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Iowa
HEALTH SCIENCES LIBRARY UNIVERSITY OF MARYLAND AT BALTIMORE
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REC’D. not IN CIRC.
January/February 1998
An Iowa Medical Society publication
The loneliest feeling in the world
The IMS/MMIC Liability Support Program helps physicians who are being sued
New easSe*
7.1$
Iowa physicians cite managed care concerns / page 10
Medicare audit activity continues , IMS advocates for members / page 9
IMS wants an individual connection with each member: Strategic planning update / page 13 First-ever retreat for Iowa's women physicians / page 9
" We Thought Mom Needed a Nursing Home"....
What she needed was Assisted Living at the newly expanded Heritage Court, where she receives personalized care from a friendly staff 24hrs. a day. There's no endowment and she had the choice of a large private or companion suite. She even has her own kitchenette with a refrigerator, freezer and microwave. Heritage Court provides light nursing care in a comfortable residential setting. Stop in or call today for a tour.
JJeriStm.
Court
Assisted Living
1499 Office Park Rd., West Des Moines
223-1224 Fountain West
A Continuum of care offered by Colby Properties Health Care Center
/ Medicine
Published by the Iowa Medical Society
January/February 1998 Vol. 88/1
on the hill
IMS asked about managed care expe- riences and got a big response
12
healthy iowans
IMS funds distribu- tion of booklet on surviving domestic violence
8
trends
The Eastern Iowa IPA favors nonexclusivity
12
reimbursement
A new medical director for Iowa Medicare
13
your IMS
How can IMS establish a connec- tion with you?
^ IMS advocate
Medicare audit activity heating up, IMS continues behind-the-scenes advocacy
legalities
You get a subpoena. Should you ignore it? No! Comply? Well, maybe . . .
future world
Nearly 500 physi- cians are on board with IMS patient survey project
your practice
Need more time to learn about HCFA’s new single system exam criteria? You’ve got it!
Iowa
Jonunry/February 1998 An Iowa Medical Society publicat
The loneliest feeling in the world
The IMS/MMIG Liability Support Program helps physicians ivbo are being si
New
<;.Z$
Iowa physicians cite managed care concerns / p
First-ever retreat for Iowa's women physicians / page 9
This month's feature:
1 # When Iowa physicians face a mal- I practice suit , they want to talk with
I \3 someone who's been there
REGULARS
5 president comments 8 changing partners
1 3 awards, obits 14 hot internet sites 1 5 MMIC’s at risk 1 5 how we learn
23
24
your money IMS Alliance news
24 next month
26 professional listing
29 classified ads
Iowa Medicine J anuary/F ebruary
3
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harting a new career course doesn't have to the New World. Staff Care
feel like re-discovering
keeps the adventure of LOCUMS exciting without
the fear of getting lost in the shuffle. We lead the indus-
try with our national medical staffing resources and 'Jt ' ' I*
confidently guide our physicians with experienced
personnel dedicated to service and satisfaction. 5?
a For more information about our LOCUM TENENS call: k.
Alton,
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Western Destinations
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president comments
Let's support
each other.
too
The Iowa Medical Society's major role is advocacy for Iowa physicians, but we need to be advocates for each
other as well.
by Harold Miller, MD
T
he major role of the Iowa Medical Society has been advocacy for the physicians of Iowa. That role remains at the forefront and will be of primary concern for the fore- seeable future. Your Medical Society has been successful in many roles over the past year dealing with due process for physicians, input on regula- tory matters and advocacy on the legislative front. In 1998, we will be looking for more ways to make a difference for Iowa physicians.
At a recent national AMA meeting, I attended a forum where physician leaders from
around the United States were discussing their various challenges, successes and failures.
This was a useful and insightful program allow- ing diverse thoughts to flow from various geo- graphic perspectives as well as several specialty views. Yet the common threads were more sig- < nificant than the individ- ual incidents. The most pervasive common thread was advocacy for physicians.
As physicians and as daily advocates for our patients, we must not lose sight of our most fundamental role of advocacy. We must remain first and fore- most advocates for our col- leagues’ fundamental rights.
We must always advocate for a right to reasonable pri- vacy. We must strongly argue for the right to fair treatment by government, which means protection from unreasonable search and seizure. We must
protect physicians’ right to free speech. This is not an all encompassing list of advocacy positions, but it must remain the nucleus of all advocacy efforts. We may find ourselves in posi - tions of disagree- ment with our colleagues on some issues, but we must always seek to look beyond the disagree- ments and remain advocates for physi- cians’ most funda- | mental rights. This should be true whether we are talk- ing about medical stu- dents, residents or a physician in practice for over 30 years.
We must never lose sight of the fact that supporting each other is the key to advancing the profession of medicine.
Editor’s Note: Due to staff changes , Iowa Medicine was published later than scheduled. We apologize if this has caused any inconvenience.
Dr. Miller is IMS president and a family physician prac- ticing in Davenport.
Iowa Medicine January/February 5
FLEX BENEFITS
A WIN-WIN!
FOR YOU & YOUR EMPLOYEES
Surprisingly, many Iowa medical offices and clinics have yet to install Section 125 Flexible Benefits Plans. Doing so is a “WIN-WIN” proposition.
Often called a “Cafeteria Plan,” this smart business option produces savings for both employees and employers.
If you haven’t considered it, you should!!
Employers may put various benefits in the employee pretax packages: health, life, disability insurance premiums, unreimbursed medical expenses, dependent care expenses, 401(k) savings, and more.
Bernie Lowe & Associates, Inc., has the ability to help you weigh the advantages of a “Cafeteria Plan.” And we have the capacity to assist you in putting into place a plan that’s in full compliance with Section 125. The employer’s tax savings most times will cover the administrative expense of providing this benefit.
If increasing employee spendable pay through reduced taxable income appeals to you and your employees ... if you want to pay a lower employer tax bill . . . then contact us at BLA for the details. As the endorsed insurance administrator for the Iowa Medical Society, we are here to provide informed help.
BERNIE LBWE 5c ASSOCIATES, INC.
Insurance Administrators to Professional Associations & Universities and Colleges
515-222-DB11 1-BBB-942-471B FAX 515-222-B915
27BB Westawn Parkway, Suite 41 □
West Bes Moines. Iowa 5B2B6-1411
March 1 5 - 1 9, 1 998
Common Viral diseases in Primary Care practice:
Keystone, Colorado
rMmM
i #§ f% | j^if
• Principles of Antiviral Therapy
• Principies of Diagnostic Virology
• Clinical Presentations and Diagnoses
• Chicken Pox
• Shingles: Diagnosis and Treatment
• Cytomegalovirus Diagnosis and Treatment
• Counseling Patients About Herpes
• Update on the Other Known Herpes Viruses
• Hepatitis A
DIAGNOSIS,
PREVENTION,
and Treatment
Sponsored by
The Division of infectious Diseases Department of Internal Medicine 1 he University of Iowa College of Medicine
• Hepatitis B
• Hepatitis D, E, F, and G
• Hepatitis C
• Update on Pediatric Viral Vaccination
• Viral Infections During Pregnancy
• Common Childhood Viral Infections
• HIV Infection
• Influenza
• Papillomavirus
• The Future of Antiviral Therapy
For further meeting information, please contact:
Ms. Deborah L. Hatz Coordinator of Programs Continuing Medical Education Division Phone:319/335-8599 The University of Iowa College of Medicine Fax:319/335-8327 300 Medicine Admin. Bldg.
Email: dhhatz@uiowa.edu Iowa City IA 52242-1101
trends
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CONTACTS
Eastern Iowa Health Care, Inc.
Dr. Dale Roberson (319) 365-3127
Dr. Steven Wahle (319) 365-3127
Daniel Langfield (319) 365-3127
EASTERN IOWA HEALTHCARE
EIHC represents its members regardless of employer affiliation or competing contracts.
Eastern Iowa Healthcare, Inc. is the Independent Physicians Association (IPA) representing 345 physicians in Cedar Rapids and sur- rounding counties.
Formed in 1985, EIHC has contracts across the alphabet spectrum: Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Third Party Administrators (TPAs) and Administrative Services Only (AS Os). To date we have not had any OWA (Other Weird Arrangements), but in these changing times it’s a definite possibility.
IPA represents physicians only. It provides a panel pay- ers want for their products. Each contractor makes direct arrangements for hospital and ancillary services. The IPA does not offer a full ser- vice (hospital, etc.) insurance or risk product of its own, preferring to partner with payers who then make other arrangements as coverage requires.
Eastern Iowa Healthcare, Inc. was built on three basic principles that have kept it legal and effective:
Ilt is nonexclusive.
Members may belong to any other organization.
2 Membership is voluntary.
There is total freedom of choice regarding decisions to join.
3 The IPA does not set fees. Purchasers who wish to utilize the IPA’s physician panel can offer fee schedules which may or may not be accepted. There is not one IPA fee schedule, rather a series of schedules depending on a specific contract and risk undertaken by the integrated system.
Over the years, the IPA has been eminently successful
with risk products, returning all withhold funds year after year.
The IPA represents its members regardless of employer affiliation or com- peting contracts. It strives to provide its physicians with a level playing field not captive to any hospital or purchaser.
As we begin 1998, the only sure thing in health care is change. EIHC is totally aware of pressures which could lead to fragmentation and chaos. The physicians who make up the board of directors are deeply involved in planning goals and policies that will allow the IPA to remain a potent force serving the patients of its area for years to come.
o
Medical Associates, Floyd Valley Hospital and the Floyd Valley Medical Foundation have announced the addition of Dr. Sheila Holcomb to the LeMars medical community.
Jon Yankey, MD, has joined the staff of Health Works at Mercy Family Care Networ, Mason City.
David Taylor, DO, has joined Dr. Stephanie Seemuth at Mercy Family Care Network- Northwood.
Call Tina Stoner at the IMS, (MS) 223-1401 or (800) 147-3070 OR email her at kstoner@iowamedicalsociety.org if you have news about physician practice changes.
8 Iowa Medicine January/Februaiy
IMS advocate
Medicare audit activity HEATING UP in Iowa
Medicare audit activity continues and IMS leaders are stepping up efforts to advocate on behalf of Iowa physicians. The fact that audit activity in Iowa has been intense in comparison with other states points to the need for such advocacy.
IMS leadership is meeting regularly with the Part B carrier to ensure that the process is fair to physicians. IMS successfully delayed additional post payment E&M audits until April of 1998. However, the scope of work for all Medicare carri- ers in 1998 will be prepay- ment reviews.
“There is obvious risk for
all of us when there is a per- ception that 40% of Iowa physicians are not providing enough documentation for their levels of coding,” com- mented John Brinkman,
MD, IMS president-elect. Dr. Brinkman has been desig- nated to head up IMS Medicare advocacy efforts.
IMS is also trying to reju- venate interest in Medicare’s
Carrier Advisory Committee (CAG). The Medicare Part B policy-setting committee meets quarterly but only 50% of its physician mem- bers attend regularly, said Dr. Brinkman.
The Office of the Inspec- tor General has assigned three investigators to inves- tigate fraud and abuse in Iowa, Dr. Brinkman added.
WHAT IS IMS DOING ABOUT IT?
•IMS leaders now meet regularly with the Medicare Part B medical director regarding audit procedures.
•IMS introduced a resolution at the AAAA interim Meeting which preserves fairness for physicians in the audit process. The Iowa Delegation's resolution was praised by physicians from across the country.
•The IMS has appointed Dr. Jose Angel, IMS vice president, to rep- resent IMS members on Medicare's Carrier Advisory Committee.
A RECENT TEST AUDIT OF 117 CHARTS OF IOWA PHYSICIANS SHOWED:
correctly coded:
47%
insufficient documentation for the level of coding:
44%
undercoded:
9%
Reaching out to WOMEN PHYSICIANS
Women physicians in Iowa have to balance their personal and profession- al lives every day. A special Iowa Medical Society pro- gram acknowledges their spe- cial needs.
The first-ever IMS Retreat for Women Physicians will be Friday, Oct. 9 - Saturday,
Oct. 10, 1998 at the new West Des Moines Marriott.
“Women physicians have busy careers and are usually the major caretaker for their
families,” comments Kathryn Opheim, MD, IMS Judicial Councilor and m ember of a committee planning the event for women physicians. “Is it any wonder we feel over- whelmed at times?”
The program will focus on communications skills, being a better negotiator in a com- petitive environment, innova- tive practice arrangements, managing the stress of a busy career and personal life and other topics women physi-
cians have mentioned in surveys.
Planning for the retreat for women physicians is in the early stages. If you have program suggestions, please call Chris McMahon at the IMS, (515) 223-1401 or (800) 747-3070. You can fax her at (515) 223-8420 or email cmcmahon@iowame.d- icalsociety.org.
Iowa Medicine January/February 9
on the hill
b Iowa's KID CARE
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key issue for the 1998 Iowa Legislature is matching dollars to support implementation of the federal State Children’s Health Insur- ance Program (SCHIP). SCHIP is designed to help states provide health assistance to low income children. Iowa is eligible for a $32.5 million federal allotment in 1998 if the state provides an $1 1 mil- lion match.
Central to the debate in Iowa will be how to cover eligible children, what benefits to provide and mechanisms for identify- ing eligible
provided under SCHIP include inpatient and outpa- tient hospital services, physi- cian medical and surgical ser- vices, lab, x-ray, well-baby and well-child care (including immunizations).
IMS will work with Iowa Academy of Family Physi- cians, the American Academy of Pediatrics Iowa Chapter and others on this significant state legislative initiative.
Managed care survey gets
BIG response
to 173,000.
Iowa’s SCHIP Task Force recommended Medicaid be expanded to 1 3 3 % of the fed- eral poverty level and that sep- arate private coverage be established for children up to the age of 19 who five in fami- lies with income up to 200% of poverty. This is consistent with the IMS position.
Basic services which must be
The Iowa Medical Soci- ety asked IMS mem- bers for input on their experi- ences with managed care, and they got it in a big way.
An unprecented 234 physicians responded with 161 acknowledging recurring problems with managed care in their practices. Delays in payment were the most frequently cited problem, along with denial of request for care, required resubmission of claims, denial of participation in the plan without adequate justification and uncoopera- tive or poor follow-up.
The survey also asked if physicians have an avenue of recourse available to them.
Sixty-eight of the physicians responding said they have an avenue of recourse; 53 said they have no recourse.
The physicians were also asked if their patients expressed dissatisfaction • with managed care. With lack of choice on health care provider being their top complaint, 147 replied yes. Denial of payment for services/denial of services, lack of direct access to spe- cialty care services and processes and procedure were among their other complaints.
The IMS department of public policy and advocacy conducted the survey to col- lect background information for the legislative session.
1 0 Iowa Medicine January/February
legalities
SUBPOENA:
a mixed
|
A subpoena does |
not |
|
necessarily rule out |
the |
|
need to obtain |
a |
|
patients consent to |
- re~ |
|
lease confidential med- |
|
|
ical records. |
by Jeanine Freeman, JD
A subpoena compels attendance of a wit- ness. A subpoena duces tecum orders you to pro- duce records or documents. Subpoenas of physicians gen- erally seek access to medical records. Physicians must maintain patients’ confidences and can be liable for unautho- rized release of patient infor- mation.
Herein lies the rub: a sub- poena is not the same as patient consent nor is a sub- poena always sufficient legal authority for release of files. Yet, a physician who ignores a subpoena is at legal risk.
A recent Rhode Island case illustrates how not to
respond. In an acrimonious divorce case, the husband’s attorney issued a subpoena for the wife’s prescription history. The pharmacy released the records without notifying the wife’s attorney or getting per- mission. The wife sued and the court granted relief, stat- ing that mere receipt of a sub- poena did not grant carte blanche to publish the infor- mation to third parties.
NEVER IGNORE A SUBPOENA
At the same time, don’t routinely give up the informa- tion requested.
EXAMINE THE SUBPOENA
Who issued die subpoena? Is the request clear? Has the patient given consent or exe- cuted a waiver? If not, is release otherwise legally authorized or required?
WORK OUT DIFFERENCES
Iowa courts recognize two valid competing interests:
1) the sacred trust of patient confidentiality; and 2) the public’s right to discover evi-
dence necessary to prosecute crime or resolve disputes. Taking differences to court is a last resort. Medical offices should keep their attorney apprised.
A current issue in Iowa relates to the subpoena authority of licensing boards. These boards have power to compel production of confi- dential medical records deemed necessary as evidence in connection with a discipli- nary proceeding. The Iowa Supreme Court has decided the burden of establishing the necessity of the information rests with the licensing boards; records and docu- ments must be relevant and essential to establishing the allegations in the complaint.
A question left unanswered is whether a medical office responding to a board-issued subpoena can presume rele- vancy has been established. IMS and the Attorney General’s Office are analyz- ing the impact of these court decisions.
Jeanine Freeman is vice president of public policy and advocacy for the Iowa Medical Society. Information in this column is not intend- ed to be legal advice. Call your attorney with specific questions or concerns.
Iowa Medicine January/Februaiy 1 1
WELLMARK names
rei m bu rsement
NEW Medicare medical director
In an unexpected develop- ment, Dr. Edward Hertko, a retired Des Moines internist, has been named the new Medicare Part B medical director. Dr. Hertko began as the new carrier medical direc- tor on January 5.
According to a Wellmark press release, Dr. John Olds, the current Medicare medical director, will assume new duties in Part A Medicare as medical director for Well- mark’s regional home health business. This is a new posi- tion recently established by
HCFA “to develop medical pohcies for administration of home health and hospice benefits and to target efforts against the rising number of fraud and abuse problems in home health.”
Dr. Hertko has done exten- sive work with diabetes.
During the past year, the Iowa Medical Society Board of Trustees has held a series of meetings with Dr. Olds regarding audits of physician offices for E&M coding doc- umentation. Iowa is the only state in the six-state North
Central Medical Association which has seen both payment audit activity and E&M cod- ing review. (For more about advocacy efforts on behalf of Iowa physicians, see page 9).
“We look forward to work- ing with Dr. Hertko in our efforts to make the audit process fair for providers and to educate physicians on cod- ing and documentation,” commented Dr. Harold Miller, IMS president.
IMS funds distribution of booklet on surviving DOMESTIC VIOLENCE
Victims of domestic
abuse will receive valu- able information when the booklet “The Healing Path: A Guide to Surviving Domestic Violence” is distributed across Iowa.
Funding for publication and distribution of 34,000 copies of the booklet will come from the Iowa Medical Society’s Education Fund.
The IMS Alliance will coordi- nate distribution of the booklet.
The booklet was first pub- fished by the Polk County Medical Society Alliance
through a grant from Healthy Polk 2000 and the Polk County Board of Supervisors. Copies were distributed to hospitals, clinics, law enforce- ment, domestic violence shel- ters, churches and schools.
The IMS Task Force on Family Violence, appointed by the Board of Trustees three years ago, has initiated several projects designed to educate Iowa physicians on diagnosing and treating vic- tims of family violence. The task force is currently work- ing on a video on child and elder abuse reporting.
12
Iowa Medicine J anuary/F ebruary
your IMS
IMS wants an INDIVIDUAL CONNECTION
with every member
The IMS Strategic
Planning Task Force has finalized recommenda- tions for the vision state- ment, core purpose and core values for the Iowa Medical Society. The core purpose and core values will form the foundation for IMS activities and priorities.
VISION STATEMENT
To become the source of lead- ership and the preeminent voice of quality health care for low ans • IMS will have
unquestioned political strength.
* IMS will be the
unquestioned voice for all physicians and patients.
• Every Iowa physician will feel an individual connection to the IMS.
• IMS will be a source of medical advocacy for public health, patients and physicians.
• IMS will be an
organization of highly trained and skilled medical professionals.
CORE PURPOSE
To assure the highest quality health care through our role as patient and physician advocate
CORE VALUES
The care of patients is the foundation of our profession. The physician-patient partnership is unique and essential for high quality care. Freedom to practice the art and science of medicine professionally is essential.
GOALS AND OBJECTIVES
1 Insight and advocacy for physicians and patients
2 Culture of quality improve- ment
3 Political objectives
4 Public health advocacy
5 Relevance of membership and participation
What would it take to make you feel that you have an individual connection with IMS?
We would love to hear your opinion, and we’re making it easy! Please respond in one of four ways:
E-mail Mike Abrams, IMS executive v.p., at:
mdabrams@iowamedicalsociety.org
Fax Mike Abrams at the IMS at (515) 223-8420
Write Mike Abrams at the IMS, 1001 Grand
Avenue, West Des Moines, Iowa 50265
Call Chris McMahon, IMS v.p. of communications, at
(800) 747-3070 or (515) 223-1401
recent
Bipartis
the Fut
dr/huntertuer-
STE pf Dubuqu^recently } president of dWgJMgldemy of Opbl^wmomPkDr. Fuerste is an IMS trustee.
JEROME GREEN- FIELD, MD of Mercy Psychiatric Services Clinic received the award for “Outstanding Achievement in the Area of Psychiatry” at the Community Mental Health Center Association of Iowa annual conference on Oct. 23.
distinctions &
The Iowa Medical Society is now accepting applications for two awards: Physician Community Service Award and Clinic Manager of th e Year Award. To nominate someone, please call Chris McMahon at the IMS (800) 747-3070 for applications. Nominations are due March 2.
