethics, served as the mod-erator. A videotape of allthree seminars is availablefor loan through theHennepin and RamseyMedical Societies. Con-tact Nancy Bauer at 612-623-2893 for a copy. ✦

HMS and RMS Continue Participation in U of M MedicalAlumni Society’s “Connections” Mentoring Program

Brian Ip, M.D., and Tori Myslajek, medicalstudent.

Jeanne Nugent, medical student and MonaGrotte, M.D.

Kenneth Kipnis, Ph.D., keynote speaker.

The panel consisted of: Kenneth Kipnis, Ph.D., John Hick, M.D.,Aggie Letheiser, MPH, Linda Hart, RN, MPH, and KarenGervais, Ph.D.

PRESIDENT ’S MESSAGEP E T E R H . K E L L Y, M . D .

RMS-Officers

President Peter H. Kelly, M.D.President-Elect Michael Gonzalez-Campoy, M.D.Past President Robert C. Moravec, M.D.Secretary Jamie D. Santilli, M.D.Treasurer Peter J. Daly, M.D.

RMS-Board Members

Kimberly A. Anderson, M.D., Specialty DirectorJohn R. Balfanz, M.D., Specialty DirectorVictor S. Cox, M.D., Specialty DirectorGretchen S. Crary, M.D., At-Large DirectorCharles E. Crutchfield, III, M.D., At-Large DirectorLaura A. Dean, M.D., At-Large DirectorThomas B. Dunkel, M.D., MMA TrusteeJames J. Jordan, M.D., Specialty DirectorRobert V. Knowlan, M.D., At-Large DirectorCharlene E. McEvoy, M.D., At-Large DirectorRagnvald Mjanger, M.D., Specialty DirectorKenneth E. Nollet, M.D., Ph.D., At-Large DirectorStephanie D. Stanton, Medical StudentLyle J. Swenson, M.D., MMA TrusteeCharles G. Terzian, M.D., Specialty DirectorDavid C. Thorson, M.D., Specialty DirectorRussell C. Welch, M.D., At-Large Director

RMS-Ex-Officio Board Members &Council Chairs

Brenda Andrewson, Alliance PresidentBrent R. Asplin, M.D., AMA Young Physician SectionBlanton Bessinger, M.D., MMA Past PresidentKenneth W. Crabb, M.D., AMA Alternate DelegateRobert W. Geist, M.D., Ethics & Professionalism

Council Chair*Michael Gonzalez-Campoy, M.D., Education

Resource Council ChairFrank J. Indihar, M.D., AMA DelegateWilliam E. Jacott, M.D., U of MN RepresentativeMelanie Sullivan, Clinic AdministratorDonald B. Swenson, M.D., Sr. Physicians

Association President*Lyle J. Swenson, M.D., Public Policy Council Chair*Russell C. Welch, M.D., Communications

Council Chair*Also elected RMS Board Member

RMS-Executive Staff

Roger K. Johnson, CAE, Chief Executive OfficerDoreen M. Hines, Membership & Web Site CoordinatorSue Schettle, Director of Marketing & Member Services


TDéjà Vu All Over Again

TO QUOTE A FAMOUS BAND, “What along, strange trip it’s been.” Of course, the Grate-ful Dead were referring to their own bizarre jour-neys but their words resound in my head everytime I think about healthcare over the past 10years. The business of healthcare is much likethe weather, the only thing one can be assuredof is that it is going to change. Also, like theweather, it seems that no matter how hard wetry, we really don’t have much control over thesechanges. However, I think that we, as physicians,no matter how frustrating it may seem, need tocontinue to exert our influence on the forcesbehind these changes.

When I first came into practice 11 yearsago, the medical landscape was still pretty muchthat of a cottage industry. There were a few large,multi-specialty clinics around but, for the mostpart, physicians practiced in small, self-ownedgroups. The scene was shifting from a traditionalfee-for-service model to more and more man-aged care, with capitated contracts becomingmore ubiquitous. Unfortunately, the cost ofhealthcare was escalating at ever increasing ratesand there was pressure to try to drive these costsdown. Health insurance companies beganchanging from traditional indemnity plans tomanaged care plans, with utilization review,prior authorization, and discounted contractswith selected physician groups and hospitals.The Clinton administration tried and failed torestructure the healthcare industry and ulti-mately left that work to be done by the states.In Minnesota, the Legislature, essentially behindclosed doors and with no physician input(though with plenty of help from the HMOsector), created Healthright, which would even-tually become MinnesotaCare. This created avery uneven playing field and allowed thehealthcare business in Minnesota to consolidateinto basically three superpowers with huge le-verage over physician groups. This, coupled withthe 1996 Balanced Budget Act (with its decreasein Medicare reimbursements), left many medi-cal practices groping to stay in business. Whatfollowed was a huge movement to mergers andbuyouts by medical practices to try to level the