I
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DECEASED MEMBERS
L. DEAN CARAWAY, MD, 69, emeritus member, family practice, Amana, Iowa, October 19.
HAROLD KLOCKSIEM, MD, 82, life member, anesthesiology, Des Moines, Iowa, September 2.
WENDELL MEYER, AID, 45, active member, anesthesiology, Cedar Rapids, Iowa, November 4.
F. DALE WILSON, MD, 86, fife member, general surgery, Davenport, Iowa, October 10.
Iowa Medicine January/F ebniary 1 3
future world
surveys off to
SUCCESSFUL start
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Integra Health and Mercy Physician Services of Cedar Rapids are the first physician clinics to sign up for the IMS sponsored patient satisfaction survey project. Two other large clinics have verbally committed, starting the project with nearly 500 physicians.
The IMS selected Health- care Research Systems of Columbus, OH to provide a standard survey tool used in physician offices. A commit- tee of Iowa physicians and clinic managers worked with HRS to develop the survey. This project provides a
statewide bench- mark which physi- cians can use to compare their individual survey responses to those of other Iowa physicians.
HRS has one of the most comprehensive survey data bases to provide comparisons to national survey responses. HRS also provides an option for clinics to install its “Ideas” software, providing the ability to analyze specific data. For example, a clinic could review the data in total, by location, by clinical department or by individual physician.
Patient satisfaction surveys are an important tool. Clinics can identify areas that need improvement, use results for compensating staff or prove quality care to insurance com- panies and employers.
For more information, contact Ed Whitver at the IMS, (515)223-1401,
(800) 747-3070 or ewhitver @iowamedicalsociety. com
* info at www.legis.state.ia.us
V
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D
K
eeping up-to-date on legislative issues has never been so easy. Since the last Iowa General Assembly ended, the legislature’s web site (www.legis.state.ia.us) has S received a makeover.
Information is updated daily, and when the legislature is in _ session, the floor action
Pi | ■■■■■•■*■ report is updated every ]\M 15 minutes.
A quick jump to the Iowa Legislature’s home page
will cut down the time you spend learning about poten- tial laws that will affect your practice. Go to the bill histo- ry to get the full text of the bill, its history through com- mittees and links to legisla- tors supporting the bill. For daily updates of legislative activities, check out the daily action reports and session briefs produced by the leg- islative information office.
Take a look at legislators’
personal pages for informa- tion about current and past committee involvement and links to their e-mail address- es. Interim, study and stand- ing committee pages list committee members with links to their personal pages, meeting minutes and final committee reports for inter- im and study committees.
Administrative rules and the full Code of Iowa are also available.
14 Iowa Medicine January/February
at risk
How thorough and effective are your office follow-up systems?
The underlying cause of many patient injuries and malpractice claims is the fail- ure of physicians and staff to implement or consistently comply with systems to fol- low up on important clinical information. The quality of patient care is undermined and you face almost certain liability if you allow patient information to be overlooked or “fall through the cracks.” Consider taking these actions to close any gaps in your own practice that may injure patients and increase your exposure to liability:
♦ Implement a tracking or logging mechanism to ensure receipt of lab results, x-ray and consultation reports and other informa- tion ordered.
♦ Ensure review of all patient information by hav- ing a physician or qualified
This column is provided by Midwest Medical Insurance Co7npany especially for Iowa Physician. For more information, call Lori Atkinson, MMIC risk management supervisor, at (800) 798-9870 or (51S) 223-1482.
health professional initial reports before filing in the medical record.
♦ Notify patients of all lab results, x-ray and consul- tation reports in a timely manner.
♦ Evaluate significant missed appointments to determine if the patient’s fail- ure to keep the appointment creates increased risk of com- plications or injury.
now we learn
YOU be the JUDGE A
disturbing article in a recent issue of The New Yorker chronicled the career of a physician who has been convicted of poisoning co-workers. He was also implicated in the deaths of a number of patients with whom he had contact.
The story unfolds as in a novel, but the events are real. While the physician pos- sessed appropriate credentials for his residency and practice positions, in each case other- wise responsible physicians and administrators often failed to obtain information about the individual’s past, which resulted in a hiring.
Elaborate verification
protocols, charac- teristic of most hospitals, were not previously fol- lowed. The physician’s engag- ing personality (and often skillful lying) convinced residency directors and other physician administrators of his capacity for the position.
This story, more than many, underlines the necessi- ty of knowing the whole person.
Demonstration of knowl- edge base is inadequate, if the emotional or psychologi- cal stage of the physician is unknown.
This column is written by Dr. Richard Nelson, associate dean, University of Iowa College of Medicine.
Iowa Medicine January/February 15
feature
Being sued:
the loneliest feeling
malpractice claim can be devastating. Knowing
Lori Atkinson is a risk man - agment supervisor with Midwest Medical Insurancce Company , a physician-owned medical malpractice insurer covering physicians, clinics and hospitals in Minnesota, Iowa, Nebraska, North Dakota and South Dakota. Debra McBride is the man- ager of risk managment in AIMIC’s Minneapolis office.
The emotional stress of a
there is emotional sup- port can be a lifesaver.
by Lori Atkinson and Debra McBride
A child was hospitalized with pneumonia and abdominal pain. An x-ray showed free air in the abdomen; an exploratory laparotomy was negative. It was deter- mined a mix-up had occurred when another boy with the same first name was taken for the x-ray by mistake. As that child had just had surgery, the presence of free abdominal air was nor- mal. The distraught surgeon called MMIC and said, "I just operated on the wrong child."
An elderly woman complained of diarrhea, stomach discomfort, weak- ness and poor appetite. Lab test results were put into her chart and given to the physician for review. He noted her glucose level to be 468 and prescribed an oral hypoglycemic medication. Two days later the patient was found in an obtunded state and rushed to the emer- gency department. Her glucose level
was 28. She suffered an occipi- tal infarction secondary to hypo- glycemia. She remained in a persistent vegetative state until her death four months later. Her physician discov- ered the high glucose report on her chart actually belonged to a diabetic patient and had been placed in the wrong chart. A malpractice claim alleg- ing improper treatment was settled with a payment to her sons.
GETTING SUED:
THE HIDDEN COSTS
Negligence. Malpractice. Lawsuit. These are stressful words for physicians.
A study of physicians’ reactions to malpractice liti- gation by Sara Charles, MD, showed over half of the physicians experienced anger, inner tension, depression, frustration, irritability and insomnia. These are the hid- den costs of malpractice.
While you cannot com- pletely avoid the emotional reactions a malpractice claim elicits, there are ways to cope. Understanding the process you face is a first step.
THE MALPRACTICE PROCESS
Medical malpractice is defined as professional negli- gence or the failure to meet the standard of care for your profession. It can be a blatant error such as operating on the wrong patient or body part, or it can be a more sub- tle error, such as failing to note that the wrong lab results were filed in a patient’s chart. Either situa- tion may lead to a claim that you breached the standard of care.
In a medical malpractice claim, the plaintiff must prove you breached the applicable standard of care, usually by using another physician to testify as an expert. This breach must be the direct cause of the patient’s injuries for the patient to recover any money.
In the second case at the beginning of this article, the doctor’s failure to note the
1 6 Iowa Medicine
wrong patient’s lab results were in the chart led to his prescribing an oral hypo- glycemic, causing the woman’s brain injuries and death. Often you know when a mistake has been made, and you can prepare for any con- sequences that follow. The physician who operated on the wrong child, as in the first case cited, knew the moment he left the OR that he faced a claim. Sometimes, however, a patient’s adverse outcome or missed diagnosis will not come to your atten- tion until the claim is brought.
GETTING THE NEWS YOU'RE BEING SUED
The news of a malprac- tice claim could reach you in one of several ways: A letter from the patient or his attor- ney may arrive in the mail or a summons or complaint may be served by your local sher- iff. This marks the beginning of the formal legal action the plaintiffs attorney files the summons or complaint with the court, stating the claims against you. You and your attorney must respond within a specific time. You may also find out about a lawsuit by an article in the local newspaper.
Feelings of anger, betray- al, shock and humiliation are not uncommon. Many physicians report an over- whelming urge to talk to
everyone about the case to try and validate their actions. Others withdraw and hope the whole thing will go away. Getting a handle on your emotions can be critical, as the technical legal process may be long and painful.
THE LAWSUIT
Once the lawsuit is begun, die discovery process begins. Hidden costs of the claim begin to accrue in the form of time because of meetings with lawyers, ans wering questions and telling what happened over and over again.
During discovery, your lawyer will help you answer, under oath, written questions from the plaintiff called “interrogatories.” Expert wit- nesses will testify for you and against you; you will be asked to review each opinion. You will most likely give a deposi- tion where the plaintiff’s lawyer will ask hundreds of questions about your profes- sional background and what happened with this patient.
As the litigation wears on, fear or humiliation may give way to anger and depression. You may just want the whole thing to be over, but fear the embarrassment of settling.
Settlement may be con- sidered at any time during the litigation process. A set- tlement is an agreement between the parties that resolves the dispute. Often,
once discovery is complete, the plaintiff realizes the case is weak and the suit is dis- missed. In other cases, a pay- ment is made on behalf of the physician to resolve the claim. The decision to settle a claim may cause feelings of self-doubt, resentment or failure. These intense feel- ings may impair your ability to evaluate the nature of the claim.
If your case is not settled or dismissed, it will go to trial. If your case goes to trial, your lawyer will expect you to attend every day. The trial may last several weeks, creating intense stress. It can be difficult to listen to the plaintiff’s attorney point out your “mistakes and failings.”
TRIAGE for litigation stress!
In a joint effort with Midwest Medical Insurance Company (MMIC), the Iowa Medical Society has devel- oped the Physician Litigation Support Program. The purpose of the program is to provide information and support to physicians experiencing stress related to the litigation process.
Iowa physicians from various specialties volunteer to serve as one-on-one, confidential helpers. These physicians have all been through a claim or litigation process and also have taken specialized training on how to provide peer support.
A brochure about the program and a litigation stress booklet can be obtained by calling Lori Atkinson at (800) 798-9870 or (515) 223-1482. Ms. Atkinson can also refer you to a physician colleague for emotional support.
Iowa Medicine January/February 1 1
You've just been sued... what next?
An evening program provided by IMS for physicians and administrators to learn • legal process
• clinic and community cautions and control • physician support mechanisms
Watch the IMS July- December practice management calendar for further details.
Des Moines July 21, 1998
Sioux City July 22, 1998
Davenport July 28, 1998
When the trial ends, you may be left with a sense of great loss, no matter the out- come.
TWO TYPES OF REACTIONS
In Dr. Sara Charles’ stud- ies, 96% of the physicians acknowledged some emo- tional reaction to being sued.
A variety of symptoms clustered into two common groups. One group described their symptoms as depressed mood, insomnia, loss of appetite, loss of energy and decreased sex drive.
A second cluster of symp- toms was characterized by feelings of overwhelming anger, frustration, irritability, headache, inner tension, gas-
tric distress, insomnia and depression.
Stress symptoms invari- ably carry over into work and family life. The anger can cause you to view every patient as a potential litigant and negatively affect your patient relationships. You
may be unable focus at work.
Some physicians react by ordering extra tests, referring difficult cases and avoiding patients with the same condi- tion as the plaintiff. The clin- ic staff may also become anxious and irritable.
EFFECT ON SPOUSES, STAFF
Spouses may suffer feel- ings of stress similar to yours. A deep sense of loss, marital isolation, fear of financial vulnerability and social isola- tion can pervade the family.
Many physicians fail to discuss their feelings with family members in an attempt to protect them from the stress. This isolation can cause more stress. You may be instructed not to discuss the case with anyone, but your feelings need to be dis- cussed so you can receive the emotional support to help you cope with the rigors of a lawsuit.
£ You're NOT ALONE
1 Realize you are not alone. Yearly, thousands of other physicians go through what you may be experiencing.
2 Involve yourself in the defense of your case. Help choose your experts, review medical literature and share your feelings with your insurance com- pany representative and
the defense attorney working with you.
3 Become informed about the legal process to decrease the fear of the unknown. Understanding the steps will help deal with the frustration of the slow-moving pace.
4 Share your emotional responses with your spouse, children and any support network you have. While you can’t discuss the actual facts of the case, you can discuss how it’s making you feel.
5 Seek professional counseling if you feel overwhelmed by your reactions. Don’t wait until your emotions interfere with your judgment, leaving you vulnerable to another mis- take.
18 Iowa Medicine January/February
BlueCross BlueShield of Iowa
Provider Service Center: Statewide: 800-562-2218
Des Moines: 515-245-4688
THROCKMORTON SURGICAL SOCIETY IOWA CHAPTER - AMERICAN COLLEGE OF SURGEONS and
IOWA ACADEMY OF SURGERY ANNUAL SPRING MEETING
SURGICAL SYMPOSIUM ON TRAUMA APRIL 17-18, 1998
Iowa Methodist Medical Center - Education Center Des Moines, Iowa
Kennth L. Mattox, M.D., FACS
Professor, Thoracic Surgery Baylor and Uniformed Services Houston, Texas
Donald D. Trunkey, M.D., F.A.C.S.
Professor & Chair, Department of Surgery Oregon Health Sciences University Hospital Portland, Oregon
Maureen F. Martin, M.D., FACS, FRCS
Hepatobiliary Surgery Iowa Health Systems Des Moines, Iowa
Gregory A. Timberlake, M.D., FACS
Director, Trauma Services Iowa Health Systems Des Moines, Iowa
Kimball I. Maull, M.D., FACS
Professor, Department of Surgery Loyola University of Chicago Maywood, Illinois
G. Patrick Kealey, M.D., FACS
Professor, Department of Surgery The University of Iowa College of Medicine Iowa City, Iowa
Matthew Weirsch, M.D.
Orthopaedic Surgeon Des Moines Orthopaedic Surgeons West Des Moines, Iowa
Akella Chendrasekhar, M.D.
Assistant Director, Trauma Services Iowa Health Systems Des Moines, Iowa
Susanne Conrad, R.N., M.S.
Executive Director
Iowa Statewide Organ Procurement Organization Iowa City, Iowa
TOPICS
"Peripheral Vascular Trauma" “Management of Shock/Hypotensive Resuscitation”
"Prioritization of Operations in Trauma Care" "Evaluation of Abdominal Trauma"
"Missed Injuries/Role of Tertiary Surbey" "Intra-abdominal Compartment Syndrome"
"Update on Pelvic Fractures" "Bum Management and Treatment"
"Pancreatic and Duodenal Trauma" "Ventilator Management"
“From Resection to Transplant: Management of Liver Trauma” "Debunking Myths in Trauma Surgery"
ACCREDITATION
Iowa Methodist Medical Center is accredited by the Iowa Medical Society to sponsor continuing medical education for physicians.
Iowa Methodist Medical Center designates this educational activity for a maximum of 9.0 hours (Friday, April 17) in category 1 credit toward the AMA Physicians Recognition Award. Each physician should claim only those hours of credit actually spent in this educational activity. Hours of credit for Saturday, April 1 8 TBA.
COST
Physician Fee $150.00 Resident Fee $35.00
CONTACT
Surgery Education Office, Iowa Methodist Medical Center 1221 Pleasant Street, Des Moines, IA 50309 Phone: (515) 241-4076
'To date, IMS has trained Brians and their
2,300 phys staff concerning E&M docu- mentation. IMS continues to offer customized programs and chart audits on an on- going basis. If you would like further details and pricing for a customized program for your practice, call IMS prac- tice management staff, Barb Pierce or Sheryl Nuzum at (800) 747-3070.
your practice
Need MORE TIME on SINGLE SYSTEM exam criteria? You've got it...
According to a recent letter to Percy Wooton, MD, president of the American Medical Association, HCFA plans to delay enforcement of the new single organ system exam criteria. This delay means that between Jan. and July 1, 1998, physicians may choose which exam criteria (the 1994 criteria or the new criteria) by which the Medicare carrier will judge their documentation.
PRE-PAY EDITS
Effective Nov. 1, 1997 through Aug. 1998, HCFA instructed all carriers to begin pre-pay edits of E&M documentation. HCFA tells carriers which codes to look at, and the carrier then ran- domly selects approximately 150 claims for review each month.
The physician will receive a letter requesting E&M documentation to support the level of service selected for that date of service. In responding, the physician should indicate which exam criteria the physician is using
(i.e., the 1994 criteria or the new criteria and in die case of a specialty exam, which body system). The carrier has 60 days to review the record and approve or “downcode” the service. If your service is downcoded, a special message will be print- ed on the remittance advice and payment reduced.
John Olds, MD, carrier medical director, has agreed to inform physicians if they have undercoded. However, the claim will be paid at the level submitted and die physician would have to resubmit the claim for addi- tional payment. If a physi- cian fails to submit the requested documentation,
the E&M service will be ' - ■ % denied.
POST-PAYMENT AUDITS
In an agreement widi the IMS, the carrier will not per- form any E&M post-pay audits for dates of service prior to April 1, 1998. However, as the carrier audits other services and if a suspected E&M problem arose, the carrier cannot
neglect its responsibil- ities to pay for only medically necessary ser- vices supported by documen- tation and, under these circumstances, may perform E&M audits. This agree- ment allows the IMS addi- tional time to educate physicians about the require- ments.
Last Chance Before Implementation
Single organ system exam criteria
& documentation guidelines-
May 1 9 Module A- multisystem, ENT, GU female, GU male
May 20 Module B: multisystem, eyes, psychiatric, skin
hematologic/lympnatic/immunologic
May 2 1 Module C: multisystem, neurological, musculoskeletal cardiovascular, respiratory
Classes will be held in Des Moines in the evening. Watch for details in the April-June IMS calendar.
Iowa Medicine January/February 21
It takes a professional to show you what the certificate doesn ’t tell you.
A GIA certificate is similar to a report card; it lists and grades a diamond’s color and clarity, but it does not tell you about the brightness or grade the cut of the diamond.
Josephs has a large inventory of high quality diamonds that carry an official GIA certificate; however, it takes more than a GIA certificate to determine if a diamond r truly “ brilliant . ”
At Josephs, our experts point out the specific cut of the diamond as well as other factors that contribute to a diamond’s real worth. With a staff of 16 registered jewelers and certified gemologists, and a selection of exceptional diamonds, Josephs offers more than a GIA certificate; we offer true, honest value.
& %
Josephs
Sixth at Locust Merle Hay Mall Valley West Mall
515-283-1961 515-276-1521 515-223-6044
ic\ MasterCard • Visa • Discover Card
American Express • Josephs Charge Account newyorkctty
your money
keeping
BALANCED
It may be time to count your blessings... from investments that is.
by Jerry Foster
If you have United States equities in your portfolio, you watched many of your investments soar during the past two years. However, other asset classes have not fared so well. Considering these factors, it is probably time to evaluate and to adjust your portfolio.
Most financial advisors suggest adjusting when an asset class is five to 10% out of balance. There is a tempta- tion to resist the discipline of rebalancing because it requires reducing a position that has been doing very well and moving to something that has not done well. This is a simple exercise of “buy low and sell high.”
When deciding whether to
rebalance, you must consider two issues: What will transac- tions and commissions cost and what will the tax conse- quences be? Costs and taxes will compromise the value of rebalancing if they are more than the “drift” amount you are trying to adjust. When rebalancing, you should liqui- date assets held for more than 18 months in order to take advantage of the new capital gains rate. Any losses in your portfolio can be used to offset gain and minimize taxes.
Using ongoing contribu- tions into your portfolio and allocating them to the appro- priate asset class will help keep the portfolio in sync with the designed allocation. In addition, by having divi- dends and income from exist- ing positions go to cash instead of reinvesting, you will create an ongoing cash position that can be used for rebalancing purposes.
If you plan on making charitable contributions, gift- ing highly appreciated assets
will
allow you to avoid the tax on the gain.
Use the cash that would have been gifted to rebalance your portfolio.
The real value of rebalanc- ing depends on whether you PROPERLY allocated your portfolio in the first place.
You can be fanatical in your rebalancing strategies, but if the portfolio isn’t designed to achieve your investment objectives or reflect your risk tolerance, it may be an exer- cise in futility.
After a good year like 1997 and in the midst of a volatile market, it may be a good time to step back and take a good hard look at your investment portfolio and develop a new strategy.
V m
W
Jerry Foster is the CEO of Foster Capital Management, a financial planning and investment company located at IMS headquarters,
(800) 798-1012.
Iowa Medicine January/February 23
Alliance news
break the CYCLE
schools. The Alliance has made great strides, but much more needs to be done. If you would like more infor- mation
write her at 1503 BAve., Oskaloosa, IA 52577.
Baby Think It Over™ has successfully
Let’s Help Break the changed stu- Cycle of Lost Dreams dents’ atti- tudes about parenting which can be the first step in changing their behavior.
Our goal is to break this cycle of poverty and lost dreams.
about how to implement the Baby Think It Over™ pro- gram in your county, our chair, Karen Messamer, would love to discuss the possiblities. Karen may be reached at (515) 673-3751; or
This article was written by Cindy Ehrecke, IMSA presi- dent
O
To address the problem of teenage pregnancy and the resulting cycle of poverty and lost dreams, the Iowa Medical Society Alliance became a leader in implementing the Baby Think It over™ program into school curricula across Iowa.