playing field, and within a few years the cottageindustry vanished. We now have huge numbersof physicians working either in an employedsetting, i.e. HealthPartners, Allina, HealthEast,or as part of a large, single specialty group, i.e.FSHM, Minnesota GI, Summit Orthopedics.It is debatable whether the goal of “better qual-ity at lower costs” was truly accomplished bythis drastic re-structuring of the landscape.

Several forces are now acting on thehealthcare market to bring about yet morechange. The managed care model has pickedmost of the low hanging fruit and the cost sav-ings of that model are no longer evident, as seenby double-digit rates in medical inflation. Muchof this increase is being fueled by a combina-tion of increased utilization by patients and byincreased hospital and pharmaceutical costs.Many patients are not satisfied with many ofthe restrictive clauses in their managed care con-tracts and their inability to seek care outside asmall network of hospitals and physicians andare opting for broader reaching plans. There isa movement to try to make the patient moreaccountable in the costs of his/her care andMedical Savings Accounts (MSAs) are gainingmore acceptance in the marketplace. The At-torney General has stepped in and taken a closerlook at the practices of the superpower healthplans and has acted to correct the deficiencieshe found in those systems. Allina has been bro-ken up into its original components of MedicaHealth Plan and the Allina Hospital System,and their respective roles in this marketplace willundergo changes. It is my understanding thatthe AG’s office is now looking at HealthPartners.

All of this leads to the conclusion that thiswill be a critical year in healthcare and the im-pact on physicians may be profound. Two are-nas will need particularly close monitoring. First,



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RMS MEMBERS, Alliance members, spouses,children and guests enjoyed an evening of recog-nition, collegiality, and enjoyment at the Town &Country Club on Friday, January 25, 2002.

Dr. Lyle Swenson, a past RMS president fromSt. Paul Cardiology, presented the PresidentialPlaque and a gift to outgoing President Dr. Rob-ert C. Moravec, HealthEast Care, Inc. Dr. Swensonpraised Dr. Moravec’s contributions and service toRMS during his term as president.

Dr. Peter H. Kelly, St. Paul Surgeons, wasinstalled by outgoing President Dr. Robert C.Moravec as the 135th president of RMS. Dr. Kellycited the rich history of RMS and the leadershipskills of its physician officers in his acceptancespeech. He reviewed the evolution of the largehealth care systems in the metro area includingthe restructuring of much of the health care sys-tem. He pointed out that the movement to givethe patient a greater role in their own health caredecisions has begun and that the State of Minne-sota has once again created a Task Force on HealthCare to look at the system. In conclusion, Dr. Kellypointed out that physicians must be involved andmust be informed about the issues. By workingtogether and by working with the government andwith the health plans, physicians can accomplishpositive change.

The 2001 RMS Community Service Awardwas presented to Dr. Joseph H. Tashjian, St. PaulRadiology, for his many contributions to the arts.For more than 10 years Dr. Tashjian has supportedthe University of Minnesota Department of Artby providing schol-arships to graduatestudents in ceram-ics, by fundraisingfor the department,and by lobbying atthe Minnesota Leg-islature for fundingfor the department.Mark Pharis repre-sented the Univer-sity of MinnesotaDepartment of Artat the RMS AnnualMeeting.

Dr. Tashjian also has a long record of contri-butions to the Guthrie Theater serving on theBoard of Directors and on many committees in-cluding the Tyrone Guthrie Circle, the CapitalCampaign Major Gifts Committee, and theGuthrie Heritage Society. His entire family is in-volved in supporting the Guthrie Theater. JonnaKosalko represented the GuthrieTheater at the Annual Meeting.

Dr. Tashjian’s support of thearts is not limited to art and the-ater. He recently created “Docs ina Box,” a group of physicians whosupport the St. Paul Chamber Or-chestra and he serves on the SPCOBoard of Directors.

His work in medicine in-cludes chairing the Radiology De-partment at Regions Hospital,serving on the Board of the Min-nesota Radiological Society, andserving as a councilor of the Ameri-

132nd Annual Meeting of the Ramsey Medical SocietyDr. Peter H. Kelly Installed as PresidentDr. Joseph H. Tashjian Receives RMS Community Service Award

Dr. Joseph H. Tashjianreceived the RMSCommunity ServiceAward for 2001.