Baby Think It Over™ is an infant simulator which pro- vides a realistic parenting experience. In less than two years, county alliances raised over $61,000 and distributed over 244 infant simulators to junior and senior Iowa high
next month
♦ Congressman Greg Ganske has won a coveted seat on the Bipartisan Commission on Medicare. What is the commission’s charge, and what is the future of Medicare audit activity in Iowa? Watch for this special feature!
♦ 1998 Annual Meeting details including a full day program on medical technol- ogy, special Town Meeting
on Strategic Planning and an Annual Banquet that will keep your feet tapping.
♦ What are the challenges faced by today’s physician CEOs? Iowa Medicine begins a series of guest columns.
♦ IMS Strategic Planning Task Force has created our vision and core purpose. IMS governance structure is next on their agenda. Watch for a
report on proposals for change.
♦ What’s going on in the Iowa Legislature? IMS is busy pushing its agenda of legislation friendly to physi- cians and patients. Find out what’s going on in this year’s Iowa Legislature and the state of managed care initia- tives pushed by the IMS.
Are you receiving your/TV/iS AdvOCUte?
In addition to Iowa Medicine, all practicing physicians should also be receiving the new IMS newslet- ter the IMS Advocate. This newsletter is being published weekly during the legislative session. If you aren’t receiving yours, please call Chris McMahon at the IMS, (515) 223-1401 or (800) 747-3070.
24
Iowa Medicine January/February
professional listing
ACUPUNCTURE
♦Yang Ahn, MD
Medicenter West 2215 Westdale Drive SW Cedar Rapids 52404 (319) 396-2000
Ahn Clinic for Acupuncture
860 22nd Avenue Coralville 52241 (319) 338-8000
ALLERGY
♦Allergy Institute, PC A.Y. Al-Shash, MD
1701 22nd Street, Suite 207 West Des Moines 50266 (515) 223-8622
4505 SW 9th Street Des Moines 50315
Allergy , Asthma & Immunology
♦Pediatric and Adult Allergy, PC Veljko K. Zivkovich, MD Robert A. Colman, MD
1212 Pleasant, Suite 110 Des Moines 50309 (515) 244-7229
Asthma , Allergy & Immunology
ANESTHESIOLOGY
♦Acute Care Anesthesia Services, LC P.O. Box 515 Ankeny 50021
(515) 964-2772 or (800) 729-7813 Anesthesiologists and CRNAs
CARDIAC SURGERY (ADULT AND PEDIATRIC)
♦ Iowa Heart Center Robert H. Zeff, MD David R. Hockmuth, MD Clay E. Beggerly, MD Mark G. Nelson, MD Bart P. Jenson, MD
411 Laurel, Suite 2250
Des Moines 50314
(515) 243-1010 or (800) 532-1844
1301 Pennsylvania Ave., Suite 115
Des Moines 50316
(515) 263-0900 or (888) 591-9248
1215 Pleasant Street, Suite 414
Des Moines 50309
(515) 241-8033 or (888) 591-9249
CARDIO-THORACIC SURGERY
♦Heart & Vascular Care The Iowa Clinic, PC Hooshang Soltanzadeh, MD Ronald K. Grooters, MD Kent C. Thieman, MD Robert F. Schneider, MD 1440 Pleasant Street, Suite 150 Des Moines 50314 (515) 241-5735
CARDIOLOGY
♦iowa Heart Center David F. Gordon, MD L. A. Iannone, MD Thomas M. Brown, MD Wm. J. Wickemeyer, MD
R. R. Rough, MD
Mark D. McGaughey, MD Timothy T. Hart, MD Magdi G. H. Ghali, MD Craig A. Stevens, MD W. Ben Johnson, MD Joel A. From, MD Margaret H. Verhey, MD Mark A. Tannenbaum, MD Philip A. Bear, DO Jeffrey J. Boyd, MD Amar Nath, MD Steven J. Bailin, MD
S. V. Advani, MD, PhD Robert H. Hoyt, MD Kevin E. Crowe, MD Michael R. Muellerleile, MD Mark S. Bissing, DO Craig A. Stark, MD
David R. Laughrun, MD Denise M. Sorrentino, MD John M. Pargulski, DO Ahmed A. Latief, MD Richard H. Marcus, MD Saima Zafar, MD Marc L. Klein, MD
411 Laurel Street, Suite 1250
Des Moines 50314
(515) 235-5000 or (800) 532-1844
1301 Pennsylvania Ave., Suite 115
Des Moines 50316
(515) 263-0900 or (888) 591-9248
1215 Pleasant Street, Suite 414
Des Moines 50309
(515) 241-8033 or (888) 591-9249
1601 NW 114th Street, Suite 330
Des Moines 50325
(515) 222-1166 or (888) 591-9247
1215 Duff Avenue Ames 50010 (515) 239-4472
405 S. Clark Street, Suite 205 Carroll 51401
(712) 792-6500 or (888) 962-9283
26 Iowa Medicine January/February
♦Midwest Cardiology Consultants, PC Abdul L. Chughtai, MD Manmohan L. Kwatra, MD Prasad R. Palakurthy, MD Martin Aronow, DO Sundeep Das, MD Des Moines Medical Center 1045 5th Avenue Des Moines 50314 (515) 244-1352
♦Heart & Vascular Care The Iowa Clinic, PC Chad L. Williams, MD David Lemon, MD Jay Yans, MD Dirk A. Ver Steeg, MD James P. Lovell, DO Martha J. Stewart, MD Frank N. Haugland, MD, PhD Allan Latcham, MD 1440 Pleasant Street, Suite 200 Des Moines 50314 (515) 241-5988
DERMATOLOGY
♦Robert J. Barry, MD
1030 Fifth Avenue, SE Cedar Rapids 52403 (319) 366-7541
Practice Limited to Disease, Cancer and Surgery of Skin
ELECTRODIAGNOSIS
♦John Milner-Brage, MD
2710 St. Francis Drive, Suite 208 Waterloo 50702 (319) 234-6446
Electromyography & Nerve Conduction Studies Certified by American Board of Electrodiagnostic Medicine
EMERGENCY MEDICINE
♦Acute Care, Inc.
P.O. Box 515 Ankeny 50021
(515) 964-2772 or (800) 729-7813 Comprehensive Emergency Medicine Practice , Locum Tenens, Doctor on Call
♦Emergency Practice Associates
P.O. Box 1260 Waterloo 50704 (800) 458-5003
Specialists in Emergency Staffing & Emergency Department Services
FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY
♦ Otologic Medical Services, PC Guy E. McFarland, ML)
Thomas E VIner, MD Douglas E. Dawson, MD Thomas A. Simpson, MD 540 E. Jefferson, Suite 401 Iowa City 52245
(319) 351-5680 or (800) 642-6217 Maxillofacial, Plastic, Head & Neck Surgery
Satellite Clinics: Washington, Mt. Pleasant, Muscatine, Fairfield and Leon
FAMILY PRACTICE
♦ Acute Care, Inc.
P.O. Box 515 Ankeny 50021
(515) 964-2772 or (800) 729-7813 Locum Tenens Doctor on Call
INFECTIOUS DISEASES
♦ Chest, Infectious Diseases & Critical Care Associates, PC Daniel H. Gervich, MD Daniel J. Schroeder, MD
Ravi JL Vemuri, MD Philip Bruno, DO Infectious Diseases 1601 NW 114th, Suite 347 Des Moines 50325-7046 24 Hours (515) 224-1777
INFERTILITY
♦ Mid-Iowa Fertility, PC Donald C. Young, DO
3408 Woodland Avenue, Suite 302 West Des Moines 50266 (515) 222-3060 Reproductive Endocrinology/Infertility IVF and GIFT Procedures Donor Oocyte Program Artificial Inseminations Reproductive Surgery Menopause Management
NEUROLOGY
♦ Iowa Medical Clinic Neurology
Laurence S. Krain, MD Andrew C. Peterson, MD Erich W. Streib, MD Sallie F. Sun, MD
600 7th Street SE Cedar Rapids 52401 (319) 398-1721 For Drs. Streib and Sim call (319) 366-7990
Neurology, EEG, EMG, Evoked Potentials and Sleep Studies
NEUROSURGERY
♦ Iowa Clinic PC Neurosurgical Services Robert Hayne, MD Thomas A. Carl strom, MD David J. Boarini, MD
1215 Pleasant, Suite 608 Des Moines 50309 (515) 241-5760 John R. Mawk, MD S. Randy Winston, MD
1601 NW 114th St., Suite 134 Clive 50325 (515) 223-3800 Neurological Surgery
♦ Iowa Medical Clinic Neurosurgery
James R. LaMorgese, MD 600 7th Street, SE Cedar Rapids 52401 (319)366-0481
Practice limited to Neurosurgery
♦ Neurological Surgery PC Douglas R. Koontz, MD 411 Laurel Street, Suite A3 50 Des Moines 503 14
(515) 246-1680
OPHTHALMOLOGY
♦ Eye Physicians and Surgeons, LLP
Stephen H. Wolken, MD Robert B. Goffstein, MD Lyse S. Stmad, MD John F. Stamler, MD, PhD
540 E. Jefferson, Suite 201 Iowa City 52245 (319) 338-3623
♦ Wolfe Clinic, PC Russell H. Watt, MD John M. Graether, MD Gilbert W. Harris, MD James A. Davison, MD Norman F. Woodlief, MD Eric W. Bligard, MD David D. Saggau, MD Steven C. Johnson, MD Todd W. Gothard, A1D Dean M. Harms, MD Louis J. Scallon, MD Daniel J. Vos, MD Gregory A. Olson, MD Charles H. Barnes, MD
309 East Church Street Marshalltown 50158 (515) 754-6200
Lakeview Medical Park 6000 University Avenue, Suite 300 West Des Moines 50266 (515) 223-8685
804 South Kenyon Road, Suite 100 Fort Dodge 50501 (515) 576-7777
Sartori Professional Building 516 South Division Street Cedar Falls 50613 (319)277-0103
1245 2nd Avenue SE Cedar Rapids 52403 (319) 362-8032
1114 Duff Avenue Ames 50010 (515) 232-2450
♦ North Iowa Eye Clinic, PC Addison W. Brown, Jr., MD Bradley L. Isaak, MD Randall S. Brenton, MD James L. Dummett, MD Mick E. Vanden Bosch, MD John J. Kownacki, MD
3121 4th Street, SW P.O. Box 1877 Mason City 50401 (515) 423-8861
ORTHOPAEDICS
♦ Iowa Orthopaedic Center, PC ORTHOPEDIC SURGERY
Marshall Flapan, MD Sinesio Misol, MD Joshua D. Kimehnan, DO Timothy G. Kenney, MD Lynn M. T .indaman, MD Jeffrey M. Farber, MD Kyle S. Galles, MD Scott A. Meyer, MD Cassini M. I grain, MD Rodney E. Johnson, MD Martin S. Rosenfeld, DO Teri S. Formanek, MD Stephen M. Naruto, MD Daniel W. Vande Lune, MD PHYSICAL MEDICINE & REHABILITATION Donna J. Bahls, MD Jill R. Meilahn, DO Jacqueline M. Stoken, DO Kurt A. Smith, DO PODIATRIC MEDICINE & FOOT SURGERY
Dennis A. Kessler, DPM 411 Laurel, Suite 3300 Des Moines 503 14 (515) 247-8400
OTOLARYNGOLOGY
♦ Phillip A. Linquist, DO, PC
1000 Illinois Des Moines 50314 (515) 244-5225
Ear, Nose and Throat Surgery, Facial Plastic Surgery, Head and Neck Surgery
Iowa Medicine January/February
27
♦ Otologic Medical Services, PC Guy E. McFarland, MD Thomas F. Viner, MD Douglas E. Dawson, MD Thomas A. Simpson, MD
540 E. Jefferson, Suite 401 Iowa City 52245
(319) 351-5680 or (800) 642-6217 Maxillofacial , Plastic, Head & Neck Surgery
Satellite Clinics: Washington, Mt. Pleasant, Muscatine, Fairfield and Leon
♦ Dubuque Otolaryngology- Head & Neck Surgery, PC James W. White, MD Craig C. Herther, MD Thomas J. Benda, Jr., MD 310 North Grandview Avenue Dubuque 52001
(319) 588-0506
♦ Iowa ENT, PC Thomas A. Ericson, MD Steven R. Herwig, DO Mark K. Zlab, MD
1215 Pleasant, Suite 408 Des Moines 50309 (515) 241-5780 or (800) 248-4443 Satellite Clinics:
Perry, Newton, Oskaloosa, Knoxville
♦ Iowa Head and Neck Associates, PC Robert T. Brown, MD Eugene Peterson, MD Richard B. Merrick, MD Robert R. Updegraff, MD 3901 Ingersoll
Des Moines 50312 (515) 274-9135
♦ Wolfe Clinic, PC Michael W. Hill, MD Daniel J. Blum, MD
309 East Church Marshalltown 50158 (515) 752-1566
Lakeview Medical Park 6000 University Avenue, Suite 310 West Des Moines 50266 (515) 224-9533
Sartori Professional Building 516 South Division Street Cedar Falls 50613 (319) 277-3105
Otolaryngology -Head and Neck Surgery , Facial Plastic Surgery, Allergy
PERINATOLOGY
♦ Des Moines Perinatal Center, PC
Neil T. Mandsager, MD Jeffrey Boyle, MD
3408 Woodland Avenue, Suite 302 West Des Moines 50266
(515) 222-3060
Maternal-Fetal Medicine Routine and Advanced (Level II) Obstetric Ultrasound Genetic Counseling Amniocentesis and CVS Antenatal Testing High-Risk Obstetrical Management High-Risk Deliveries
PHYSICAL MEDICINE & REHABILITATION
♦ Rehabilitation Medicine Associates
Younker Rehabilitation Center 1200 Pleasant Des Moines 50308 (515) 241-6434
2600 Grand Avenue, Suite 102 Des Moines 50312 (515) 283-1570
PULMONARY MEDICINE
♦ Chest, Infectious Diseases & Critical Care Associates, PC Roger T. Liu, MD
Steven G. Berry, MD Donald L. Burrows, MD Michael Witte, DO Gerard A. Matysik, DO 1601 NW 114th, Suite 347 Des Moines 50325-7046 24 Hour (515) 224-1777
VASCULAR SURGERY
♦ Iowa Heart Center Alan R. Koslow, MD Laurie H. Kuestner, MD
411 Laurel Street, Suite 2250
Des Moines 50314
(515) 243-1010 or (800) 532-1844
♦Heart & Vascular Care The Iowa Clinic, PC Douglas B. Dorner, MD David H. Stubbs, MD Anson A. Yeager, MD Douglas W. Massop, MD 1440 Pleasant Street, Suite 100 Des Moines 50314 (515) 241-5700
the
/ru’v/Medicine team
IMS president
Harold Miller, MD Executive editor
Michael Abrams Managing editor
Christine McMahon Production coordinator
Tina Stoner
Iowa Medicine, Journal of the Iowa Medical Society (ISSN 0746-8709), is published bi- monthly by the Iowa Medical Society. Subscription price:
$25 per year. Periodicals postage paid at Des Moines, Iowa and at additional mailing offices. Postmaster: Send address changes to Iowa Medicine, Journal of the Iowa Medical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. Advertising:
Tina Stoner, Iowa Medicine, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone (515) 223-1401. Editorial content: The Society is unable to assume responsibility for the accuracy of that which is sub- mitted. Editorial inquiries should be directed to the Editor, Iowa Medicine, 1001 Grand Avenue, West Des Moines, Iowa 50265.
Copyright 1998 Iowa Medical Society.
28 Iowa Medicine January/February
classified ads
Family Practi ti on er C re ston-
BC/BE FP to join eight-physician multispecialty practice in south- west Iowa. Competitive salary, fringes, bonus and a great place to raise a family. Excellent schools, great recreational areas, limited call duty and you have a vote in the operation of the clinic. Send CV or call Mike Brentnall, admin- istrator, Creston Medical Clinic, PC, 526 New York Avenue, Creston, Iowa 50801; (515) 782- 2131 or fax (515) 782-6425.
Internal Medicine Opportunity
Looking for an exciting practice opportunity in a premier rural set- ting? If you would like the anemi- ties of a small town, but want the benefits of the big city, Grinnell is the answer. We are a dynamic, thriving community and the home for Grinnell College, one of the premier liberal arts institutions in the US.
Grinnell Regional Medical Center is an 81 -bed, JCAHO accredited institution with a staff of 26 physicians. Practice oppor- tunities are available in the recent- ly completed 36,000 sq. ft. medical arts building, which houses a 6,000 sq. fit. fitness and rehabilita- tion center. A variety of practice arrangements are available.
vGrinnell
Regional
Health Care for Life
Todd C. Linden, President 210 Fourth Avenue Grinnell, Iowa 50112 (515) 236-2300
Not Just Another Recruitment Ad— -Opportunities at North Memorial owned and affiliated clinics will give you a shot of adrenaline because we practice in a care management environment that FPs, IMs and OB/GYNs thrive on. Guide your patients through their entire care process at one of our 25 clinics in urban or semi-rural Minneapolis locations. Interested BC/BE MDs, call (800) 275-5790 or fax CV to (612) 520-1564.
Family Physicians— -If you think that you can find happiness in a small town in Iowa, please contact me. Jerry Hess, Mercy Family Care Network, 1000 4th Street, SW, Mason City, Iowa 50401.
(5 15) 422-5551, fax (5 15) 422- 6388, toll free (888) 877-5551.
Family Practice Faculty Position-Established, communi- ty-based, University-affiliated, 6-6- 6 residency enjoying strong hospital and medical community support seeks a residency-trained board-certified physician. Position includes teaching and patient care, including obstetrics.
Administrative responsibilities commensurate with interest and experience. Competitive salary and benefits. Letter and CV to John Sutherland, MD, Northeast Iowa Family Practice Residency Program, 2055 Kimball Avenue, Waterloo, Iowa 50702. (319)272-2532.
United States Southwest
A major metropolitan city in the culturally rich environ- ment of the sunny American southwest. Position available now. A private neurosurgical clinic is looking for a BE/BC associate with broad neuro- surgical training and/or expe- rience. Stereotactic neuro- surgery both fixed frame and frameless plus radiosurgery are presently being per- formed. Additional training or experience in spinal surgery and instrumentation tech- niques would augment cur- rent selection review. Please send CV and cover letter to:
Mitchell Smigiel, MD, FACS Charles Chang, MD 1600 Medical Center Drive Suite 400
El Paso, Texas 79902
LOCUM TENENS
FAMILY PRACTICE WITH OB
Family practice board certified physi- cian. recent Kansas University Medical Center graduate with the sur- gical background available for short term practice coverage which may include ER call, clinics and inpatient services with or without OB for up to two weeks at a time. Liability insur- ance provided. Iowa license current. Please contact:
Vadim Braslavsky, MD 7800 England Dr., #101 Overland Park, Kansas 66204 Telephone (913) 383-3285
Internet address and information: http://www.concentrie.net/~Locumdr/l .htm E-mail: locumdr@pol.net
Mankato Clinic, Ltd.— A pro- gressive group practice is seeking additional BE/BC physicians in the following specialties: acute/ urgent care, family practice, oncol- ogy/hematology, orthopedic surgery and general internal medi- cine practice. The Mankato Clinic is a 70-doctor multispecialty group practice in south central Minnesota with a trade area popu- lation of +250,000. Guaranteed salary first year, incentive there- after with full range of benefits and liberal time off. For more infor- mation, call Roger Greenwald, executive vice president, at (507) 389-8500 or Byron C. McGregor, medical director, at (507) 389-8548 or write 1230 East Main Street, P.O. Box 8674, Mankato, Minnesota 56002-8674.
Staff Physician— Student Health Services. To provide primary med- ical care for students attending the University of Iowa. Interest and knowledge of college health issues including sports medicine is desir- able. BE/BC in family medicine, internal medicine or pediatrics is preferred. Salary commensurate. Send letter of application and resume to Mary Khowassah, MD, Student Health Service, The University of Iowa, Iowa City, Iowa 52242. The University of Iowa is an Affirmative Action/Equal Opportunity Employer. Women and minorities are encouraged to apply.
Iowa Medicine January/February 29
Internal Medicine— Iowa City Internal Medicine is seeking a gen- eral internist. We are a group of nine internists with a well-estab- lished east-side outpatient clinic and are on staff at Mercy Hospital. The 70,000 inhabitants of the Iowa City area enjoy the advan- tages of a comfortable small-town atmosphere in combination with the University’s cosmopolitan diversity of culture and recreation- al opportunities. Many 19th centu- ry homes grace the residential area of Iowa City and entire neighbor- hoods have joined efforts to pre- serve and improve them. Iowa City has over 500 acres of parks graced with swimming pools, nature trails and picnic facilities. The Coralville Reservoir, Lake Macbride and Kent Park are major recreation centers near the city. Education is Iowa City’s heritage. Iowa City’s population has the highesst per- centage (38.6%) of college educat- ed adults of any city in the US.
For additional information please contact Steve Cooper, Administrator, (319) 338-7862 or evenings (319) 351-3456 or Dr. Craig Champion (319) 338-7862 or evenings (319) 338-7097.
Oncologist, Urgent Care, ENT, Dermatologist
There is an immediate opening at Brainerd Medical Center for the following specialties: oncology, urgent care, ear, nose and throat and dermatology.
Brainerd Medical Center, P.A.
• 36-physician independent multispecialty group
• Located in primary service area of 50,000 people
• Almost 100% fee-for-service
• Excellent fringe benefits
• Competitive compensation
• Exceptional services available at 162 -bed local hospital, St. Joseph’s Medical Center
Brainerd, Minnesota
• Surrounded by the premier lakes of Minnesota
• Located in central Minnesota less than 2 1/2 hours from the Twin Cities, Duluth and Fargo
• Large, very progressive school district
• Great community for families
Call Administrator collect: Curt Nielsen
(218) 828-7105 or (218) 829-4901 2024 South 6th Street Brainerd, Minnesota 56401
WHAT ARE
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Marshalltown, Iowa— State-of- the-art facilities and exceptional quality of fife with practice oppor- tunities available in orthopaedic surgery, internal medicine and pediatrics. Pursue one of these opportunities and obtain privileges at the community’s 176-bed facility that has been awarded accredita- tion with commendation by the JCAHO. An outstanding compen- sation package is available for each of the opportunities and the hospi- tal offers educational loan forgive- ness, interviewing and moving expenses. For additional informa- tion contact Jill Lutes at (800) 542-0014, Marshalltown Medical & Surgical Center, 3 South 4th Avenue, Marshalltown, Iowa 50158
30 Iowa Medicine January/February
• Emergency Medicine • Locum Tenens
• Ambulatory Care Clinic System • Anesthesia
ACUTE CARE, INC.
FOR MORE INFORMATION, PLEASE CALL 800.729.7813 OR 515.964.2772, OR FAX YOUR CV TO 515.964.2777 FOR CONSIDERATION, e-mail address: melissam@acutecare.com home page: http://www.acutecare.com
It’s a bold new world of health care. A host of innovative health care relationships fill the landscape, and each requires distinct direction and coverage for liability expo- sures. Our capabilities encompass unique solutions to help smooth the way for physi- cian groups, physicians, and an assortment of health care alliances.
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foiv/Medicine
March/ April 1998 An Iowa Medical Society publication
university of maryuand AT
Baltimore
of time?
The Bipartisan Commission is charged with saving Medicare , and Rep. Greg Ganske lobbied hard to be chosen as a member
The joys (and sorrows) of managing physicians / page 8
Who will be held responsible for managed care decisions? / page 1 1
IMS comments on pharmacists' proposal for immunization reimbursement / page 18
" We Thought Mom Needed a Nursing Home"....
What she needed was Assisted Living at the newly expanded Heritage Court, where she receives personalized care from a friendly staff 24hrs. a day. There's no endowment and she had the choice of a large private or companion suite. She even has her own kitchenette with a refrigerator, freezer and microwave. Heritage Court provides light nursing care in a comfortable residential setting. Stop in or call today for a tour.
Assisted Living
1499 Office Park Rd., West Des Moines
223-1224 fountain West
A Continuum of care offered by Colby Properties Health Cate Center
M:/ Medicine
Published by the Iowa Medical Society
March/April 1998 Vol. 88/2
8
trends
special feature
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Managing a group of physicians takes skill and diplomacy, says this physician CEO |
The IMS opposes a proposed rule to give pharmacists Medicaid reim- bursement for immunizations |
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IMS advocate |
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| 2 healthy iowans |
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Your managed care |
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concerns have been |
IMS Committee on |
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shared with the |
Public Health |
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insurance |
supports name- |
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commissioner |
specific HIV reports |
on the hill
IMS active on Medicaid increase, SCTIIP and other issues in Iowa Legislature
14
future world
Getting your practice computers ready for the millennium and online telemedicine information
13
your IMS
IMS Task Force on Strategic Planning envisions a more member-friendly IMS
legalities
When it comes to managed care decisions, whose liability is it, anyway?
12
reimbursement
Wellmark hopes to offer Medicare managed care products in Iowa
your practice
Hardware melt- downs can be catastrophic — and it happened to this Iowa practice
This month's feature:
Greg Ganske persisted , and he got what he wanted ... a seat on the National Bipartisan Commission on the Future of Medicare
REGULARS
5 president comments
8 changing partners
1 3 awards, obits 15 MMIC’s at risk 15 how we learn
23 your money
24 IMS Alliance news 24 next month
26 professional listing
29 classified ads
Iowa Medicine March/April 3
IOWA MEDICAL SOCIETY • EXPERIENCE THE PARTNERSHIP
An organization that advocates for physicians and patients?
Julius Conner, MD Polk County Department of Public Health Des Moines
That’s right! The core purpose of the Iowa Medical Society is to assure the highest quality health care through its role as physician and patient advocate. All Iowa physicians care about the well-being of Iowans, no matter what other professional and personal concerns affect their day-to-day practices. Working together as partners on long and short-term projects, IMS physicians are able to contribute to the overall health of Iowa patients.
"The Iowa Medical Society has proven a great resource for educating physicians and patients about public health concerns."
Julius Conner, MD
IMS seeks opportunities to educate physicians and patients about public health concerns. Your membership dues this year have helped pay for a new video that will train mandatory reporters to recognize the signs of dependent adult and child abuse. Physician contributions to the LMS Education Fund helped support the distribution of 7,500 domestic abuse victim education and intervention booklets.
"The Iowa Medical Society brings into focus important public health issues such as consumer access to medical care and quality of care in managed care contracts. IMS also promotes important legislative actions which will impact the health of Iowans."
Rizwan Shah, MD
Concern for public health extends to ensuring that Iowans have access to quality medical care. Before managed care products even hit the Iowa marketplace, the IMS worked with other health care organi- zations and Iowa insurance companies to create the “Principles of Agreement,” a document which protects the rights of patients as well as physicians under managed care. Last year, patients also received the right to choose their physicians thanks to a point-of-service law proposed and supported by the IMS. The new IMS Committee on Public Health takes advantage of the partnership of IMS members to further support public health advocacy activities.
Rizwan Shah, MD Pediatrician \ Blank Children's Hospital Des Moines
Experience the partnership! Contact Jeanine Freeman at (800) 141-3010 for more information on how you can participate in IMS public health initiatives. Not a member ? Contact Sheryal Westbrook at (800) 141-3010 for membership information.
TA/TC
president comments
A salute to your IMS Task Force on Strategic Planning
The IMS Task Force on Strategic Planning put in plenty of long hours cre- ating a new IMS.
by Harold Miller, MD
A team of your fellow physicians gave freely of themselves recently to conclude a strate- gic planning effort for the Iowa Medical Society. I cer- tainly appreciate the signifi- cant sacrifices made by the members of the Task Force on Strategic Planning. They spent 12 intellectually chal- lenging yet fall work days on the project.
Strategic planning and reorganization is a long and complicated process requir- ing input not only from the leadership and members of our organization, but also from interested and concerned outside stake- holders. The Task Force on Strategic Planning heard
those many voices as they carried out their delibera- tions.
This group of physicians reached consensus on many issues. They represented dis- parate medical specialties, different modes and styles of practice as well as various geographic locations. Varied opinions and honest dis- course evolved to unanimity of voice on a number of issues, none more important than the espousal of our pur- pose and values.
This unity of voice created the following statements.
OUR CORE PURPOSE
To assure the highest qual- ity of health care in Iowa through our role as physician and patient advocate.
OUR CORE VALUES
IThe care of patients is the foundation of our profession.
2 The physician-patient partnership is unique and essential for high quality
3 The freedom to practice the art and science of medi- cine professionally is essential.
These statements are more than mere verbiage. Evolving from that source, they repre- sent heartfelt ideals and the spirit of our organization.
I have been proud to be a part of the strategic planning effort which is finishing its work product. All of us who are members of the Iowa Medical Society should be thankfiil to the Task Force on Strategic Planning and the work done for us. Please feel free to give them your input.
I also urge you to attend the Town Meeting on Strate- gic Planning at 10 a.m. Sat- urday, April 1 8 at the downtown Des Moines Mar- riott, Des Moines, Iowa.
This is your chance to give us your perspective.
Dr. Miller is IMS president and a family physician prac- ticing in Davenport.
Iowa Medicine March/April 5
FLEX BENEFITS
A WIN-WIN!
FOR YOU & YOUR EMPLOYEES
Surprisingly, many Iowa medical offices and clinics have yet to install Section 125 Flexible Benefits Plans. Doing so is a “WIN-WIN” proposition.
Often called a “Cafeteria Plan,” this smart business option produces savings for both employees and employers.
If you haven’t considered it , you should!!
Employers may put various benefits in the employee pretax packages: health, life, disability insurance premiums, unreimbursed medical expenses, dependent care expenses, 401 (k) savings, and more.
Bemie Lowe & Associates, Inc., has the ability to help you weigh the advantages of a “Cafeteria Plan.” And we have the capacity to assist you in putting into place a plan that’s in full compliance with Section 125. The employer’s tax savings most times will cover the administrative expense of providing this benefit.
If increasing employee spendable pay through reduced taxable income appeals to you and your employees ... if you want to pay a lower employer tax bill . . . then contact us at BLA for the details. As the endorsed insurance administrator for the Iowa Medical Society, we are here to provide informed help.
BERNIE LOWE & ASSOCIATES, INC.
Insurance Administrators to Professional Associations & Universities and Colleges
515-EE2-BB11 1-8BB-94E-471B FAX 515-EEE-B915
E7BB Westown Parkway. Suite 41 □
West Bes Moines. Iowa 5BE66-1411
Iowa Medical Society
Annual Meeting
A New
Downtown Des Moines Marriott Friday April 1 7 - Sunday April 1 9
Managed care panel of payers
You have questions?
They have answers.
Friday April 17 - 1-2:30 p.m. - Downtown Des Moines Marriott
Managed care is on the forefront of national and state policy debates. According to a recent survey conducted by the Iowa Medical Society, many Iowa physicians have concerns regarding certain payer policies and procedures. Here’s your opportunity to hear from and question the managed care organizations. Our panel will include:
John Deere Health Care, Inc.
Charles Parsons , vice president of operations Richard Bartsh, MD, executive vice president and chief medical officer
Principal Health Care of Iowa, Inc.
Lou Garcia , executive director
Medicaid
Don Herman , administrator Harry Gill , MD, program manager
Wellmark Health Plan of Iowa, Inc.
Peter Roberts, president and chief executive officer Eric Book, MD, senior vice president and chief medical officer
Richard Calkins, JD will facilitate the panel. Calkins has over eight years experience in mediating various disputes from breach of contract cases to disputes between insurance carriers. There will be a question and answer session.
Fax your questions NOW to Cheri Jensen at the IMS at (515) 223-8420 (no cover sheet necessary) to help guide the presentation & question and answer session.
Iowa Medicine March/April 7
trends
LEADERSHIP {HIbIMIW
CD
CD
C
• I"
c
•
_g
D_
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The physician CEO rarely issues a directive which is obediently followed by the physician partners.
11
Dr. Thomsen is the president and CEO of the Mason City Clinic. He has served in that role for three years on a full time basis.
PHYSICIAN
An Iowa physician CEO describes the joys (and sorrows) of managing a group of physicians.
by Timothy Thomsen, MD
Unlike corporate
America, an environ- ment where the CEO says “jump” and people ask “how high?,” the physician CEO rarely issues a directive which is obediently supported and followed by the physician partners. Rather he or she will find that the group members will be upset, agi- tated and unsupportive. Physicians want to partici- pate in the decision making process. Appreciating this is critical to understanding physician leadership.
The crux of the Physician Leadership Dilemma is the decision-making process. All physicians are intelligent and have mastered an informa- tion processing method that is highly effective for medical decisions. The method which produces a diagnosis or a decision requires the colla- tion of many kinds of data. In
business decisions, physicians naturally resort to their med- ical decision-making skills. A physician business decision requires large amounts of data presented over a period of time and is often con- founded by conflicting frag- ments of information or opinions of fellow physicians. Most opinions are generated with considerable bias and little valid data. A physician leader must commit incredi- ble time to listen, understand and communicate in order to effectively lead and achieve closure on a decision.
One of the major responsi- bilities of a physician leader is physician development. All physician leaders should spend at least one hour per physician annually in a pri-
vate, relaxed conversation. This means spending time with every physician, not simply the ones you know and enjoy. When a physician stops in your office or calls, respond immediately. Rarely do physicians allow them- selves the luxury of unstruc- tured one-on-one conver- sation and you must capital- ize on this. Through these conversations the CEO gains knowledge, credibility and indispensability; the physi- cian learns to establish boundaries, resolve conflicts, solve problems and grow personally and professionally.
As the physician leader, you are the only one with the power to take on the tough, thankless physician issues. Relationships are your job!
Joseph Lohmuller, MD accepted the position of medical director for Genesis Trauma Services.
Don Rotenberg, MD, Robert Savereide, MD and Neil McMahon, MD have joined Covenant Clinic in Waterloo.
Jose Angel, MD accepted the position of medical director for Mercy Central Internal Medicine Clinic, Des Moines.
Call Tina Stoner at the IMS, (SI 5) 223-1401, (800) 747-3070 or email her at kstoner@iowamedicalsociety.org if you have news about physician practice changes.
8 Iowa Medicine March/April
IMS advocate
Managed care survey * COMMISSIONER'S DESK
Results of the managed care survey of Iowa physicians have been turned over to Iowa Insurance Com- missioner Therese Vaughan.
The survey, which was answered by over 250 physi- cians, shows widespread con- cern over denials of requests for care, late payments, repeated resubmission of claims and other problems.
IMS staff met with Com- missioner Vaughan to reiter- ate concerns voiced in the surveys, asking her to study physician responses. Man- aged care resolutions passed by the 1997 IMS House of Delegates were also shared with Commissioner Vaughan.
Ms. Vaughan said that man- aged care is top on her agenda for the year. She has asked Iowa payers to formally respond to questions regard- ing their policies.
In response to concerns expressed by IMS members in the survey, a special panel of payers has been arranged for the IMS Annual Meeting on Friday, April 17. Physicians may submit questions to the panel prior to the meeting. (See page 7.)
The panel of payers will include executive staff from Principal Health Care of Iowa, Inc., John Deere Health Care, Inc., Wellmark Health Plan of Iowa, Inc. and
Medicaid.
Also on the managed care front, health care organizations and payers which negotiated the Prin- ciples of Agreement for Managed Care recently met to work on the 1998 version of the fluid docu- ment. The IMS helped negotiate the Principles two years ago because a gentleman’s agreement — if adhered to voluntarily by all parties — was preferable. However, IMS has not ruled out the possibility of other initiatives if the agreement proves ineffective.
Legislators, IMS Board shed light on ISSUES
Sen. John Redwine (R- Sioux City), Iowa’s only physician lawmaker, says he is “amazed at how much med- ical business we do in the Legislature,” and urges his col- leagues to talk with their legislators about health care issues.
“Believe me, they respect your opinions,” the Sioux City family physician told the
IMS Board of Trustees during a special dinner program with legislators.
Legislators
expressed mixed views of the State Children’s Health Insurance Program, particularly about expanding Medicaid to cover more chil- dren. Some legislators hesi- tate to commit to the pro- gram when “federal funding could dry up at any time.”
Most of the leg- islators said they support SCHIP and feel the pro- gram will probably be funded through a public/private partnership.
Rep. Chuck Gipp (R-Decorah) advised the IMS Board to “get more members of your profession” to run for legislative seats.
“Your expertise is needed,” he said.
Legislators attending IMS program
♦ Sen. Mary Kramer (Senate president)
♦ Sen. Stewart Iverson (Senate majority leader)
♦ Sen. Mike Gronstal (Senate Minority leader)
♦ Rep. Chuck Gipp (representing the House majority)
♦ Rep. Dave Schrader (House minority leader)
♦ Sen. John Redwine (physician legislator)
♦ Bob Rafferty (Governor's chief of staff)
Iowa Medicine March/April 9
a
IMS has drafted bill language to lessen legal burdens of reporting spontaneous terminations of pregnancy.
11
on the hill
on a MENU of issues
At press time, the Iowa Legislature was nearing the first funnel deadline when bills in committee are consid- ered dead.
MEDICAID REIMBURSEMENT
Great news for physicians is the likely passage — AT LAST! — of an increase in reimbursement. The recom- mended 2 % increase is modest but an improvement over the zero increases since 1990.
MANAGED CARE
Legislation similar to the managed care liability law will be introduced, according to lawmakers. Significant action is not likely this session. IMS continues to work on the reg- ulatory front and to negotiate with the industry itself. (See page 9.) Under federal legisla- tion introduced by Rep. Charles Norwood (R-GA), employer-sponsored plans would not be exempt from lia- bility under ERISA.
HEPATITIS B VACCINATIONS
Senate File 2177, intro- duced by Sen. John Redwine (R-Sioux City), requires evi- dence of hepatitis B immu- nization prior to the child’s entry into school; a study bill on the House side would require evidence prior to entry
in secondary grades. The pub- lic health goal of these bills is laudable although IMS has questioned the need for a mandate, since 81% of Iowa infants have been immunized. IMS supports public health funds to help parents meet the mandate.
STATE CHILDREN'S HEALTH INSURANCE PROGRAM
IMS has formed a working group including the Iowa Academy of Family Physi- cians, the Iowa Chapter of the American Academy of Pedi- atrics, IH & HS, U of I, and Iowa Health Systems/Blank Children’s Hospital to thrash out recommendations for SCHIP in Iowa. IMS is meet- ing with key legislators, regu- lators and others to collabo- rate on a final design. If Medicaid is expanded to 1 3 3 % of poverty, a move not fully supported by legislators, eligible children in that income range could be cov- ered by July 1; SCtHP-eligi- ble children served outside Medicaid likely could not be enrolled until January 1999.
REPORTING OF SPONTA- NEOUS TERMINATIONS OF PREGNANCY
IMS has drafted bill lan- guage to lessen legal burdens
of reporting spontaneous ter- minations of pregnancy. The Department of Public Health (DPH) wants this data for epi- demiological purposes.
HIV NAME REPORTING
Senate File 2161 requires reporting of positive HIV test results to the DPH by name or unique identifier. Anony- mous testing would no longer be available. Contact and noti- fication would be done in the same way as other sexually transmitted diseases. IMS sup- ports this legislation. ( Seepage 12.) Over 30 states require HTV-positive reporting by name or identifier.
PRUDENT LAYPERSON STANDARD FOR EMERGENCY SERVICES
Rules have been filed by the commissioner of insurance adopting the prudent layper- son standard for emergency services. HMOs are required to pay for emergency services no matter who provides them.
1 0 Iowa Medicine March/April
lego I ities
PATIENT CARE DENIALS:
who's liable, an
Courts and state legisla- tures are redefining who is liable when treatment decisions by health plans prove bad for patients.
by Jeanine Freeman, JD
Debates on managed care liability in Congress and state legislatures have spread to the courts.
The Texas “Managed Care Responsibility Act” says health plans must exercise ordinary care when making treatment decisions. Similar legislation likely will be intro- duced this year in Iowa.
In a landmark California decision, a patient claimed denial of a requested hospital stay resulted in amputation of her leg. The court found no liability, in part because the physician did not appeal the denial.
The same court later said
discharge of a patient (denial of continued inpatient stay for a depressed patient who later committed suicide) does not rest solely with the physician and that the plan’s decision was a substantial factor in the patient’s death.
NO RECOURSE WITH ERISA
Employment Retirement Income Security Act (ERISA) is oft-cited as a barrier to recovery against any employ- er-sponsored health or wel- fare benefit plan. A prolifera- tion of ERISA benefit plans has left many employees absent recourse except for limited remedies afforded by federal law.
The answer may turn on defining the nature of utiliza- tion review. In a 1992 case involving the death of an unborn child following denial of inpatient care for the mother by an ERISA plan, the court found utilization review to be part and parcel to benefit determinations exempt from state court reach under ERISA. Three years later, though, the Supreme
Court poked a hole in the ERISA dike by upholding a state surcharge imposed on ERISA plans, finding that state laws of general applica- bility are not preempted sim- ply because they also affect ERISA plans. Do state negli- gence laws affect ERISA plans or do they strike at the heart of benefits administration, a preempted activity?
Legal challenge to the Texas law is asking this ques- tion. Recent cases have found that quality of care challenges are not precluded by the ERISA preemption.
FEDERAL LEGISLATION INTRODUCED
Federal legislation intro- duced by Rep. Charles Nor- wood (R-Georgia) would clarify that plan liability is a matter of state law. Employ- ers say the encroachment on the ERISA preemption will increase costs and force them to drop plans, which will hurt employees.
The debate continues.
Jeanine Freeman is vice president of public policy and advocacy for the Iowa Med- ical Society. Information in this column is not intended to be legal advice. Call your attorney with specific ques- tions or concerns.
Iowa Medicine March/April 1 !
reimbursement
<
£
The IMS Committee on Publi< Health believes HIV/ AIDS should be treated the same way other sexually transmitted diseases are treated .
managed care products
Wellmark Health Plan of Iowa, Inc. is seek- ing HCFA approval to sell two Medicare managed care products to Iowa seniors. If approved by HCFA, Well- mark will begin marketing in the fall of 1998.
Wellmark plans to sell two products: 1) a basic product with no premium (and higher member copayments) and 2) a value-added product with prescription drug coverage for a monthly premium.
HCFA requires that Medicare managed care be
sold in contiguous counties. Wellmark will begin by mar- keting to seniors in two tar- geted geographic areas: 1) Polk, Boone, Dallas and War- ren counties and 2) Linn, Cedar, Iowa, Johnson, Jones and Benton counties.