Outgoing President Dr. Robert Moravecreceives the Presidential Plaque from Dr.Lyle Swenson, a past RMS president.

Dr. Peter Kelly (right) is installed as thenew president by Dr. Robert Moravec.

can College of Radiology. He is a frequent lec-turer on detecting breast cancer and on chest dis-eases and he assists radiology residents withpreparing for their oral exams.

The evening entertainment was provided bythe Singsations who sang and danced to a widerange of sparkling Broadway songs to the swing-ing tunes of jazz and the blues. ✦

Colleagues from St. Paul Radiology, P.A. andDr. Peter Kelly congratulate Dr. Tashjian onreceiving the Community Service Award.(From left): David Kispert, M.D., Kay Savik(Dr. Tashjian’s spouse), Carl Bretzke, M.D.,Joseph Tashjian, M.D., David Eckmann, M.D.,Linda Bohn, M.D., and Peter Kelly, M.D.

Beth Jordan, M.D., James Jordan, M.D.,John Mageli, M.D., with spouse, Louise,socialize together.

St. Paul Surgeons, Ltd. partners and spouses show theirsupport for their colleague, Dr. Peter Kelly, RMS president.(From left): Kathy Wahlstrom, Kyle Wahlstrom, M.D.,Madee Wilton, Andrew Fink, M.D., Peter Wilton, M.D.,Cheri Fink, Peter Kelly, M.D., Nancy Kelly, Jeffrey Hill, DianeOgren, M.D., Debbie Rupp and William Rupp, M.D.


Governor Jesse Ventura has commissioned theGovernor’s Task Force on Health Care Costs toexamine the current status of the health caresystem in Minnesota. This is being chaired byHealth Commissioner Jan Malcolm. The grouphad their first meeting on 12/20/01. Theircharge is: 1) to develop strategies to re-engageconsumers in health care decisions; 2) examineand publicize components of health care costsdrivers; 3) examine changes needed in healthbenefit design to address numbers one and two;4) identify quality improvement strategies; and5) propose new risk pooling arrangements.Many of the people in attendance were the sameas those present during the health care reformsof the 1990s. Senator Linda Berglin stated thatshe is particularly interested in two cost drivers:obesity, and the consolidation of providers —especially specialists and their impact on overallhealth care costs. As noted above, this consoli-dation was almost a direct result of theMinnesotaCare legislation of the 1990s. Déjàvu?

The second area of interest is the re-shap-ing of Medica Health Plan. Medica is now atotally separate entity from Allina. The Boardof Directors has taken as its charge to re-exam-ine Medica and its relationship with its mem-bers, the business community and physicians.There is great optimism that a new directionwill be found to allow for comprehensive carefor the community while providing physiciansthe tools they need to continue to train, retainand recruit top-level doctors. This strategic plan-ning will occur over the next six months. Medicacovers about one million lives, mostly concen-trated in the metro area, and any major changeswill affect most physicians in this area.

Physicians need to be represented in theseprocesses and the MMA along with RMS andother county medical organizations are activelyinvolved at this point. However, the need forindividual physicians to be involved and ap-prised of the current situation is more impera-tive than ever. We, at RMS, will work hard tokeep our members up-to-date on these and othercritical issues. It is my hope in the coming yearthat we physicians will be an integral compo-nent in helping to reshape this marketplace andbe able to work with the government and thehealth plans to effect positive change and a win-win scenario for all. ✦

President’s Message(Continued from page 24)

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RMS UPDATE

In Memoriam

ActiveM. Jennifer Abuzzahab, M.D.Eastern Virginia Medical SchoolPediatric EndocrinologyChildren’s Hospitals & Clinics

Jerald Barnard, M.D.University of MinnesotaObstetrics/GynecologyWoodbury Obstetrics & Gynecology

Thomas F. Kraemer, M.D.University of MinnesotaPhysical Medicine & RehabilitationKraemer Clinic

Joseph M. Lasnier, M.D.University of KansasPulmonary/Critical Care MedicinePulmonary & Critical Care Associates, P.A.

Monique M. Regard, M.D.Baylor UniversityObstetrics/GynecologyParkview Ob/Gyn

Joel J. Smith, M.D.University of MinnesotaOrthopaedic Surgery/Trauma, Sports MedicineRegions Hospital

Nickolas P. Tierney, M.D.University of MinnesotaObstetrics/GynecologyKendall Center for Women, P.A.

Todd M. Watanabe, M.D.UCLA School of MedicinePediatric OphthalmologySt. Paul Eye Clinic, P.A.

Mark V. Wedul, M.D.University of MinnesotaOphthalmologyLexington Eye Associates

James T. Young, M.D.University of MinnesotaOrthopaedic SurgerySummit Orthopedics, Ltd.

1st Year in PracticeNicholas M. Mittica, M.D.Jefferson Medical CollegeOphthalmology/GlaucomaSt. Paul Eye Clinic, P.A.

Benjamin D. Suhr, M.D.Boston UniversityGeneral SurgeryMinnesota Surgical Associates, P.A.

Scott A. Uttley, M.D.University of New MexicoOphthalmologySt. Paul Eye Clinic, P.A.

ResidentJon Fuerstenberg, M.D.University of Minnesota

Jessica Nicholson, M.D.University of Minnesota

Medical Student(University of Minnesota)Brett W. AdamsMelanie A. DixonAmit P. KachaliaJosephine M. O’GaraJessica M. Pike

JOHN ALDEN, JR., M.D., died January 9at the age of 79. He graduated from theUniversity of Minnesota in 1946. Dr. Aldenwas a Fellow of the American College ofSurgeons. He was one of the foundingpartners of the practice that is now St. PaulSurgeons, Ltd. He joined RMS in 1948.

DANIEL L. FINK, M.D., died at the age of87. He graduated from the University ofMinnesota in 1939. Dr. Fink was one of thelongest practicing radiologists in Minnesota.He joined RMS in 1947.

P. THEODORE WATSON, M.D., died onJanuary 1 at the age of 83. He graduated fromthe University of Minnesota in 1943. Dr.Watson practiced obstetrics and gynecology inSt. Paul from 1946 to 1980 after serving twoyears as a Navy physician. The WatsonEducation Center at St. John’s Hospital wasdedicated to Dr. Watson and his wife Jeannein 1992. Dr. Watson joined RMS in 1948.

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New MembersRMS welcomes these new members to the Society.

Schools listed indicate the institution where the

medical degree was received.

If you have any questions, contactDoreen Hines

at 612-362-3705or [email protected]

A Call for DelegatesIf you are interested in serving as aDelegate, please contact us at yourearliest convenience.

A Call for ResolutionsResolutions are due at the RamseyMedical Society no later than Friday,May 17.

RMS CaucusDates and places to be announced(late May/early June)7:00 – 8:30 a.m.

MMA Annual MeetingWed-Fri, September 25-27, 2002Northland Inn, Brooklyn Park, MN


D

RMS ALLIANCE NEWSB R E N D A A N D R E W S O N

DID YOU KNOW THAT INVOLVEMENTin your local Medical Society and Alliance isgood for your health? Public health researchershave established beyond reasonable doubt thatsocial connectedness, whether it be from closefamily ties, friendship networks, affiliation andinvolvement in religious and civic organizations,or participation in social events, is a powerfuldeterminant of our well being. This is one ofmany fascinating facts that Robert D. Putnampresents in his book: Bowling Alone, the Collapseand Revival of American Community. Not onlyis this type of social involvement good for yourhealth and sense of happiness, but it also canlead to: better educational systems and improvethe welfare of children; safer, more productiveneighborhoods; economic prosperity; and amore effectively functioning government. So,why aren’t more Americans involved in theircommunities? Finding the answer to this ques-tion is vitally important to the future of our lo-cal Medical Society and Alliance.

Putnam presents a mountain of data tosupport why what he calls social capital (whichincludes active involvement in local clubs andorganizations) fell by more than one half in thelast several decades of the 20th century. Years ago,people belonged to bowling leagues, but todaythey are more likely to bowl alone. “Bowlingalone” is Putnam’s metaphor for disconnectedindividuals. While the causes of this civic dis-engagement are difficult to isolate, Putnam doesmake strong arguments that the main causes arepressures of time and money, sprawl, technol-ogy and mass media, and generational differ-ences.

Time pressure is the excuse that I hear mostfrequently. We certainly seem busier now; wefeel more rushed and life seems very hectic. ButPutnam’s evidence seems to indicate that Ameri-cans have no less free time than earlier genera-tions and may actually have more. The problemmay lie more in how those gains in free time aredistributed. Coordinating schedules has becomemore burdensome causing collective forms of

civic engagement to decline more rapidly thanindividual forms (Have you ever tried to set upa meeting for three or more busy people?). Pres-sures of time and money, including the pres-sures on two-career families have contributedto the decline in our social and community in-volvement, but Putnam estimates that it ac-counts for no more than 10 percent of theproblem.