Primary care providers will be paid on a capitation basis and specialists will be paid according to the Medicare fee schedule.
As a health improvement company, Wellmark wants to work closely with physicians and hospitals to provide a
healthy iowans
name-specific HIV reports
eporting of HIV/AIDS J-Vjn Iowa was considered at a recent meeting of the Iowa Medical Society’s new Committee on Public Health.
The 15 -member commit- tee is chaired by Larry Beaty, MD. Representatives of state government and the U of I are observers.
Both the committee and the IMS Board of Trustees have gone on record in sup- port of an amendment to Iowa law that would require name identification for HIV-
positive reports to the Department of Public Health.
Heterosexual women whose partners are IV drug users are particularly at risk of contracting AIDS.
According to a widely- reported study published in the Archives of Internal Medi- cine in February, four of every 10 HIV-infected people do not inform sexual partners about their condition. Nearly two-thirds of those don’t use a condom.
The effectiveness of treat-
viable option for Medicare bene- ficiaries. The products will focus on prevention and well- ness as well as the traditional illness benefits included in Medicare Parts A and B.
As Medicare managed care risk contracting makes an entrance into Iowa, the IMS will work with Wellmark and other experts to educate Iowa physicians and their staff regarding this important con- tracting decision.
ment augers in favor of early contact and intervention.
The IMS Committee on Public Health believes that HIV/AIDS should be han- dled in the same way other sexually transmitted diseases are handled.
However, the committee was clear in condemning breaches of confidentiality.
1 2 Iowa Medicine March/ April
your IMS
Future vision ior the IMS
One Iowa physician ties for representation, a
summed it up well: “If clearer role in the policy- making process and more opportunities for top-quality education in the IMS envi- sioned by the task force.
Representation in the IMS House of Delegates would be based on a “local / choice” model through T wliich physicians
can orgamze
had plenty of (:JJL ^ ^ feedback as
they finalized \ T y
their recommenda-
kne Iowa physician * summed it up well: “If I can call the IMS and talk to a person who knows me — maybe someone I’ve seen at a meeting — and that person is supportive and helpful, it makes me feel con- nected.”
The IMS Task ^
Force on Strate- gic Planning
around their county, their hospital, their group or other demo- \ graphic.
A group with 1 5 regis - tered members would get a delegate.
The new IMS would be governed by a 15 -member Board of Trustees which would include six district directors, six at-large direc- tors and three officers. The
lions for how the IMS should look and operate in the future. Top on their agenda is increased 'connectedness' between the organization and physician members.
Iowa physicians will have more opportunity for input, more and better opportuni-
DECEASED MEMBERS
ROBERT JONGEWAARD, MD, 75, life member, family practice and general surgery, Wesley, June 1997.
AC HI LIT PANDULLO, MD, 70, active member, general practice and internal medicine, West Des Moines, November 4, 1997.
ELLEN ANSPACH, MD, 87, life member, family practice, Mitchellville, November 11, 1997.
ROBERT HOFFMANN, MD, 79, life member, general surgeon, Des Moines, November 30, 1997.
ROBERT Y O UN GM ANN, MD, 88, life member, family practice, Cedar Rapids, January 10, 1998.
GORDON FLYNN, MD, 74, emeritus member, family practice, Davenport, January 14, 1998.
Exercise YOUR
Board would meet (and accept policy resolutions) four times per year.
The final report of the Task Force on Strategic Planning is available by call- ing Chris McMahon at the IMS, (800) 747-3070 or by visiting the IMS web site: iowamedicalsociety.org.
distinctions &
>
First ___ Amendment rights
Be part of the IMS democracy!
How?
Strategic Planning Town Meeting
When?
Saturday, April 1 8, 10 a.m.
Where?
Downtown Des Moines Marriott, Des Moines.
BERY ENGEBRETSEN,
MD was recognized as a 1997 American College of Physician Executive Manage- mentSeholar. / RONALD ROTH, MD and JOHN BRUNKH O RSI , AID were recently honored for longtime membership in the Ametican Academy of Family
1 SILVAN,
I
o
to
DO was accepted as a fellow to the American Academy of Family Physicians and received the Physicians’ Recognition Award.
MARY ANN ABRAMS, MD and Ritaann Carpenter will head up Des Moines Mercy Hospital’s new Women’s Services Program.
CHRISTOPHER BLODI, MD was selected as the new Councillor represent- ing Iowa in the American Academy of Ophthalmology.
Iowa Medicine March/April 1 3
future world
Are your computers
READY?
Most people are aware that computers are not ready for the year 2000. Some computers will register the year 2000 as 1900. What are you doing to prepare your practice for the millennium?
The obvious computer requiring immediate fix is the one used for billing, schedul- ing, electronic medical records and financial records. If you haven’t already done so, you should contact the vendor who sold you the soft- ware ASAP to determine if it is compatible for the year 2000.
But this is only one of many
computers m your office. Technology has made it very easy to put calendars and clocks in most electronic equipment. Be sure to check your lab equipment, which often stamps the date and time on reports, particularly if the equipment interfaces with the hospital’s computer system. The same applies to radiology equipment.
Other equipment that should be investigated includes time clocks; account- ing software for general ledgers, accounts payable and payroll; electronic billing
software, etc.
Take time to critically look at your equipment and soft- ware to ensure everything is ready for the year 2000.
These are not quick fixes. Some have even speculated that many lawsuits will arise between business partners if one party has not conscien- tiously addressed this issue.
For more information, con- tact Ed Whitver of the IMS at (800) 747-3070.
National Laboratory for the Study of Telemedicine:
telemed. medadmin. uiowa. edu
For a quick introduction to telemedicine, take a look at the National Labora- tory for the Study of Telemedicine web site from
National Library of Medicine:
www. nlm. nih.gov
University of Michi- gan Health System:
www. med. umich. edu/ telemedicine
the University of Iowa Col- lege of Medicine. The site describes telemedicine as the electronic transmission of medical information and ser- vices (data, video) from one site to another using tele-
line telemedicine intro
communication technologies.
But a definition of telemedicine is not all you’ll find at this site. This site covers the benefits of telemedicine to a rural state such as Iowa, describes sever- al pilot projects in Iowa and links you to other sites about telemedicine.
Among its links is the National Library of Medi- cine, the project’s source of funding. The NLM is fund-
ing 18 other projects explor- ing uses of telemedicine. You’ll find summaries and links to these projects at the NLM web site.
For the real world impli- cations of telemedicine, check out the University of Michigan Health System’s web site. Under its telemedi- cine section, the site covers equipment costs, legal impli- cations and reimbursement issues of telemedicine.
1 4 Iowa Medicine March/April
at risk
Proofreading:
Was it 66
Many physicians say they are too busy to proofread their dictation and frequently use a “dictated but not read” stamp. They believe this will protect them from liability. In reality, this is a dangerous practice and emphasizes for a plaintiff’s attorney that the dictation was not read.
Inaccuracies in dictation can make some cases inde- fensible. For example, a patient alleged a physician failed to reduce a dislocated finger joint, claiming the wrong joint was worked on. The physician was certain that the dislocation was appropriately treated, but in reviewing the dictation, real- ized that the wrong joint was identified throughout the treatment notes. The tran- scriptionist had typed “DIP” instead of “PIP” supporting the claim that the wrong joint was treated.
This column is provided by Mid- west Medical Insurance Company especially for Iowa Physician. For more information, call Lori Atkinson, MMIC risk manage- ment supervisor, at (800) 798- 9870 or (SIS) 223-1482.
mg. or 660 mg .?
One of the most important reasons to review your dicta- tion is to prevent patient injuries. In one case, a physi- cian dictated a prescription for Methotrexate and the dosage was transcribed as 660 mg. instead of 66 mg. The patient nearly died of an overdose. Another physician
how we learn
who failed to catch the “left” versus “right” mistake in his dictation operated on the wrong kidney.
Although reviewing dicta- tion may seem a daunting task, the extra minutes may prevent patient injuries and malpractice litigation.
Learning from the Pi
The value of learning
from the past generates a certain cynicism in our time. Our troubled history as a nation suggests to some people that reliance on previ- ous decisions may only lead to continuing turmoil.
In medicine, we are trained to develop our understanding of disease in increments. Occasionally the advance of science creates a large incre- ment of progress — but the new almost always builds on the old.
This past year a team of scientists demonstrated this principle in a highly publi- cized quest to recover viral
material from vic- tims of the 1918 influenza epidemic.
They extracted body tissue from the corpses of indi- viduals interred in the Alaska permafrost for almost 80 years! They hoped that the genetic analysis of that material may cast fight on the virulence of modem influenza strains.
Technology has enabled these present-day sleuths to proceed... relying on past events to teach.
This column is written by Dr. Richard Nelson, associate dean, University of Iowa College of Medicine.
Iowa Medicine March/April 1 5
National Bipartisan
featu re
Is Medicare running out of
i 1
:fT
Rep. Greg Ganske has
National
Bipartisan
gotten himself involved Commission on the
I#::
■ M
in a very hot issue... and he did it deliberately.
by Chris McMahon
Rep. Greg Ganske
(R-Iowa) was persis- tent, and it paid off. In December, Ganske, a Des Moines surgeon serving his second term in Congress, scored an appointment to the
Future of Medicare.
The com- mission’s charge is
simple — save the Medicare program.
“The Balanced Budget Act of 1997 makes Medicare solvent for another decade but the clock is ticking,” comments Ganske. “In about 10 years, the first of the baby
Commission on the FUTURE of MEDICARE
Appointed by President Clinton Stuart Altman, professor of health policy, Brandeis University
Laura D’Andrea Tyson, chair, National Economic Council
Bruce Vladeck, former HCFA administrator under President Clinton Anthony Watson, chair, Health Insurance Plan of Greater New York
Appointed by House Minority Leader Gephardt
Rep. John Dingell, D-Michigan Rep. Jim McDermott, D-Washington
Appointed by Senate Minority Leader Daschle
Sen. Bob Kerrey, D-Nebraska
Sen. John Rockefeller IV, D-West Virginia
Appointed by the President, Senator Lott and Speaker Gingrich.
Sen. John Breauz, D-Louisiana
Appointed by House Speaker Gingrich
Rep. Michael Bilirakis, R-Florida Rep. Greg Ganske, R-Iowa Rep. Bill Thomas, R-California Samuel Howard, chair, Phoenix Healthcare Corporation of Nashville
Appointed by Senate Majority Leader Lott Sen. Bill Frist, R-Tennessee Sen. Phil Gramm, R-Texas Deborah Stellman, health policy specialist for Ronald Reagan
Hlene Gordon, member, Sen. Lott’s staff
1 6 Iowa Medicine March/April
boomers will enter the pro- gram. That’s when time to save the program runs out.”
Ganske is one of two physicians on the Commis- sion; the other is Sen. Bill Frist (R~Tennessee). Seats on the Commission were highly coveted, and Ganske worked hard to be chosen.
“When I ran for Con- gress, several issues were top priorities on my agenda. Medicare is one of those issues,” he explains. “The Commission is charged with making Medicare solvent, and I want to be part of that effort.”
In addition to examining the financial health of Medicare, the Commission is also charged with making
recommendations regarding covered benefits and benefi- ciary contributions.
Some trial balloons regarding solutions such as means testing for beneficia- ries or increases in the Medicare tax have been met with staunch opposition from various groups.
President Clinton added another wrinkle when he proposed letting people under age 65 buy into the Medicare program. Sen. Phil Gramm (R-Texas), also a member of the Bipartisan Commission, hkened this to “inviting more passengers aboard the Titanic,” though the President asserts that his proposal is budget-neutral.
Ganske realizes he’s involved in a very hot issue. In fact, the issues of Medicare and Social Security have been called the Third Rail for politicians.
A daunting number of controversial issues have been assigned to the Com- mission ( See box this page.) and others may arise. For example, it seems inevitable the Commission will con- front the issue of physician supply when graduate med- ical education funding is addressed.
“Let’s face it. If these were easy issues to solve, someone would have solved them by now,” comments Ganske, who has said he will exhaust every possible option
Tasks facing the National Bipartisan Commission on the Future of Medicare
• Review and analyze the long-term financial condition of the Medicare program
• Identify threats to the financial integrity of the Federal Hospital Insurance Trust Fund
• Make recommendations to ensure the solvency of the Medicare program
• Make recommendations for establishing appropriate balance of benefits covered and beneficiary contributions
• Make recommendations regarding financing of graduate medical education, including consideration of alternative broad-based sources of funding
• Make recommendations on modifying age-based eligibility to correspond to changes in age-based eligibility under the OASDI program and on the feasibility of allowing individuals to buy into Medicare at age 62
• Make recommendations on the impact of chronic disease and disability trends on future costs and quality of services
before considering another tax hike to fund Medicare.
Historically, congression- al commissions which are appointed to address thorny topics don’t have an impres- sive track record of success. Ganske is making no promis- es beyond a pledge to try his best to solve Medicare’s woes.
“The Commission starts meeting in early March, and I’m eager to get going,” says Ganske.
The Commission is charged with making recom-
mendations by March 1 , 1999. Congressional com- missions also don’t have a history of meeting deadlines, but one of Ganske’s staff members predicts he will be just as tenacious in meeting the deadline as he was in his efforts to get appointed to the Commission in the first place.
U
If these were easy issues to solve, someone would have solved them by now.
Chris McMahon is vice president of communications for the Iowa Medical Society.
Iowa Medicine March/April 1 7
VI
w
8
E
U
Administering vaccina- tions is more than a technical act. The patient's health must be evaluated and reactions monitored.
V
The Iowa Medical Society is stating its opposition to proposed rulemaking that would give pharmacists Med- icaid reimbursement for immunizations.
Don Herman, administra- tor of the Iowa Department of Human Services (DHS), asked IMS to comment on the pharmacists’ proposal. The IMS consulted with physician members including pediatricians, other physician organizations, the IMS Leg- islative Committee and rep- resentatives of the Iowa Pharmacists Association. The result was a letter to Mr. Herman expressing opposi- tion and asking that the rule- making process not proceed.
“The Iowa Medical Society recognizes the critical role pharmacists have played in patient care,” said the letter. “However, pharmacists have not administered immuniza- tions in the regular course of their practices nor, in most cases, have pharmacists been trained in this area.”
REQUEST TOO BROAD
The letter cited the “wide- open nature of the request” for rulemaking as the key
basis for IMS opposition.
The requested rule is broadly stated: to reimburse pharma- cists for administration of immunizations. No limita- tions are described.
The IMS raised a number of questions regarding train- ing for pharmacists giving immunizations, how patients will know the pharmacist has received the training, quality standards, communication between the pharmacist and the patient’s regular physi- cian and what pharmacists will do if the patient has a negative reaction to an immunization.
FRAGMENTATION OF CARE
IMS is also very concerned about the potential for frag- mentation of medical care.
“The IMS strongly believes patients are best served by coordinated, com- prehensive health care ser- vices. Administering vaccin- ations is more than a techni- cal act. The patient’s health must be evaluated, quality controls in place and the reactions monitored.”
IMS believes the proposed rulemaking is premature.
“The Department has been
asked to sanction, through reimbursement, a practice act prior to effective addressing of the appropriateness of the practice or the parameters under which such act can occur,” stated the IMS letter.
SCOPE OF PRACTICE ISSUE
At the crux of the argu- ment is the pharmacists’ con- tention that administration of vaccines already falls within their scope of practice. The IMS argues that the code does not grant the broad authority pharmacists want.
In his reply to the IMS statement, Don Herman said the IMS has raised “appro- priate” questions and that the DHS is confining its review “to Medicare policy and its applicability to the adult Medicaid population.”
This article contains excerpts from a letter written by Jeanine Freeman, IMS vice president for public policy and advocacy. Any IMS member may get a copy of the entire letter by calling Cheryl Peers at the IMS, (515) 223- 1401 or (800) 747-3070 or by visiting the IMS web site: iowamedicalsociety.org.
1 8 Iowa Medicine March/April
Provider Service Center: Statewide: 800-562-2218
Des Moines: 515-245-4688
THROCKMORTON SURGICAL SOCIETY IOWA CHAPTER - AMERICAN COLLEGE OF SURGEONS and
IOWA ACADEMY OF SURGERY ANNUAL SPRING MEETING
SURGICAL SYMPOSIUM ON TRAUMA APRIL 17-18, 1998
Iowa Methodist Medical Center - Education Center Des Moines, Iowa
Kennth L. Mattox, M.D., FACS
Professor, Thoracic Surgery Baylor and Uniformed Services Houston, Texas
Donald D. Trunkey, M.D., F.A.C.S.
Professor & Chair, Department of Surgery Oregon Health Sciences University Hospital Portland, Oregon
Maureen F. Martin, M.D., FACS, FRCS
Hepatobiliary Surgery Iowa Health Systems Des Moines, Iowa
Gregory A. Timberlake, M.D., FACS Director, Trauma Services Iowa Health Systems Des Moines, Iowa
Kimball I. Maull, M.D., FACS
Professor, Department of Surgery Loyola University of Chicago Maywood, Illinois
G. Patrick Kealey, M.D., FACS
Professor, Department of Surgery The University of Iowa College of Medicine Iowa City, Iowa
Matthew Weir sell, M.D.
Orthopaedic Surgeon Des Moines Orthopaedic Surgeons West Des Moines, Iowa
Akella Chendrasekhar, M.D.
Assistant Director, Trauma Services Iowa Health Systems Des Moines, Iowa
Susanne Conrad, R.N., M.S.
Executive Director
Iowa Statewide Organ Procurement Organization Iowa City, Iowa
TOPICS
"Peripheral Vascular Trauma" “Management of Shock/Hypotensive Resuscitation”
"Prioritization of Operations in Trauma Care" "Evaluation of Abdominal Trauma"
"Missed Injuries/Role of Tertiary Surbey" "Intra-abdominal Compartment Syndrome"
"Update on Pelvic Fractures" "Bum Management and Treatment"
"Pancreatic and Duodenal Trauma" "Ventilator Management"
“From Resection to Transplant: Management of Liver Trauma” "Debunking Myths in Trauma Surgery"
ACCREDITATION
Iowa Methodist Medical Center is accredited by the Iowa Medical Society to sponsor continuing medical education for physicians.
Iowa Methodist Medical Center designates this educational activity for a maximum of 9.0 hours (Friday, April 17) in category 1 credit toward the AMA Physicians Recognition Award. Each physician should claim only those hours of credit actually spent in this educational activity. Hours of credit for Saturday, April 1 8 TBA.
COST
Physician Fee $150.00 Resident Fee $35.00
CONTACT
Surgery Education Office, Iowa Methodist Medical Center 1221 Pleasant Street, Des Moines, IA 50309 Phone: (515) 241-4076
your practice
A Technological Meltdown
could be the end...
If you can't recover from
a technology crisis
1 0 days, you could go
out of business.
According to a recent study in Information Week , the chances of an orga- nization having a software systems disaster are 1 in 100.
Hardware and software crashes are more likely than fires or floods and just as de- vastating. Does your practice have a disaster recovery team to contain the problem?
IMPLEMENTING A TEAM
1 . Once the team of criti- cal employees has been selected and responsibilities assigned, an off-site com- mand center should be selected. The command cen- ter is a centralized place for the recovery operation with no concerns about access, power supply and phone lines.
2. Prepare a comprehen- sive fist of vendor contacts. This master fist should rep- resent the best available out- side expertise.
3. Perform regular, thor-
ough equipment mainte- nance.
BACKING UP YOUR SYSTEMS
It is absolutely necessary to perform regular back-ups, preferably on a daily basis. The back-up should always be housed at an off-site loca- tion. The disaster recovery team should be regularly challenged to practice restoration of data. Many systems have nuances as to how data is loaded.
CHOOSE VENDORS CAREFULLY
Your software and hardware vendors must be able to respond effectively to the crisis. Keep these
questions in mind when choosing your vendor:
How substantial is your vendor?
Do they have a number of installations of the system you are considering?
Do you have a customized system? If so, there may be limited vendors who are familiar with your version.
Is your vendor committed to full-scale support of the software they sold you? Do they have a trained, full-time support staff or is support a part-time job for their staff members? A reputable vendor will have resources to assist you in a crisis.
Information gathered from Contingency Planning: Prepare Now for Possible Sys- tems Disasters by Eugene Hoekendorf guest writer for Group Practice Journal — November/December 1997 pages 38-40.
Des Moines practice faces computer crisis
In September 1997, Central Iowa Oncology and Hematology in Des Moines experienced a disaster — a crash of its hard drive. Martha Owen, business manager, was prepared, “We back-up daily in case of a system dis- aster and remove the back-up to an off-site location on a weekly basis.”
Owen also experienced, as this article suggests, “nuances as to how data is loaded.” The new hard drive had to be partitioned identically to the previous hard drive to restore her back-up. Again, Owen was prepared with a back-up of the original set-up. This proves the value of backing-up and practicing a recovery to find those nuances.
As a result of this technology crisis, the practice has purchased two hard disk drives with separate information. “This strategy assures that I will not lose everything in the event of another disk drive crash.” Finally, Owen suggests insurance for technology disasters. Owen was pleasantly surprised at the insurance policy cost for protecting the practice from equipment costs and lost time.
Iowa Medicine March/April 2 1
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"After the sale , it's the SERVICE that counts'
your money
Be sure to understand all your options when you buy life insurance.
by Jerry Foster
In the process of finan- cial planning, most like- ly you will identify the need for some life insurance to liquidate debt, maintain continuity of lifestyle for your family or ensure the proper distribution of assets for heirs.