Increased suburban sprawl is also suggestedas a reason for the decline in civic involvement.Regardless of your opinions of suburban sprawl,it does appear to impact civic disengagementdue to the time involved in commuting (Ameri-can adults have been shown to average 72 min-utes a day driving), increasing social homogeneitywithin the suburbs, and the disruption of com-munity “boundedness.” During the 1950s and60s, political scientists showed that residents of“well defined and bounded” communities weremore likely to be involved in civic affairs. Buthere again, Putnam estimates the impact ofsprawl to account for no more than 10 percentof the decline in involvement within our com-munities.

The biggest culprits of the decline in civicinvolvement, according to Putnam, are two hugeand overlapping influences: technology andmass media, and generational differences. Tech-nology, especially television, has tended to makeAmericans more isolated, passive and detachedfrom our communities. Studies indicate thatAmericans now watch three to four hours oftelevision per day, absorbing an increasing pro-portion of our leisure time. We used to turn onthe television to watch a particular program, nowwe turn on the television just to see what is on.This increasing dependence on television is as-sociated not just with less involvement in ourcommunities, but also with less social commu-nication of all types. Whether television andmass media (including the internet) are thecauses of civic disengagement or a symptom isless clear, but their impact is astounding.

The impact of generational differences is

also fascinating. Putnam presents evidence todiscount the idea that people of different agesbehave differently because they are at differentpoints in a common life cycle. He presents evi-dence that each generation since the 1950s hasbeen less engaged in community affairs than itsimmediate predecessor. Studies seem to indicatethat being raised after World War II was a dif-ferent experience than being raised before it.During WWII there was an increase in patrio-tism and collective solidarity within the U.S.and afterwards those energies were redirectedinto community life. Unfortunately, televisionwas introduced in America around 1948, andwithin seven years 75 percent of Americanhouseholds were watching it.

All of these facts are fascinating, but don’ttell us what we need to do to get more involve-ment in our Alliance and Medical Society. Nam-ing the problem however is an essential first stepto solving it. Interestingly, during the past 10years there has been an increase in volunteeringand community service by young people in col-leges and high schools, but whether this is a last-ing phenomenon or a reflection of strongerencouragement (including graduation require-ments and efforts to improve college admissionsefforts) remains to be seen. We have also seenan increased sense of unity within the UnitedStates since September 11th as Americans try tounderstand and make a difference in our world.Our President has called for increased volun-teer efforts within our communities and abroad.We all need to begin a dialogue on how we canadapt our organizations to the 21st century whilestill providing meaningful and regular serviceto our medical community. I welcome yourthoughts and ideas. ✦


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HMS-Officers

Chair David L. Swanson, M.D.

President T. Michael Tedford, M.D.

President-Elect Michael B. Ainslie, M.D.

Secretary Richard M. Gebhart, M.D.

Treasurer Paul A. Kettler, M.D.

Immediate Past Chair Virginia R. Lupo, M.D.

HMS-Board Members

Michael Belzer, M.D.

Carl E. Burkland, M.D.

Jeffrey V. Christensen, M.D.

Andrea J. Flom, M.D.

Kathy Larson, Alliance PresidentRonald D. Osborn, D.O.

James A. Rhode, M.D.

David F. Ruebeck, M.D.

Richard D. Schmidt, M.D.

Leah Schrupp, Medical StudentMarc F. Swiontkowski M.D.

Michael G. Thurmes, M.D.

D. Clark Tungseth, M.D.

Michael J. Walker, M.D.

Joan M. Williams, M.D.

HMS-Ex-Officio Board Members

Paul F. Bowlin M.D., Senior Physicians AssociationLee H. Beecher, M.D., MMA-TrusteeKaren K. Dickson, M.D., MMA-TrusteeJohn W. Larsen, M.D., MMA-TrusteeRobert K. Meiches, M.D., MMA-TrusteeHenry T. Smith, M.D., MMA-TrusteeDavid W. Allen, Jr., MMGMA Rep.

HMS-Executive Staff

Jack G. Davis, Chief Executive OfficerNancy K. Bauer, Associate Director

CHAIR ’S REPORTD A V I D L . S W A N S O N , M . D .

But it’s gonna take money —Taking Health Care Costs to Task

But it’s gonna take money,A whole lot of spending money.It’s gonna take plenty of money,To do things right, child.—George Harrison

THE GOVERNOR’S TASK FORCE on HealthCare Costs is now realized and has met at leastthree times by the time you read this. The TaskForce is chaired by Health Commissioner JanMalcolm and is comprised of members of thehouse and senate as well as the Commissionersof Human Service, Commerce, Employee Re-lations, and Finance. The Task Force has beengiven authority to study and resolve the burdenof rising health care costs. Those commercialcosts have been rising in Minnesota at a rate of11 percent per year over the past three years.

David Allen, a member of our Board, hasattended the proceedings. The meetings areopen to the public.

It comes as no surprise that health care costsare on the rise. What is interesting is how thenumbers play out in Minnesota, especially com-pared to the nation as a whole.

In 1999, the per capita spending was$3,528, which is 82 percent of the national percapita spending of $4,309. We Minnesotansspend 9.7 percent of our state economic dollarson health care, while the rest of the countryspends 12.7 percent. No astonishment here —we have always taken pride in our efficiency,although it has cost us dearly in reimbursementfrom Medicare and other Federal programs. (Asyou know, reimbursement rates for states are basedon historical expenditures — efficient utilizersare punished with lower reimbursement rates.)

Of the cost increases that have occurred inthe U.S., 42 percent of the increase was due tothe increased payments to physicians. There isno data accounting for the reasons for the in-crease. It may all be increased utilization (seepharmacy utilization below). It may be due to adocumented increase in the utilization of spe-cialty services over primary care. It is possiblethat there has been a significant increase in phy-

sician reimbursement income in the past twoyears, right?

Pharmacy costs accounted for 22 percentof the increase costs: 48 percent of this increaseis due to an increase in the total number of pre-scriptions written; 28 percent was due to an in-crease in the prices of novel drugs less than threeyears old; and 24 percent was due to an increasein the prices of old-timers more than three yearsold. So the expense of new-release drugs seemsto be a relatively small part of the rise in phar-macy expense.

The average Minnesota health insurancepremiums in 1999 were $6,218, which is 3 per-cent higher than the national average of $6,058.High premiums and low spending, why mightthat be? Perhaps it is a consequence of cost shift-ing from the increasingly marginal Medicare re-imbursement. Or, as some have suggested, itmight relate to long-care benefits, which areperceived as “generous” in Minnesota. Or, asAttorney General Mike Hatch has indicated,perhaps HMO administrative costs are muchhigher than we have been generally led to be-lieve in the past. The Minnesota Departmentof Health seems to think that this latter expla-nation is not the case.

The good news is that many on the TaskForce feel that the long-term growth in healthcare spending has peaked and will likely declinein the coming years. To me, this seems surpris-ing, given the new era of diagnostic imaging,minimally invasive but even more expensiveinterventional technology, and wondrous thera-peutic devices like basal ganglia electronic pac-ers for Parkinson’s disease patients.

Predicting declines in health care spend-ing seems like Wall Street making “buy” rec-ommendations for Enron. For one thing, we



HMS NEWS

ActiveMichael D. Alter, M.D.Medical College of Ohio at ToledoPulmonary DiseaseMinnesota Lung Center

Steven D. Anderson, M.D.University of Minnesota Medical SchoolFamily PracticeAllina Medical Clinic-Woodlake

Azber A. Ansar, M.D.Al-Ameen Medical College, KamatakaUniversity, BijapurInternal Medicine

Mary Kay Barrett, M.D.University of Minnesota Medical SchoolFamily PracticePark Nicollet Clinic-Carlson Parkway

Lian S. Chang, M.D.University of Minnesota Medical SchoolPsychiatry

Yun-sen Ralph Chu, M.D.Northwestern University Medical SchoolOphthalmologyChu Laser Eye Institute, P.A.

Gary D. Cravens, M.D.Indiana University School of MedicineGeneral SurgeryIngenix Health Intelligence

G. Scott Giebink, M.D.University of Minnesota Medical SchoolPediatricsUniversity of Minnesota Medical School

Richard J. Granger, M.D.University of New Mexico School of MedicineInternal MedicineHennepin County Medical Center

Steven P. Hanovich, M.D.University of Minnesota Medical SchoolInternal MedicineColumbia Park Medical Group P.A.

Brenda Jo Harris, M.D.University of Minnesota Medical SchoolObstetrics & GynecologyOakdale OB/GYN, P.A.