What kind of insurance is appropriate? Term insurance covers shorter term needs like debt reduction.
A WELL-KEPT SECRET
However, longer term needs like lifestyle protection may need permanent protec- tion like whole, universal or variable fife.
No matter what kind of insurance is needed, consider- ation should be given to a well-kept secret that’s been
around for over 10 years — low load life insurance.
Every fife insurance policy carries loads. Loads are fees for expenses to maintain a policy, mortality charges and sales commissions.
One of the biggest loads on a fife insurance policy is the cost of acquiring you as a cus- tomer — the cost of brochures, mailings, telemar- keting, advertising and agent commissions.
PURCHASED DIRECTLY
Low-load insurance has been a well-kept secret because it’s a policy that can only be purchased directly from an insurance company or a fee-only advisor. The insurer pays no sales fees to anyone. With no agents to pay, an insurer can make the same profit on a low-load pol- icy as on a traditional one while charging you less.
An important benefit of a low-load policy is that you get a higher immediate cash sur- render value, which provides
greater fl exibility if your needs change. Higher cash value on your policy means the magic of compounding works for you sooner.
Traditional policies can’t always be ruled out because there are times when they are the best solution. The key to planning is understanding all options and selecting the best product to meet your objec- tives and provide for your family.
Jerry Foster is the CEO of Foster Capital Management, a fee-only financial planning aitd investment management company located at IMS head- quarters, (800) 798-1012.
the secret of Low-Load
life insurance
Iowa Medicine March/April 23
Alliance news
This article was written by Cindy Ehrecke, IMSA president
O
HONORING Iowa
the physicians of Iowa. Happy Doctor’s Day!
Doctor’s Day has been celebrated by medical alliances and hospitals across this country for the past 65 years. In 1933, the first Doctor’s Day was planned to honor Dr. Crawford Long, the first physician to use ether to perform painless surgery. March 30 is the day set aside to honor this nation’s physicians.
In Iowa, the IMS Alliance has chosen to honor our doc- tors by requesting that Gov- ernor Branstad sign a proclamation declaring
next month
♦ To help us plan for our October Retreat for Women Physicians, we surveyed women physicians across Iowa. Read about their choices for the retreat pro- gram.
♦ Over 200 physicians answered our fax survey on recommendations of the IMS Task Force on Strategic
March 30 as Doctor’s 1
Day. The IMS Alliance *
also coordinates state- wide distribution of tray liners which will be used by hospitals and nursing homes to alert patients to the significance of the day. i
Individual county med- %
ical alliances have J
planned additional events — blood drives, variety shows and donations to AMA-ERF — to honor the physicians in their area.
Our hats go off to you —
Planning. Check out this response report.
♦ What’s the latest news from the University of Iowa College of Medicine? Read the special feature on devel- opments in medical educa- tion.
♦ In a recent presentation to the IMS Executive Council,
Roger Tracy of the Universi- ty of Iowa College of Medi- cine presented some startling statistics about physician sup- ply in Iowa.
♦ By late April, the legisla- ture will be winding down for the year. Read about the outcome of IMS initiatives and other issues of interest to physicians.
Watch your mail for A. New Vision. . .
The IMS Annual Meeting: A New Vision will be April 17-19 at the downtown Des Moines Marriott. Watch your mail for the upcoming program and registration information. It will be a weekend packed with technological advances in medicine, a town meeting on strategic planning, a panel of payers and much more!
24
Iowa Medicine March/April
TflUal
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To reach your local office, call 800-344-1899.
ay On A rt-'
professional listing
ACUPUNCTURE
♦Yang Ahn, AID
Medicenter West 2215 Westdale Drive SW Cedar Rapids 52404 (319) 396-2000
Ahn Clinic for Acupuncture
860 22nd Avenue Coralville 52241 (319) 338-8000
ALLERGY
♦Allergy Institute, PC A.Y. Al-Shash, MD
1701 22nd Street, Suite 207 West Des Moines 50266 (515) 223-8622
4505 SW 9th Street Des Moines 50315
Allergy , Asthma & Immunology
♦Pediatric and Adult Allergy, PC Veljko K. Zivkovich, MD Robert A. Colman, MD
1212 Pleasant, Suite 110 Des Moines 50309 (515) 244-7229
Asthma , Allergy & Immunology
ANESTHESIOLOGY
♦Acute Care Anesthesia Services, LC P.O. Box 515 Ankeny 50021
(515) 964-2772 or (800) 729-7813 Anesthesiologists and CRNAs
CARDIAC SURGERY (ADULT AND PEDIATRIC)
♦ Iowa Heart Center Robert H. Zeff, MD David R. Hockmuth, MD Clay E. Beggerly, MD Mark G. Nelson, MD Bart P. Jenson, MD
411 Laurel, Suite 2250
Des Moines 50314
(515) 243-1010 or (800) 532-1844
1301 Pennsylvania Ave., Suite 115
Des Moines 50316
(515) 263-0900 or (888) 591-9248
1215 Pleasant Street, Suite 414
Des Moines 50309
(515) 241-8033 or (888) 591-9249
CARDIO-THORACIC SURGERY
♦Heart & Vascular Care The Iowa Clinic, PC Hooshang Soltanzadeh, MD Ronald K. Grooters, MD Kent C. Thieman, MD Robert E Schneider, MD 1440 Pleasant Street, Suite 150 Des Moines 50314 (515) 241-5735
CARDIOLOGY
♦lowa Heart Center David F. Gordon, MD L. A. lannone, MD Thomas M. Brown, MD Wm. J. Wickemeyer, MD
R. R. Rough, MD
Mark D. McGaughey, MD Timothy T. Hart, MD Vlagdi G. H. Ghali, MD Craig A. Stevens, AID W. Ben Johnson, AID Joel A. From, MD Margaret H. Verhey, AID Mark A. Tannenbaum, AID Philip A. Bear, DO Jeffrey J. Boyd, AID Amar Nath, AID Steven J. Bailin, AID
S. V. Advani, AID, PhD Robert H. Hoyt, MD Kevin E. Crowe, AID Michael R. Muellerleile, MD Mark S. Bissing, DO Craig A. Stark, MD
David R. Laughrun, AID Denise M. Sorrentino, AID John M. Pargulski, DO Ahmed A. Latief, AID Richard H. Marcus, AID Saima Zafar, AID Marc L. Klein, AID
411 Laurel Street, Suite 1250
Des Moines 50314
(515) 235-5000 or (800) 532-1844
1301 Pennsylvania Ave., Suite 115
Des Moines 50316
(515) 263-0900 or (888) 591-9248
1215 Pleasant Street, Suite 414
Des Moines 50309
(515) 241-8033 or (888) 591-9249
1601 NW 114th Street, Suite 330
Des Moines 50325
(515) 222-1166 or (888) 591-9247
1215 Duff Avenue Ames 50010 (515)239-4472
405 S. Clark Street, Suite 205 Carroll 51401
(712) 792-6500 or (888) 962-9283
♦Alidwest Cardiology Consultants, PC Abdul L. Chughtai, AID Manmohan L. Kwatra, AID Prasad R. Palakurthy, MD Martin Aronow, DO S undeep Das, AID Des Moines Medical Center 1045 5th Avenue Des Moines 50314 (515) 244-1352
♦Heart & Vascular Care The Iowa Clinic, PC Chad L. Williams, AID David Lemon, MD Jay Yans, MD Dirk A. Ver Steeg, AID James P. Lovell, DO Martha J. Stewart, AID Frank N. Haugland, AID, PhD Allan Latcham, AID 1440 Pleasant Street, Suite 200 Des Moines 50314 (515) 241-5988
DERMATOLOGY
♦Robert J. Barry, AID
1030 Fifth Avenue, SE Cedar Rapids 52403 (319) 366-7541
Practice Limited to Disease, Cancer and Surgery of Skin
ELECTRODIAGNOSIS
♦John Milner- Brage, AID
2710 St. Francis Drive, Suite 208 Waterloo 50702 (319) 234-6446
Electromyography & Nerve Conduction Studies Certified by American Board of Electrodiagnostic Medicine
EMERGENCY MEDICINE
♦Acute Care, Inc.
P.O. Box 515 Ankeny 50021
(515) 964-2772 or (800) 729-7813 Comprehensive Emergency Medicine Practice, Locum Tenens, Doctor on Call
♦Emergency Practice Associates P.O. Box 1260 Waterloo 50704 (800) 458-5003
Specialists in Emergency Staffing & Emergency Department Services
26 Iowa Medicine March/April
FACIAL PLASTIC AND RECONSTRUCTIVE SURGERY
♦ Otologic Medical Services, PC Guy E. McFarland, MD Thomas F. Viner, MD Douglas E. Dawson, MD Thomas A. Simpson, MD
540 E. Jefferson, Suite 401 Iowa City 52245
(319) 351-5680 or (800) 642-6217 Maxillofacial, Plastic, Head & Neck Surgery
Satellite Clinics: Washington, Mt. Pleasant, Muscatine, Fairfield and Leon
FAMILY PRACTICE
♦ Acute Care, Inc.
P.O. Box 515 Ankeny 50021
(515) 964-2772 or (800) 729-7813 Locum Tenens Doctor on Call
INFECTIOUS DISEASES
♦ Chest, Infectious Diseases & Critical Care Associates, PC Daniel H. Gervich, MD Daniel J. Schroeder, MD
Ravi K. Veinuri, MD Philip Bruno, DO Infectious Diseases 1601 NW 114th, Suite 347 Des Moines 50325-7046 24 Hours (515) 224-1777
INFERTILITY
♦ Mid-Iowa Fertility, PC Donald C. Young, DO
3408 Woodland Avenue, Suite 302 West Des Moines 50266 (515) 222-3060 Reproductive Endocrinology/Infertility IVF and GIFT Procedures Donor Oocyte Program Artificial Inseminations Reproductive Surgery Menopause Management
NEUROLOGY
♦ iowa Medical Clinic Neurology
Laurence S. Krain, MD Andrew C. Peterson, MD Erich W. Streib, MD Sallie E Sun, MD
600 7th Street SE Cedar Rapids 52401 (319) 398-1721 For Drs. Streib and Sun call (319) 366-7990
Neurology, EEG, EMG, Evoked Potentials and Sleep Studies
NEUROSURGERY
♦ Iowa Clinic PC Neurosurgical Services Robert Hayne, MD Thomas A. Carlstrom, MI) David J. Boarini, MD
1215 Pleasant, Suite 608 Des Moines 50309 (515) 241-5760 John R. Mawk, MD S. Randy Winston, MD
1601 NW 114th St., Suite 134 Clive 50325 (515) 223-3800 Neurological Surgery
♦ Iowa Medical Clinic Neurosurgery
James R. LaMorgese, MD 600 7th Street, SE Cedar Rapids 52401 (319) 366-0481
Practice limited to Neurosurgery
♦ Neurological Surgery PC Douglas R. Koontz, MD 411 Laurel Street, Suite A3 50 Des Moines 50314
(515) 246-1680
OPHTHALMOLOGY
♦ Eye Physicians and Surgeons, LLP
Stephen H. Wolken, MD Robert B. Goffstein, MD Lyse S. Stmad, MD John F. Stamler, MD, PhD
540 E. Jefferson, Suite 201 Iowa City 52245 (319) 338-3623
♦ Wolfe Clinic, PC Russell H. Watt, MD John M. Graether, MD Gilbert W. Harris, MD James A. Davison, MD Norman F. Woodlief, MD Eric W. Bligard, MD David D. Saggau, MD Steven C. Johnson, MD Todd W. Gothard, MD Dean M. Harms, MD Louis J. Seal Ion, MD Daniel J. Vos, MD Gregory A. Olson, MD Charles H. Barnes, MD
309 East Church Street Marshalltown 50158 (515) 754-6200
Lakeview Medical Park 6000 University Avenue, Suite 300 West Des Moines 50266 (515) 223-8685
804 South Kenyon Road, Suite 100 Fort Dodge 50501 (515) 576-7777
Sartori Professional Building 516 South Division Street Cedar Falls 50613 (319)277-0103
1245 2nd Avenue SE Cedar Rapids 52403 (319) 362-8032
1114 Duff Avenue Ames 50010 (515) 232-2450
♦ North Iowa Eye Clinic, PC Addison W. Brown, Jr., MD Bradley L. Isaak, MD Randall S. Brenton, MD James L. Dummett, MD Mick E. Vanden Bosch, MD John J. Kownacki, MD 31214th Street, SW P.O. Box 1877 Mason City 50401 (515)423-8861
ORTHOPAEDICS
♦ Iowa Orthopaedic Center, PC ORTHOPEDIC SURGERY
Marshall Flapan, MD Sinesio Misol, MD Joshua D. Kimelman, DO Timothy G. Kenney, MD Lynn M. Lindaman, MD Jeffrey M. Farber, MD Kyle S. Gaffes, MD Scott A. Meyer, MD Cassini M. Igrarn, MD Rodney E. Johnson, MD Martin S. Rosenfeld, DO Teri S. Formanek, MD Stephen M. Naruto, MD Daniel W. Vande Lune, MD PHYSICAL MEDICINE & REHABILITATION Donna J. Bahls, MD Jill R. Meilahn, DO Jacqueline M. Stoken, DO Kurt A. Smith, DO PODIATRIC MEDICINE & FOOT SURGERY
Dennis A. Kessler, DPM 411 Laurel, Suite 3300 Des Moines 50314 (515) 247-8400
OTOLARYNGOLOGY
♦ Phillip A. Linquist, DO, PC
1000 Illinois Des Moines 50314 (515) 244-5225
Ear, Nose and Throat Surgery, Facial Plastic Surgery, Head and Neck Surgery
Iowa Medicine March/April 2Z
♦ Otologic Medical Services, PC Guy E. McFarland, MD Thomas E Viner, MD Thomas A. Simpson, MD
540 E. Jefferson, Suite 401 Iowa City 52245
(319) 351-5680 or (800) 642-6217 Maxillofacial, Plastic, Head & Neck Surgery
Satellite Clinics: Washington, Mt. Pleasant, Muscatine, Fairfield and Leon
♦ Dubuque Otolaryngology- Head & Neck Surgery, PC James W. White, MD Craig C. Herther, MD Thomas J. Benda, Jr., MD 310 North Grandview Avenue Dubuque 52001
(319) 588-0506
♦ Iowa ENT, PC Thomas A. Erieson, MD Steven R. Herwig, DO Mark K. Zlab, MD
1215 Pleasant, Suite 408 Des Moines 50309 (515) 241-5780 or (800) 248-4443 Satellite Clinics:
Perry, Newton, Oskaloosa, Knoxville
♦ Iowa Head and Neck Associates, PC Robert T. Brown, MD Eugene Peterson, MD Richard B. Merrick, MD Robert R. Updegraff, Ml)
3901 Ingersoll
Des Moines 50312 (515)274-9135
♦ Wolfe Clinic, PC Michael W. Hill, MD Daniel J. Blum, MD 309 East Church Marshalltown 50158 (515) 752-1566
Lakeview Medical Park 6000 University Avenue, Suite 310 West Des Moines 50266 (515) 224-9533
Sartori Professional Building 516 South Division Street Cedar Falls 50613 (319)277-3105
Otolaryngology-Head and Neck Surgery, Facial Plastic Surgery, Allergy
PERINATOLOGY
♦ Des Moines Perinatal Center, PC
Neil T. Mandsager, MD Jeffrey Boyle, MD 3408 Woodland Avenue, Suite 302 West Des Moines 50266 (515) 222-3060
Maternal-Fetal Medicine Routine and Advanced (Level II) Obstetric Ultrasound Genetic Counseling Amniocentesis and CVS Antenatal Testing High-Risk Obstetrical Management High-Risk Deliveries
PHYSICAL MEDICINE & REHABILITATION
♦ Rehabilitation Medicine Associates
Younker Rehabilitation Center 1200 Pleasant Des Moines 50308 (515) 241-6434
2600 Grand Avenue, Suite 102 Des Moines 50312 (515) 283-1570
PULMONARY MEDICINE
♦ Chest, Infectious Diseases & Critical Care Associates, PC Roger T. Liu, MD
Steven G. Berry, MD Donald L. Burrows, MD Michael Witte, DO Gerard A. Matysik, DO 1601 NW 114th, Suite 347 Des Moines 50325-7046 24 Hour (515) 224-1777
VASCULAR SURGERY
♦ Iowa Heart Center Alan R. Koslow, MD Laurie H. Kuestner, Ml)
411 Laurel Street, Suite 2250 Des Moines 50314
(515) 243-1010 or (800) 532-1844
♦Heart & Vascular Care The Iowa Clinic, PC Douglas B. Domer, MD David H. Stubbs, MD Anson A. Yeager, MD Douglas W. Massop, MD 1440 Pleasant Street, Suite 100 Des Moines 50314 (515) 241-5700
the
/oh v/Medicine team
IMS president
Harold Miller, MD
Executive editor
Michael Abrams Managing editor
Christine McMahon Production coordinator
Tina Stoner
Iowa Medicine, Journal of the Iowa Medical Society (ISSN 0746-8709), is published bi- monthly by the Iowa Medical Society. Subscription price:
$25 per year. Periodicals postage paid at Des Moines, Iowa and at additional mailing offices. Postmaster: Send address changes to Iowa Medi- cine, Journal of the Iowa Med- ical Society, 1001 Grand Avenue, West Des Moines, Iowa 50265. Advertising:
Tina Stoner, Iowa Medicine, 1001 Grand Avenue, West Des Moines, Iowa 50265. Phone (515) 223-1401. Editorial content: The Society is unable to assume responsibility for the accuracy of that which is sub- mitted. Editorial inquiries should be directed to the Edi- tor, Iowa Medicine, 1001 Grand Avenue, West Des Moines, Iowa 502 65. Copy- right 1998 Iowa Medical Soci- ety.
28 Iowa Medicine March/April
classified ads
Family Physician— -Progressive group practice in Oskaloosa, Iowa is seeking an additional BC/BE family physician. Competitive salary and benefit package. Call schedule 1:9. Full time ER cover- age. For additional information contact Linda Cohrt, office man- ager, Family Medical Center, PC, 1225 C Avenue East, Oskaloosa, Iowa, (515) 672-2090 or fax CV to (515) 672-2258.
United States Southwest
A major metropolitan city in the culturally rich environ- ment of the sunny American southwest. Position available now. A private neurosurgical clinic is looking for a BE/BC associate with broad neuro- surgical training and/or expe- rience. Stereotactic neuro- surgery both fixed frame and frameless plus radiosurgery are presently being per- formed. Additional training or experience in spinal surgery and instrumentation tech- niques would augment cur- rent selection review. Please send CV and cover letter to:
Mitchell Smigiel, MD, FACS Charles Chang, MD 1600 Medical Center Drive Suite 400
El Paso. Texas 79902
Marshalltown, Iowa— -State-of- the-art facilities and exceptional quality of fife with practice oppor- tunities available in orthopaedic surgery and internal medicine. Pursue one of these opportunities and obtain privileges at the com- munity’s 176-bed facility that has been awarded accreditation with commendation by the JCAHO. An outstanding compensation package is available for each of the oppor- tunities, and the hospital offers educational loan forgiveness, inter- viewing and moving expenses. For additional information contact Jill Lutes at (800) 542-0014, Marshall- town Medical & Surgical Center, 3 South 4th Avenue, Marshalltown, Iowa 50158
LOCUM TENENS
FAMILY PRACTICE WITH OB
Family practice board certified physi- cian. recent Kansas University Med- ical Center graduate with the surgical background available for short term practice coverage which may include ER call, clinics and inpatient services with or without OB for up to two weeks at a time. Liability insurance provided. Iowa license current. Please contact:
Vadim Braslavsky, MD 7800 England Dr., #101 Overland Park, Kansas 66204 Telephone (913) 383-3285
Internet address and information: http://www.concentric.net/~Locumdr/l -htm E-mail: locumdr@pol.net
Janesville, Wisconsin — Dean Medical Center a 395+ physician multispecialty group is actively recruiting a BE/BC Internist for our Riverview Clinic in Janesville, Wisconsin (population 60,000 and is located 40 miles southeast of Madison). Janesville is a beautiful, family-oriented community with excellent schools and abundant recreational activities. There are 60 physicians located at our Riverview Clinic which is a new facility overlooking the scenic Rock River. Currently there are 12 internal medicine physicians at the Riverview location. The call schedule will be 1:12 for weekdays and weekends. Excellent compen- sation and benefits will be provid- ed with full time employment leading to shareholder status in two years. For more information contact Scott Lindblom, Medical Staff Recruiter, Dean Medical Center, 1808 West Beltline High- way, Madison, Wisconsin 53175, work (608) 250-1550, home (608) 845-2390 or fax (608) 250-1441.
Black & white, full color, and Web page design Clients include; Smithsonian Institute Press, William C. Brown, & Mosby Greta Strief, Medical Illustrator 515.985.6518 greverie @ aol.com
Mankato Clinic, Ltd.— -A pro- gressive group practice is seeking additional BE/BC physicians in the following specialties: acute/ urgent care, family practice, oncol- ogy/hernatology, orthopedic surgery and general internal medi- cine practice. The Mankato Clinic is a 70-doctor multispecialty group practice in south central Minneso- ta with a trade area population of +250,000. Guaranteed salary first year, incentive thereafter with full range of benefits and liberal time off. For more information, call Roger Greenwald, executive vice president, at (507) 389-8500 or Byron C. McGregor, medical director, at (507) 389-8548 or write 1230 East Main Street, P.O. Box 8674, Mankato, Minnesota 56002-8674.