John R. Hering, M.D.University of Minnesota Medical SchoolFamily PracticeMonticello Clinic

Maria Hoenack-Cadavid, M.D.Universidad del Valle, Division de Ciencias de laSalud, CallPsychiatryHennepin County Medical Center

Michael Y. Hu, M.D.University of Minnesota Medical SchoolVascular SurgeryGeneral and Vascular Surgery

Stefan D. Kramarczuk, M.D.University of Minnesota Medical SchoolPediatricsPark Nicollet Clinic-Bloomington

Katarzyna Joanna Litak, M.D.Akademia Medyczna we Wroclawiv, WroclawPsychiatryHennepin County Medical Center

Christine M. McCarthy, M.D.University of Iowa College of MedicineFamily PracticePark Nicollet Clinic-Wayzata

Michael Patrick McCue, Sc.D., M.D.Harvard Medical SchoolNeurological SurgeryNeurosurgical Assoc., Ltd.

Amy J. Meath, M.D.University of Minnesota Medical SchoolObstetrics & GynecologyLakeview Clinic, Ltd.

Mark R. Mount, M.D.St. Louis University School of MedicineOtolaryngologySouthdale Otolaryngology

Glennon K. Park, M.D.University of Minnesota Medical SchoolInternal MedicineVeterans Administration

Lorinda F. Parks, M.D.University of Minnesota Medical SchoolFamily PracticeNorth Memorial Family Practice Clinic

Lisa A. Posey, M.D.Michigan State University College of HumanMedicineOtolaryngologySouthdale Otolaryngology

Judith B. Snook, M.D.University of Minnesota Medical SchoolPediatricsMetropolitan Pediatric Specialists, P.A.

Robert W. Snook, M.D.University of Minnesota Medical SchoolPediatricsMetropolitan Pediatric Specialists, P.A.

Michael W. Stanley, M.D.University of Alabama School of MedicinePathology-Anatomic/ClinicalHennepin Faculty Associates

Trond A. Stockenstrom, M.D.University of Minnesota Medical SchoolOphthalmologyEye Care Associates, P.A.

John G. Strickler Jr., M.D.University of Virginia School of MedicinePathology-Anatomic/ClinicalAbbott Northwestern Hospital

Maria Lynn Thrall, M.D.University of Minnesota Medical SchoolFamily PracticePark Nicollet Clinic-Shakopee

New MembersHMS welcomes these new members to the Soci-

ety. Schools listed indicate the institution where

the medical degree was received.


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have been seriously neglecting our medical in-frastructure in Minnesota. The populationgrows while the number of hospital and ex-tended care beds has declined. In the next threedecades, according to City planners, there willbe at least a million additional souls needingmedical care in the Twin Cities. Where is theplan to build hospitals and long-term care fa-cilities? Where are the thousands of needednurses, physicians, technicians, and support staffgoing to come from? How are we going to meetour future needs?

That’s gonna cost money, a whole lot ofspending money. It’s gonna take plenty of moneyto do things right. ✦

David L. Swanson M.D., Board Chairman,Hennepin Medical Society can be reached at:[email protected].

Kathryn A. Vidlock-Granley, M.D.University of Minnesota Medical SchoolFamily PracticeSilver Lake Clinic, P.A.

Michael D. Wengler, M.D.University of Minnesota Medical SchoolOrthopedic SurgeryDowntown Orthopedics, P.A.

Sandy Kay Wiita, M.D.University of Minnesota Medical SchoolFamily PracticeEating Disorders Institute

Wang Ying, M.D.Lingham Medical College, Lingham University-Sun Yat-sen, CantonDiagnostic RadiologyHennepin County Medical Center

ResidentsJ. Kyle Anderson, M.D.University of Minnesota Medical SchoolUrology/Urological Surgery

James George Capes, M.D.University of Illinois College of MedicinePediatrics

Thomas William Flaig, M.D.University of Minnesota Medical SchoolFamily PracticeHennepin County Medical Center

Tara A. Forcier, M.D.University of North Carolina School ofMedicinePediatricsUniversity of Minnesota Medical School

Anna D. Guanche, M.D.Louisiana State University School of MedicineDermatology

Alexander V. Panyutich, M.D.Byelorussia Medical Institute, MinskHematology Oncology

Patrick M. Ridgely, M.D.University of Minnesota Medical SchoolPsychiatry

StudentsMaryam Beltran ShaplandMatthew Robert BraaschChristine M. Braun

Erik Sean CarlsonSarah Elizabeth CarterChristoper G. ChoukalasMichael Edward DarinShelby L. EischensBrant N. HackerBrett Reed Hendel-PatersonGary D. JosephsenJonathan D. KirschLindsay Jane MillerJoseph Igor NovikAmy Elizabeth NygaardMichael T. RhodesChristopher C. RuppKristina E. TrimbleKhuong Minh VuongTy D. WeisAdam J. WeisbrodSteve J. Wisniewski

Chair’s Report(Continued from page 29)

If you have any questions, contactKathy Dittmer, executive assistant,

at 612-623-2885or [email protected]

A Call for DelegatesIf you are interested in serving as aDelegate, please contact us at yourearliest convenience.

A Call for ResolutionsResolutions are due at the HennepinMedical Society no later than Friday,May 17.

HMS CaucusThursday, June 67:00 – 8:30 a.m.Location to be announced.

MMA Annual MeetingWed-Fri, September 25-27, 2002Northland Inn, Brooklyn Park, MN

In Memoriam

JAMES T. GARVEY, M.D., died December17 at the age of 77. He graduated from St.Louis University School of Medicine. Dr.Garvey was a founding partner of theMinneapolis Clinic of Psychiatry andNeurology. He was a past president of theHennepin County Psychiatric Association,and a professor at the U of M Department ofPsychiatry. Dr. Garvey joined HMS in 1955.

JEAN L. HARRIS, M.D., died December14. She was 70. She graduated from theMedical College of Virginia CommonwealthUniversity School of Medicine, Richmond.Dr. Harris was acting mayor of Eden Prairie.She joined HMS in 1994.

JOHN T. PEWTERS, M.D., died at the ageof 89. He graduated from the University ofMinnesota and completed his residency atKing County General Hospital in Seattle.Dr. Pewters was a co-founder of theAmerican Association of Family Practice, anda charter member of the American Board ofFamily Practice. He joined HMS in 1939.

EDWARD SALOVICH, M.D., diedNovember 8. He was 74. He graduated fromthe University of Minnesota Medical School.Dr. Salovich joined HMS in 1961.


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HMS ALLIANCE NEWSK A T H Y L A R S O N

WE, AS MEMBERS of the Hennepin MedicalSociety Alliance, are proud of “our” physiciansand appreciate all they do for the health andwell-being of our community. Besides support-ing the goals of HMSA, which are defined inour mission statement as “working in partner-ship with others, to promote the health and well-being of its members and the communitythrough education, advocacy and service,” wewant to recognize the physicians who continueto deliver excellent health care despite thechanges and challenges of medicine.

One specific way we can honor physiciansthis month is through our fund-raising effortsto support the AMA Foundation. Our currentfund drive is designated as an emphasis to high-light March 30, Doctors’ Day. Again this yearwe’re planning a “no show” event with the goalof simply raising funds to support today’s medi-cal schools and their students. We need to re-member that the medical student of today willbe our physician tomorrow. Donors can choosewhich of the nation’s medical schools to sup-port and choose among a number of funds such

as: The Medical School Scholars’ Fund for medi-cal students in need of assistance; or The Fundfor Better Health which promotes local publichealth programs.

We are looking forward to our possible in-volvement with one of the Kids Cafe sites thiswinter. It will be part of our SAVE (StopAmerica’s Violence Everywhere) project. KidsCafes are located at four Twin Cities’ sites thatprovide nutritious meals to kids plus an oppor-tunity to learn cooking techniques, manners,and other valuable life skills. This is part of anationwide after school nutrition and self-es-teem program for high risk and homeless youthand is part of America’s Second Harvest, a na-tional network of food banks. HMSA memberand WCCO Radio food personality, SueZelickson, founded the local Kids Cafes andrecently was honored by Marquette Catering asthe recipient of the first “Food Humanitarianof the Year” award.

Plans for the 19th annual Body Works(health fair for Minneapolis Public school thirdgraders) are underway and we are in the processof signing up the nearly 100 volunteers that willbe needed for the week of April 8-12. We areonce again grateful to Lutheran Brotherhoodfor generously donating the use of their audito-rium and to the Hennepin Medical Founda-tion for their continued financial support of thisproject. Diane Gayes (952-935-8828) and TrishVaurio (952-929-7360) would appreciate it ifyou called them to volunteer before they needto call you.

An energetic group of HMSA members en-joyed Fitness Day at the Marsh in January. Theday included choices of classes, a healthy lunchand a presentation of a nutrition lecture. It wasa good way to start off the new year. ✦

HMSA members gather at the Marsh for the 6th annual HMSA“Make Fitness Happen.”

Volunteers are neededfor the

If you are intersted in volunteering, please callDiane Gayes (952-935-8828) or Trish Vaurio (952-929-7360).

the week of April 8-12.

19th Annual Body Works(health fair for Minneapolis public school third graders)

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