1998 Primary Care Update
Friday-Sunday May 22-24, 1 998 Okoboji, Iowa
This program will deal with such issues as agricultural accidents and diseases, alternative therapy and updates on new drugs, office gyne- cology, HIV information, diabetic management and more!
Category 1—13 hours AAFP-12.5 hours For more information call the Creighton University School of Medicine Continuing Medical Education Division at (800) 548- CMED.
Designed for primary care physicians, nurse practitioners and physician assistants
No Assembly Line Here — FPs, IMs and OB/GYNs at North Memorial-owned and affiliated clinics don’t hand patients off to the next available specialist. Guide your patients through their entire care process at one of our 25 prac- tices in urban or semi-rural Min- neapolis locations. Interested BC/BE MDs, call (800) 275-4790 or fax CV to (612) 520-1564.
Family Physician -If you think that you can find happiness in a small town in Iowa, please contact me. Jerry Hess, Mercy Family Care Network, 1000 4th Street, SW, Mason City, Iowa 50401. (515)422-5551, fax (515) 422- 6388, toll free (888) 877-5551.
Iowa Medicine March/April 29
Family Practice
Franciscan Skemp Healthcare- Mayo Health System, based in La Crosse, WI, has over 160 physi- cians/associate providers at 12 clinics and three hospitals in WI, MN, IA.
WAUKON, IA: BC/BE family physi- cian with full range of family medi- cine, including OB, to join three BC family physicians and two cer- tified PAs in brand new clinic facil- ity completed 1997. The Waukon Clinic adjacent to 40 bed commu- nity hospital. Waukon, pop. 4,000, located in beautiful northeast Iowa, 17 miles from Upper Missis- sippi River and 50 miles from La Crosse.
PRAIRIE DU CHIEN, WI: Devel- oping new practice and building new clinic facility in Prairie du Chien, WI, located on Upper Mis- sissippi River, 60 miles south of La Crosse. Two BC/BE primary care physicians and associate provider needed to staff our newest medical facility in Prairie du Chien, com- munity of 6,000 with service area of 22,000. Community hospital has 49 beds. OB is preferred, not required.
CONTACT: Tim Skinner at skinner.timothy@mayo.edu or Bonnie Guenther at guenther.bonnie@mayo.edu.
Phone: (800) 269-1986 or fax CV to (608) 791-9898.
Fransican Skemp Healthcare- Mayo Health System 700 West Avenue South La Crosse, WI 54601
Healthcare
MAYO HEALTH SYSTEM
Internal Medicine — Iowa City Internal Medicine is seeking a gen- eral internist. We are a group of nine internists with a well-estab- lished east-side outpatient clinic and are on staff at Mercy Hospital. The 70,000 inhabitants of the Iowa City area enjoy the advan- tages of a comfortable small-town atmosphere in combination with the University’s cosmopolitan diversity of culture and recreation- al opportunities. Many 19th centu- ry homes grace the residential area of Iowa City and entire neighbor- hoods have joined efforts to pre- serve and improve them. Iowa City has over 500 acres of parks graced with swimming pools, nature trails and picnic facilities. The Coralville Reservoir, Lake Macbride and Kent Park are major recreation centers near the city. Education is Iowa City’s heritage. Iowa City’s population has the highest per- centage (38.6%) of college educat- ed adults of any city in the U.S.
For additional information please contact Steve Cooper, Administra- tor, (319) 338-7862 or evenings (319) 351-3456 or Dr. Craig Champion (319) 338-7862 or evenings (319) 338-7097.
WHAT ARE
WII LOOKING FOR?
Are you looking to practice challenging medicine with a compensation plan to keep you satisfied and more time to enjoy fife?
EMERGENCY PRACTICE ASSOCIATES provides emer- gency medicine opportunities in Midwest locations that make life worth living and work worth working.
Look no further. Call Emer- gency Practice Associates today.
WW77-
(800) 458-5003
PO Box 1260 Waterloo, IA 50704
Oncologist, Urgent Care, ENT, Dermatologist
There is an immediate opening at Brainerd Medical Center for the following specialties: oncology, urgent care, ear, nose and throat and dermatology.
Brainerd Medical Center, P.A.
• 36-physician independent multispecialty group
• Located in primary service area of 50,000 people
• Almost 100% fee-for-service
• Excellent fringe benefits
• Competitive compensation
• Exceptional services available at 162-bed local hospital, St. Joseph’s Medical Center
Brainerd, Minnesota
• Surrounded by the premier lakes of Minnesota
• Located in central Minnesota less than 2 1/2 hours from the Twin Cities, Duluth and Fargo
• Large, very progressive school district
• Great community for families
Call Administrator collect: Curt Nielsen
(218) 828-7105 or (218) 829-4901 2024 South 6th Street Brainerd, Minnesota 56401
Obstetrician-Gynecologist — BC/BE obstetrician-gynecologist needed to join our very busy, five physician Ob/Gyn department.
We specialize in gynecologic surgery, obstetrics, infertility and diseases of women. Our seventy- five person multispecialty clinic is physically connected to a large regional referral hospital and serves a population base of 250,000. Full range of medical specialties and support services. Mason City offers small town, Midwestern living, abundant out- door recreational and cultural amenities and convenient access to metropolitan areas. Our school systems are ranked on top both at state and national levels. No J-l option available. Submit CV to : Michelle Moran, Mason City Clin- ic, PC, 250 S. Crescent Drive, Mason City, IA 50401. (515) 422- 6506 or toll free (800) 622-141 1. Fax: (515)422-6593.
30 Iowa Medicine March/April
• Emergency Medicine • Locum Tenens
• Ambulatory Care Clinic System • Anesthesia
ACUTE CARE , INC.
FOR MORE INFORMATION, PLEASE CALL 800.729.7813 OR 515.964.2772, OR FAX YOUR CV TO 515.964.2777 FOR CONSIDERATION, e-mail address: melissam@acutecare.com home page: http://www.acutecare.com
Blazing A New Path For Medical Liability Protection
It’s a bold new world of health care. A host of innovative health care relationships fill the landscape, and each requires distinct direction and coverage for liability expo- sures. Our capabilities encompass unique solutions to help smooth the way for physi- cian groups, physicians, and an assortment of health care alliances.
Our goal — to make medical liability your last concern. We’re a liability insurance partner you can count on for:
• Flexible products that adapt to change
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• Over $260 million in assets
• An A.M. Best rating of “A” (Excellent)
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• Offices in Minnesota, Nebraska and Iowa
For information on all our products and services, please call the Marketing Department at 1-800-498-9587.
N N ftH
MIDWEST MEDICAL INSURANCE COMPANY
university of
MARYLAND AT
BALTIMORE
recognized national!
House of Delegates directs legislative efforts Create a patient accessible web site — for
E&M Coding — Education hasn't lessened physician confusion / pa
fonv/Medicine
May/June 1998 An Iowa Medical Society publication
Medical
musical
chairs:
Physician supply in Iowa is on the rise and job opportunities are declining —
" We Thought Mom Needed a Nursing Home"....
What she needed was Assisted Living at the newly expanded Heritage Court, where she receives personalized care from a friendly staff 24hrs. a day. There's no endowment and she had the choice of a large private or companion suite. She even has her own kitchenette with a refrigerator, freezer and microwave. Heritage Court provides light nursing care in a comfortable residential setting. Stop in or call today for a tour.
Court
Assisted Living
1499 Office Park Rd., West Des Moines
223-1224 fountain W^st
A Continuum of care offered by Colby Properties Health Care Center
Iowa Medicine
Published by the Iowa Medical Society
May/June 1 998
Vol. 88/3
8
trends
9
10
14
futur
rid
13
20
Public citizen group releases book on “Questionable” doctors
IMS advocate
IMS asked to participate in national E&M coding study
on the hill
As the gavel falls on
1998 legislature, IMS gears up for
1999
CHMIS searches for new identity as legislature repeals original law; build a patient accessible web site for free!
your IMS
Dr. Regina Benjamin — - winner of Nelson Mandela Award — will speak at IMS Retreat for Women Physicians
12
12
21
snapshots
Check out this page of photos from the 1998 Annual Meeting
healthy iowans
IMS involved in SCHIP, other public health efforts
legalities
Treating minors can present a real dilemma for Iowa physicians
reimbursement
Increases in reimbursement for NPs, PAs allowed by Balance Budget Act.
your practice
What happens when physicians have been educated but are still confused about E&M coding?
fcwMedicine
Medical
musical
chairs:
E&M Coding — Education hasn't lessened physician confusion / 1
This month's feature:
The latest data show that physician supply could become a very big issue in Iowa in the near future.
REGULARS
president comments changing partners awards, obits risk management how we learn
5 8
13 15 15
23 your money
24 IMS Alliance news 24 next month
26 professional listing
29 classified ads
Iowa Medicine May/June 1998 3
Adhesive bandage, which plaintiff alleges defendant pulled rapidly from skin, violently tearing three hairs from plaintiff's arm,
which resulted in severe shock, trauma, disfigurement, chronic debilitating pain and permanent psychological damage.
Even the most absurd claims can be damaging if they’re not handled properly. Which is why the full weight of our more than 60 years of experience in medical liability insurance is brought to bear on each and every claim, no matter how frivolous that claim may appear. In fact, when appropriate, we have appealed cases all the way to the United States Supreme Court, at no additional cost to policyholders. Because you can’t put a bandage on a damaged reputation.
""StRlill
Medical Servia
St. Paul Fire and Marine Insurance Cot
president comments
Will we avoid the
ICEBERGS ahead?
Leaving office proudly and with great happi- ness, Dr. Harold Miller gives credit where credit is due.
by Harold Miller, MD
This is my last col- umn as president of the Iowa Med- ical Society. I would prefer to be known as a person who delegated well, allowed oth- ers to accomplish goals and encouraged others to day- dream and to consider a variety of vie ws and new alternatives to solving prob- lems. I would most of all like to give credit to those who worked so hard to make me look good in accomplishing some of their goals.
I leave office very proud of your medical society. I am certain that those who follow me will work diligently and thoroughly in completing their tasks. The society will
be in strong hands. The younger members of our profession who have sought and received leadership posi- tions deserve your support. Their actions and accom- plishments bring honor to our entire profession.
The profession of medi- cine, like the Titanic, is well structured and large in size. Also like that great ship, we have an experienced and well trained crew. It is captained by those who have gained the wisdom only years at the helm can deliver.
Yet, as we head into the icy waters before us, will we be handicapped by our mas- sive size and unable to maneuver well? Or will we be unable to change course easily because we lack ade- quate rudder? Will we lack the foresight to recognize the icebergs?
Indeed, there will be many icebergs that lie ahead. And we all remain passengers on this ship, the profession which we care about so very much. There are far too few
lifeboats, if any.
Hugh R.K. Barber, MD recendy wrote that “the pre- sent health care system was founded on taxes, charity and devoted volunteers, but now it is being over-run by major corporations that are rich in resources but bankrupt in morals and ethics.” He also asked why HMOs and insur- ance companies are so responsive to Wall Street and so indifferent to Main Street.
We must seek our friends with care and choose our enemies without temerity and with even more care.
And to quote from a former AMA leader, “When we do circle the wagons, remember to shoot out.”
Dr. Miller is IMS president and a family physician prac- ticing in Davenport.
Iowa Medicine May/June 1998 5
STOP, LOOK, AND LISTEN!
We’re conditioned from childhood to STOP, LOOK AND LISTEN!!
This old railroad slogan is big
Around our shop, since we’ve got a room or two of model trains.
Come and see them if you get a chance.
So what does STOP, LOOK AND LISTEN mean to you and all of us?
STOP!
We all need to
Stop and review our and your critical insurance protection,
At least annually.
Are they secure and cost effective in today’s uncertain market?
LOOK!
We need to
Look around at what’s happening in the volatile Insurance industry these days.
Whether it’s health, life, disability Or any other coverage, it’s critical that you know What the options are!!
LISTEN!
Listen is what we do at Bernie Lowe & Associates.
We work daily at counseling with and finding the best alternatives
For our clients.
We are here to furnish information and help our clients Day in and day out.
Please contact us.
BERNIE LOWE & A55DCIATE5. INC.
Insurance Administrators to Professional Associations &
Universities and Colleges
1 -BOO-942-471 B FAX 515-222-0915
2700 Westown Parkway. Suite 410 West Des Moines. Iowa 50266-1411
515-222-0B11
IOWA MEDICAL SOCIETY • EXPERIENCE THE PARTNERSHIP
An organization that advocates for physicians and patients?
Julius Conner, MD Polk County Department of Public Health Des Moines
That’s right! The core purpose of the Iowa Medical Society is to assure the highest quality health care through its role as physician and patient advocate. All Iowa physicians care about the well-being of Iowans, no matter what other professional and personal concerns affect their day-to-day practices. Working together as partners on long and short-term projects, IMS physicians are able to contribute to the overall health of Iowa patients.
"The Iowa Medical Society has proven a great resource for educating physicians and patients about public health concerns."
Julius Conner, MD
IMS seeks opportunities to educate physicians and patients about public health concerns. Your membership dues this year have helped pay for a new video that will train mandatory reporters to recognize the signs of dependent adult and child abuse. Physician contributions to the IMS Education Fund helped support the distribution of 7,500 domestic abuse victim education and intervention booklets.
"The Iowa Medical Society brings into focus important public health issues such as consumer access to medical care and quality of care in managed care contracts. IMS also promotes important legislative actions which will impact the health of Iowans."
Rizwan Shah, MD
Concern for public health extends to ensuring that Iowans have access to quality medical care. Before managed care products even hit the Iowa marketplace, the IMS worked with other health care organi- zations and Iowa insurance companies to create the “Principles of Agreement,” a document which protects the rights of patients as well as physicians under managed care. Last year, patients also received the right to choose their physicians thanks to a point-of-service law proposed and supported by the IMS. The new IMS Committee on Public Health takes advantage of the partnership of IMS members to further support public health advocacy activities.
Rizwan Shah, MD Pediatrician Blank Childrens Hospital Des Moines
Experience the partnership! Contact Jeanine Freeman at (800) 747-3070 for more information on how you can participate in IMS public health initiatives. Not a member ? Contact Sheryal Westbrook at (800) 747-3070 for membership information.
IMS
trends
"SECRET" list
Iowa ranks third in the nation in the number of seri- ous disciplinary actions against physicians according to “Questionable Doctors: 1998 Edition”. The book was recently released by Dr. Sid- ney Wolfe’s public citizen health research group. While the book’s foreword says information on doctors who have been disciplined is often “kept secret from patients,” the book actually contains information available to the public through state medical boards. In Iowa, major news- papers including the Des Moines Register regularly pub- lish names of doctors disci- plined by the BME. Iowa’s third place discipline ranking
— an average 8.57 serious actions per 1,000 physicians
— earned a “best state” des- ignation from Dr. Wolfe’s group.
%/%
CD
V)
union feasibility
The California Medical Association (CMA) House of Delegates has voted to conduct a feasi- bility study of creating a union subsidiary to bar- gain collectively for state government-employed physicians and residents. The CMA board was scheduled to vote on the proposal to create a guild in May. (New York Times , February 22, 1998) Market Trends.
G>
C
5)
c
Stephen Gleason, DO is the new vice president for medical affairs of Catholic Health Initiatives for the Central Midwest Region.
Rick Turner, MD, Des Moines, was app- ointed chief medical officer of Mercy Clinics.
Valerie Bonnet, MD relocated her practice to Maternal Health Center, Bettendorf, Iowa.
Surgeon Willie McClairen, Jr., MD is the new medical director for Mercy Trauma Ser- vices.
Lisa Veach, AID recently assumed respon- sibilities as 1998 medical staff president at Iowa Methodist Medical Center.
Contact Tina Stoner at the IMS, (SIS) 223-1401, (800) 747-3070 or by email at kstoner@iowamedicalsociety.org if you have news about physician practice changes.
MBS ggg
graduates
Congratulations to the following graduates of the IMS Medical Business Specialist program: Sandra Nicholson, Iowa Heart Center; Danette Pease, Wolfe Clinic, West Des Moines; Robin Aaronson, Bradley DeWall, Davenport; Maralee Dyson, UIHC-Depart- ment of Neurology, Iowa City; Janell Behnke, UIHC- Department of Neurology, Iowa City.
8 Iowa Medicine May/fune 1998
IMS advocate
IMS House of Delegates SAITS
The IMS House of Dele- gates said yes to a new vision for IMS.
The plan, created by a 16- member task force, revamps the organization so it is better prepared to meet the needs of today’s physicians. It won overwhelming approval from delegates attending the IMS Annual Meeting April 18-19.
IMS governance structure will be revamped to be more accessible, responsive and supportive of informed deci- sion-making. A new core mis- sion and values will be the foundation for IMS activities. The IMS Judicial Council
and Executive Council will be phased out in 1999 and a new Board of Directors created. The 15-member board will include six geographic repre- sentatives and three officers. Statewide elections will be held to fill the remaining six seats, with candidates chosen by a nominating committee. The committee will be charged with choosing candi- dates based on expertise, interests and demographics other than geography.
Beginning in 1999, physi- cians will be able to elect how they are represented in the IMS House of Delegates.
Financial deunification of the IMS and county medical societies will occur in three years.
— »
YES to
Physicians at the April Annual Meeting directed the current board of trustees to cre- ate a committee to study various modes of repre- sentation.
The plan also calls for financial deunification of the IMS and county societies following a three-year phase in.
A new IMS clinic adminis- trators section will be created for clinic executives of prac- tices which have 80 percent IMS membership.
IMS E&M advocacy recognized NATIONALLY
^ | Yie American Medical JL Association (AMA) invited IMS to be one of 12 state medical societies to par- ticipate in a new committee on E&M coding.
IMS became heavily involved in member advocacy in 1996 when Iowa physicians began experiencing a com- paratively intense level of Medicare audit activity. Last December, the IMS delega- tion introduced a resolution at the AMA House of Dele- gates which dealt with physi-
cian rights when audited.
The focus of the advisory committee will be input on correcting the E&M coding guidelines and education efforts for physicians.
“This invitation demon- strates that IMS efforts on behalf of its members have come to the attention of orga- nized medicine nationally,” commented Harold Miller, MD, IMS president. “For a small state such as Iowa to be included recognizes the quali- ty of our advocacy efforts.”
Other states included on the AMA committee include Florida, Texas, New York, California and Pennsylvania.
Two physicians will repre- sent IMS on the advisory committee — Michael Guffy, MD of Ames and John Brinkman, MD of Mason City. Last year, Dr. Brinkman, incoming IMS president, was appointed by the IMS Board to head up IMS Medicare advocacy efforts. (See page 2 1 for more news about IMS Medicare advocacy.)
Iowa Medicine May/June 1998 9
on the hill
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IMS prepares for 1 999
The gavel has fallen on the 1998 session of the Iowa General Assembly. How did issues of interest to the house of medicine fare this year?
For the first time since 1990, a two percent increase in Medicaid reimbursement for physicians was approved. Early lobbying by IMS assured executive branch and legislative support. The Department of Human Ser- vices (DHS) must study the adequacy of Medicaid reim- bursement rates for physi- cians and report to the legislature in January 1999.
An exciting achievement for the medical community was passage of legislative authorization for implemen- tation of Title XXI, the state children’s health insurance program (SCHIP) in Iowa. House File 2517 created the Healthy and Well Kids in
Plans for 1 999
To create a statutory duty of care for managed care health plans
To alter Iowa's HIV testing requirements to minimize the current burdens of informed consent and to treat HIV like other sexually transmitted diseases To repeal Iowa's certificate of need law
Iowa (HAWK-I) program, governed by a seven-person board and administered by the DHS. An IMS working group of physicians from the Iowa Academy of Family Physicians, the Amer- ican Academy of Pediatrics-Iowa Chapter, the Uni- versity of Iowa and Blank Children’s Hospital met weekly through- out the session and effectively advocated for passage of this bill.
An IMS bill to assure reim- bursement to county medical examiners regardless of the deceased’s county of resi- dence passed and has been signed by the governor.
IMS amendments to light- en the current burden for reporting spontaneous termi- nations of pregnancy met with considerable resistance; legislative leaders, however, understand that IMS will pursue this issue in 1999.
The physician Hen bill, opposed by the trial bar, failed to come out of Senate Judiciary Committee.
An exemption for Iowa nonprofit hospitals from pay- ment of sales tax on sales and
services to be used in hospital operations passed. The 1998 IMS House of Delegates directed the IMS board to study the feasibility of a physician sales tax exemption.
Students who default on loans from the College of i Aid Commission are subject to disciplinary action by their respective licensing board.
interim studies are called for in legislation: decentralization of the Iowa Indigent Patient Care (State Papers) program and review of Medicaid prior authoriza- tion and drug utilization review systems.
And what about next year? The 1998 House of Delegates directed IMS leg- islative attention to managed care issues, particularly cre- ation of a statutory duty of care for managed care health plans; change in Iowa’s HIV testing requirements to mini- mize the current burdens of informed consent and to treat HIV like other sexually trans- mitted diseases; and repeal Iowa’s certificate of need law.
1 0 Iowa Medicine May/June 1998
legaliti
minors: a medi
care DILEM
Who calls the shots when minors seek abor- tions or treatment for mental illness or STDs?
by Jeanine Freeman, JD
Physicians face many issues in providing care to minors.
AMA policy advises physi- cians, within the bounds of the law, to promote autono- my of minors, but encourage parental involvement.
The law has long recog- nized the right and duty of parents to control the med- ical care of their children. Generally minors should not be treated without their par- ents’ consent; however, the minor’s best interests control the treatment.
In Iowa, a minor is defined as a person under the age of 18, married or living indepen- dendy.
If a pregnant minor is seek- ing an abortion, Iowa’s parental notification law must
be consulted. If the minor is seeking ongoing prenatal care, parental involvement should be encouraged, but if refused, confidential care should be provided. At birth, the mother then directs the infant’s care, but if the physi- cian believes she is incapable, parental, social service or court involvement must be considered.
In Iowa, minors by law may consent to treatment for sub- stance abuse; for venereal dis- ease, AIDS, and other sexual- ly transmitted diseases in- cluding contraceptive ser- vices; and for mental illness. Positive HIV results must be reported to the minor’s legal guardian, unless there is an exception.
Emergency care can be provided without consent when the patient is unable to consent and no other person who can consent is available. If parents authorize someone to consent for their child’s care in their absence, autho- rization should be in writing, provided to the physician by the parents and relied upon
only for routine or emergency care. Reasonable effort should be made to contact the par- ents.
Unless a divorce decree or other court order directs oth- erwise, parents enjoy equal rights and responsibilities for the medical care of their chil- dren. When parents disagree, further counseling is advised and intervention may be required.
Parental refusal of medical care for their children on reli- gious grounds poses sensitive legal interests that must be balanced. Iowa case law sup- ports intervention on behalf of the child whose care is compromised. By statute, a parent may execute an affi- davit to refuse mandated childhood immunizations on religious grounds. Parents who refuse medical care for their child based solely on religious beliefs are not guilty of child abuse, but a court may order the medical care.
Jeanine Freeman is vice president of public policy and advocacy for the Iowa Med- ical Society. Information in this column is not intended to be legal advice. Call your attorney with specific ques- tions or concerns.
Iowa Medicine May/June 1998 1 1
reimbursement
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with increased
Effective January 1, the Balanced Budget Act allowed for increased reim- bursement and removal of site restrictions for nurse practi- tioners, clinical nurse special- ists and physician assistants.
Carriers have been instructed to begin issuing NP/CNS/PA provider numbers “on a pri-
ority basis in the most expedi-
Unclear on non-physician practitioner billing?
IMS Services will present a day- long workshop on NP/CNS/PA (and others) billing on August 4, 1 998 in Newton, Iowa at the DMACC conference center. Mark your calendar now!
sSSH rH&
NP/PA reimbursement
tious manner possible.” Regardless of the setting, NPs, CNSs and PAs will receive reimbursement at 85 percent of the physician fee schedule.
The implementing instruc- tions made it clear that these provider types can continue to bill “incident to” a physi- cian receiving 100 percent of the physician fee schedule. However, HCFA is consider- ing policy changes that will decrease “incident to” reim- bursement to 85 percent.
Points to consider
Payment differential: “Incident to” services are paid at 100 percent of the fee schedule while NP/CNS/PA direct billing is paid at 85 percent.
2 If you choose “incident to” and 100 percent reimbursement, is your office 100 percent compliant with Medicare’s “incident to” requirements?
3 Can your billing system handle services billed both ways?
healthy iowans
IMPACT on
public health
Several initiatives affecting public health were passed in 1998, many as appropria- tions bills.
A bill sparked in part by the IMS Committee on Public Health, Senate File 2161 requires reporting of positive HIV test results by name to the Department of Public Health.
Children will be required, as of school year 1999-2000, to show proof of immuniza- tion for hepatitis B prior to
enrollment. Senate File 2341 applies to children bom after July 1, 1994.
The Department of Health appropriations bill, Senate File 2280, requires establish- ment of a task force to evalu- ate current infectious disease laws and to report back by January 1, 2000. That bill also designates a statewide poison control center; creates a domestic abuse death review team patterned after the child death review teams; establish-
es the AAP/ACOG perinatal guidelines as a basis for the Iowa statewide perinatal pro- gram; and implements methamphetamine control measures.
House File 2340 includes OB/GYN services in the state volunteer provider program.
Organ procurement efforts in Iowa will be monitored under Senate File 2285 which requires annual reports on organ donation rates.
12
Iowa Medicine May/June 1998
your IMS
IMS member distinctions & b
i *
MARION ALBERTS,
MI) was honored for 27 years of service as scientific editor of Iowa Medicine.
DAVID CARLYLE, MI) was a guest author on “Devel- oping Health Coverage for Iowa Children,” in a recent issue of the Des Moines Register.
GEORGE DRAKE, MD was named Physician Precep- tor of the Year by the Drake University College of Pharma- cy and Health Sciences.
MICHAEL GIUDICI, MD and RICHARD SADLER, MD implanted the world’s first biventricular pace- maker-defibrillator into a male patient with dilated cardiomy- opathy.
BOB LARSON, MD
donated 83 large cartons of medical supplies and equip- ment to Berlin, El Salvador after closing his clinic in Beaverdale.
PAULA MAHONE, MD and KAREN DRAKE, MD
tied for first place in the “Top 10 fist of all-time achievements in Black Health History” for delivery of the septuplets.
MCFARLAND CLINIC was featured in a recent issue of Medical Economics in an arti- cle on how to build market leadership.
MONTGOMERY COUNTY MEMORIAL HOSPITAL in Red Oak, Iowa will receive a grant from the National Rural Health Associ-
ation to support innovative programs in continuing profes- sional education.
MARY RADIA, DO received the Drake University of Pharmacy and Health Sci- ences Achievement Award.
LYNN STRUCK, MD, has taken office as the first woman president of the Polk County Medical Society.
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DECEASED MEMBERS
MARSHAL HUSTON, MD, 88, life member, otolaryngology, Cedar Falls.
HAROLD RODDY, MD, 86, emeritus member, obstetrics and gynecology, Mason City, February 2, 1998.
RAYMOND BUNGE, MD, 92, fife member, urology, Johnson County, February 20, 1998.
RAYMOND SHANK, MD, 73, emeritus member, anesthesiology, Cedar Rapids, February 17, 1998.
Creative piQCllCG arrangements
Innovative practice arrangements was the number one topic of interest for Iowa women physicians answering a recent survey conducted by Iowa Medical Society. The survey results are the basis for planning the IMS Retreat for Women Physicians October 9-10 in West Des Moines.
Kathryn Opheim, MD of Sioux City is chairperson of
the planning committee for the retreat. A panel is being assembled to discuss new practice arrangements. The panel, which will be moder- ated by Jane Winston, MD of Des Moines, will tenta- tively include a physician who heads an all-women OB/GYN group in Califor- nia.
Other program topics at the retreat will include nego-
tiating for success and how women can do a better job of commu- nicating in a male- dominated workplace. Paula Mahone, MD (see “Awards and Distinctions” column above) will also be a guest speaker.
Watch your mail this summer for a program brochure.
Dr. Regina Benjamin, AMA's young physician trustee, has won the 1 998 Nelson Mandela Award for Health and Human Rights. The award, presented to Dr. Benjamin by Archbishop Desmond Tutu, rec- ognizes achievement and leader- ship in health care for the disadvantaged.
Dr. Benjamin will speak at the Iowa Medical Society's first retreat for women physicians October 9-1 0 at the West Des Moines Marriott.
Iowa Medicine May/June 1998 1 3
Legislature SO
future world
(A
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American Medical Association:
www.ama-assn. org
Salu.net: www.salu.net
no more
CHMIS fund
Iowa’s Community Health Management Information System (CHMIS) will go through yet another transi- tion in 1998. A bill repealing the CHMIS law passed the 1998 Iowa Legislature.
The bill does not appropri- ate any more funds to CHMIS and recommends using the remaining funds to develop a transition plan for the future of CHMIS. Any funds remaining after the transition plan is developed will be used for a study of the uninsured population of Iowa and related health data needs.
The IMS will participate in a committee to create a tran-
sition report which is due to the legislature December 1 1998. The committee’s charge is to explore the use and collection of health information for health policy and plan- ning decisions in Iowa, as well as what agency or public/private partnership will best serve this function.
The committee will review the CHMIS mission state- ment, accomplishments and failures. It will also identify what other organizations are collecting and disseminating health information to the general public and will rec- ommend to the CHMIS Gov-
marketing your practice online
atients are increasingly turning to home com- puters as a first resource in researching everything from auto prices to zoo attractions and even physicians, making it important for physicians to market their practices online.
Practices who want to test the online waters before investing a lot of time and money in designing a web site should take advantage of two free online site design opportunities.
As part of the American Medical Association’s Physi- cian Select, an Internet-based physician locator, AMA members receive a free web page. While simple in design, these pages can include per- sonalized practice informa- tion, such as office hours, practice philosophy, managed care affiliations or achieve- ments. See www.ama-assn.org for more information.
You can create a complete web site for free through
Salu.net ( www.salu.net ), a physician-run company spe- cializing in practice sites.
You have a choice of six dif- ferent designs complete with personalized information, a patient discussion group and patient education resources. You can update your site regularly using a simple form on the Salu.net web site. As part of Salu.net, you have access to its member site of resources designed for physicians.
14 Iowa Medicine May/June 1998
Patient complaints:
Your response is critical
Patient complaints.
Doesn’t everyone get one eventually? Many physi- cians have reported a surpris- ing increase in the number of complaints. Are more patients complaining? Stud- ies have established that angry patients are more like- ly to sue if they have a bad outcome. Often the first warning sign is a complaint. How you respond may mean the difference between a dis- cussion and a lawsuit.
Verbal complaints may be the most challenging. Your immediate reaction may be defensive. The following techniques will help you avoid a defensive report:
• Stop and consider what the patient has said instead of immediately reacting.
• Empathize with the patient using phrases such as, “I understand...” or “You sound frustrated....”
• Establish a complaint procedure in your office to
This column is provided by Mid- west Medical Insurance Company especially for Iowa physicians. For more information, call Lori Atkinson, MMIC risk manage- ment supervisor, at (800) 798- 9810 or (SIS) 223-1482.
help defuse the situation.
Written complaints allow more time to formulate a reply but are often more dif- ficult to answer. Always respond! A thoughtful response may resolve the issue and prevent a lawsuit or BME complaint. Some tips to consider before putting
pen to paper:
• Draft a response that is conciliatory, not defensive.
• Answer all questions.
• Keep it simple and objective. Avoid medical jargon.
• Put yourself in the patient’s position and imag- ine receiving the letter.
h
ow we learn
Education ,s ESSENTIAL
Medical education is not an abstract con- cept. The educational process is rich and diverse. It requires complex institutions, such as academic medical centers and an entire spec- trum of regional and com- munity health care facilities. The process engages physi- cians and other health care professionals in almost every conceivable practice setting.
Most importantly, educa- tion requires the commit- ment of people as patients. Students, residents and prac- ticing physicians cannot acquire or improve their knowledge and skills without
the cooperation of individu - als receiving health care.
Equally essential is the commitment of the educator and learner to patients, and especially to vulnerable pop- ulations that might otherwise not receive necessary care and services. Patients with complex health conditions, patients whose illnesses defy known treatments, patients who have no insurance or ability to pay — these are the patients with whom educa- tors and their institutions have a special contract. This social mission of medical education has deep roots and must endure.
This column is written by Dr. Richard Nelson, associate dean, University of Iowa College of Medicine.
Iowa Medicine May/June 1998 1 5
feature
Medical
musical
lowas physician supply is increasing while man- aged care and use of physician extenders are reducing opportunities.
by Chris McMahon
Experts are seeing an unprecedented trend in Iowa’s physician supply, and it’s a trend that is
occurring faster than anyone anticipated.
Roger Tracy, widely
acknowledged as the guru of physician sup- ply in Iowa, says our state is experiencing a “steady increase” in the num- ber of physicians and a simultaneous decline in the number of job opportunities for physicians in all areas, including family practice.
UNPRECEDENTED TRENDS
“I’m seeing things I thought I wouldn’t see in my career,” comments Tracy, director of the University of Iowa’s Office of Statewide Clinical Education Programs. The staff includes six people who spend the bulk of their time tracking job opportuni- ties, supply and movement of Iowa physicians and other health professionals.
During the period from 1977 to 1996, the number of Iowa physicians increased by 42 percent. About 50 percent of the increase in recent years has been in primary care (family practice, general internal medicine, pediatrics
1 6 Iowa Medicine May/June 1998
Number of PA graduates per year 1984-1996
and obstetrics/gynecology). Sixty percent of Iowa’s pri- mary care physicians are now in networks or integrated health systems.
“There are only 29 inde- pendent medical communi- ties among towns large enough to have a hospital,” Tracy adds.
On December 31, 1997, there were 4,416 practicing Iowa physicians. Based on analysis of current trends, Tracy believes there will be 5,000 practicing Iowa physi- cians by 2005. Although Iowa’s net gain is only half the national average, it is problematic because of an
accompanying trend toward declining job opportunities, even in primary care.
“We still had 150 family practice positions open in Iowa last year, but this num- ber is declining,” Tracy explains.
THE GREENING OF IOWA PHYSICIANS
The days of physicians continuing to practice into their seventies are nearly over. The average age of retirement for Iowa physi-
cians is about 60; only 1 1 percent of practicing Iowa physicians are over age 60.
Less surprising is the fact that nearly half of Iowa’s net gains are women. “Women now comprise 1 7 percent of
our physician population,” Tracy says. “By 2005, they will likely account for approximately 25 percent.” The supply of physicians continues to increase and there is a major shift in career interests, with more young physicians choosing primary care.
“In Iowa, we’ve done an excellent job of producing family physicians and attract- ing family physicians from other states,” Tracy reveals.
If the state’s physician pop-
ulation is changing, Iowa’s health care system evolution is even more dramatic.
“There have been substan- tial changes in Iowa’s health care system, due in part to managed care. Iowa has not seen the level of managed care market penetration that is occurring in other states, but there is a perception here that managed care will have an even greater impact in the future.”
BIG PUSH TOWARD COST-EFFICIENCY
Tracy says this perception has brought a real push toward cost efficiency, and this push has drastically changed Iowa’s health care landscape.
Communities of under 2,000 with no hospitals have stopped looking for a full- time physician, moving instead to satellite clinics populated by physician extenders.
“There has been a tremen- dous increase in physician
Chris McMahon is vice president of communications for the Iowa Medical Society.
U —
The number of PA training programs has tripled during the last three years. By 2000, PA programs will be graduating approximately 5,000 students nationally.
Iowa Medicine May/June 1998 1 Z
assistant and nurse practi- tioner enrollment,” Tracy says. “The number of PA training programs has tripled during the last three years.
By 2000, PA programs will be graduating approximately 5,000 students nationally.”
REPOPULATING NON- HOSPITAL COMMUNITIES
With the increase in physi- cian supply and a decline in job opportunities in the met- ropolitan areas, physicians
have begun moving into communities which at one time had one or more physi- cians but in recent years have had only part-time services.
“Physicians are repopulat- ing non-hospital communi- ties at a noticeable rate,” Tracy explains. “General internists are entering prac- tice in rural communities by the legion.”
During the past two years, 150 specialists entered prac- tice in towns with popula-
tions under 30,000.
“This is absolutely unprecedented,” Tracy com- ments.
DECLINING METRO OPPORTUNITIES
In all, the Statewide Fami- ly Practice Training Program has retained 60 percent of its graduates over the life of the program; half of these gradu- ates have selected rural towns for their practices. In the past two years, more than 70 per- cent of the gradu- ates have stayed in Iowa due to the influence of Iowa’s primary care physi- cian networks. Rural towns are faring well due to the decline of fam- ily practice oppor- tunities in metro areas.
“Ninety-eight percent of lowans who reside in towns without physicians are within 1 5 min- utes from the nearest prima- ry care physician,” reveals Tracy.
The trends in physician supply are extremely advan- tageous for those recruiting physicians.
“Recruitment has become very precise. Physicians and administrators who call our office in search of a physician give us five or six specific demographics and then we
try to fill their order,” Tracy says. “But before they call, they have established the need for another physician without a doubt.”
WHAT'S AHEAD?
Tracy says the trend toward increasing numbers of physicians and decreasing job opportunities shows no sign of abating. The increased number of women entering the physician job market could have a slight effect on the trend, since women physicians are more likely to work part-time, to take fami- ly leave and to spend more time with their patients.
“These factors would seem to indicate it may take more women to fill the same num- ber of positions,” Tracy spec- ulates.
Medical school deans, medical students and resi- dents in training are “very sensitive” to the trends,
Tracy concludes.
“Medical students are wor- ried about their futures.
Deans of medical schools are very aware of increasing sup- ply. They realize this could become a very big issue in the future.”
1 8 Iowa Medicine May/June 1998
Provider Service Center: Statewide: 800-562-2218
Des Moines: 515-245-4688
1998 Annual Meeting Recap
William Kuyper, MD and his son Jake are late for a very important meeting.
Dubuque Brass — Andy Butler, French horn; Hunter Fuerste, MD, trombone; Timm John- son, tuba; Mark Falb, trumpet; and Gary Kirst, trumpet — entertained the banquet crowd with the William Tell Overture in double time.
Physicians visited the Vision Center throughout the week- end to hear about the IMS Strategic Plan. (And received a free mouse pad!)
Jose Angel, MD member of the IMS Task Force on Strategic Planning, discussed the new vision for the IMS with Edward Hertko, MD.
Paul Seebohm, MD and his wife Dorothy won two airline tickets by pre-registering for the annual meeting. "Other places I've been affili- ated with have either sent me out to pasture or over the hill, but the IMS is sending me into space," Dr. Seebohm quipped.
Dr. Joyce Brothers delighted banquet guests with her wit and wisdom.
20 Iowa Medicine May/June 1998
your practice
E&M CODING: Physicians are
educated but still CONFUSED
Education can't over- come problems inherent in the guidelines, IMS tells congressmen.
The IMS is raising seri- ous concerns about version two of HCFA’s E&M documentation guidelines.
E&M Medicare billing codes describe the level of history, exam and medical decision-making of physician visits. The first version of the E&M guidelines was released by HCFA and the American Medical Associa- tion (AMA) in 1994, with the goal of giving physicians a way to judge their level of documentation.
IMS, in partnership with the local Medicare carrier, has been actively educating Iowa physicians since the first guidelines were released. Data show these efforts have been successful. Iowa physi- cians use the E&M high level codes at a rate consis- tency less than other physi- cians in the nation. Over- coding has decreased by 27 percent; undercoding has
decreased 17 percent.
However, no amount of education can overcome the problems inherent in the guidelines, IMS representa- tives said in a recent letter to Iowa’s congressional delega- tion. “Iowa physicians remain concerned about the complexities of the guide- lines,” said Harold Miller, MD, IMS president. “Along with extremely detailed requirements, the results of trained auditors using the guidelines cannot be repli- cated.”
Some physician offices have asked IMS practice management staff to “audit the auditors.” In 44 of 102 patient records, IMS staff and the auditors have dis- agreed on the appropriate code. In another test audit, IMS staff and the Medicare carrier disagreed in 50 of 117 records.
“The E&M guidelines are the latest example of detailed government regulations that are subject to interpretation and, in these cases, produced results which cannot be replicated,” Dr. Miller told Iowa congressmen.
Concern over both ver-
sions of the guide- lines has generated at least two letters to the AMA — one from IMS and one from John Olds,
MD former medical director for Iowa Medicare carrier.
In his letter to the AMA, Dr. Olds cited the success of joint education efforts by his agency and IMS as proof physicians “can learn to doc- ument E&M services and code them accurately.”
However, he cited the lack of “broad-based review and comment from the affected specialties” as the reason physician concern over the guidelines continues — even in Iowa where education has been intense.
The possible failure to solicit input has led to “a feeling that the guidelines are cumbersome and place physicians at risk for unjust fraud enforcement,” Dr.
Olds said.
The IMS continues work- ing with AMA on improving the guidelines and to ensure that underdocumenting is not treated as fraud.
U
In 44 of 1 02 patient records, IMS and auditors have disagreed on the appropriate code.
11
Iowa Medicine May/June 1998 21
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your money
IRAs
really
IRA owners and their beneficiaries can be sig- nificantly affected by new distribution rules.
by Jerry Foster
For many people, an IRA is one of their largest and most trea- sured assets; yet it is their most carelessly handled asset. Distribution strategies for the owner and beneficiaries of IRAs can be significandy affected if careful thought is not given to the beneficiary designation of the IRA.
The Taxpayer Relief Act of 1997 provided amendments to proposed regulation regarding tax deferred retire- ment plans. Previously, only an irrevocable trust could be named an IRA beneficiary if tax deferral was a goal. The new ruling allows IRA owners to use revocable trusts as the beneficiary of the IRA. This
is the heir
apparent?
will allow for several planning strategies, including the fol- lowing:
1A trust allows trustees to control the distribution of the IRA assets even after the trustee dies. This is important if there is a concern about the bene- ficiary of the trust being able to