MetroDoctors

2 September/October 2012 MetroDoctors The Journal of the Twin Cities Medical Society

Physician Co-editor Lee H. Beecher, M.D.Physician Co-editor Peter J. Dehnel, M.D.Physician Co-editor Gregory A. Plotnikoff, M.D., MTSPhysician Co-editor Marvin S. Segal, M.D.Physician Co-editor Richard R. Sturgeon, M.D.Physician Co-editor Charles G. Terzian, M.D.Managing Editor Nancy K. BauerAssistant Editor Katie R. Snow

TCMS CEO Sue A. SchettleProduction Manager Sheila A. HatcherAdvertising Representative Betsy PierreCover Design by Outside Line Studio

MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413.

To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of TCMS.

Send letters and other materials for consideration to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. E-mail: [email protected].

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September/OctoberIndex to Advertisers

TCMS Officers

President: Peter J. Dehnel, M.D.

President-elect: Edwin N. Bogonko, M.D.

Secretary: Lisa R. Mattson, M.D.

Treasurer: Kenneth N. Kephart, M.D.

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

TCMS Executive Staff

Sue A. Schettle, Chief Executive Officer(612) 362-3799

[email protected]

Jennifer J. Anderson, Project Director(612) [email protected]

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors(612) [email protected]

Andrea Farina, Executive Assistant(612) [email protected]

Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota(612) [email protected]

Katie R. Snow, Project Coordinator(612) [email protected]

For a complete list of TCMS Board of Directors go to www.metrodoctors.com.

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MetroDoctors The Journal of the Twin Cities Medical Society September/October 2012 3

V O L U M E 1 4 , N O . 5 S E P T E M B E R / O C T O B E R 2 0 1 2

CONTENTS

Page 29

Page 10

2 Index to Advertisers

5 IN THIS ISSUE

Geriatric Care — A Prelude By Marvin S. Segal, M.D.

6 PRESIDENT’S MESSAGE

A 20/20 Vision for Health Care in 2020 By Peter J. Dehnel, M.D.

7 TCMS IN ACTION

By Sue Schettle, CEO

CARING FOR OUR ELDERLY

8 Where is Geriatrics at the University of Minnesota’s Academic Health Center? By Ken Kephart, M.D.

10 Colleague Interview: A Conversation With James Pacala, M.D.

14 Boiling Down the Basics of Cognitive Impairment and Alzheimer’s Disease for Family Practitioners By Richard Golden, M.D.

17 Baby Boomers Reckoning on Medicare By Stephen T. Parente, Ph.D.

19 The Role of the Long-Term Care Medical Director By John W. Mielke, M.D., CMD

23 Long-Term Care Insurance — Preventive Medicine for Your Retirement? By Deb Newman, CLU, ChFC, LTCP

25 The Minnesota Board on Aging: Your Link to an Expert in Local Services By Jean K. Wood

27 Own Your Future

28 Patience Breeds Success By Jennifer Anderson

Senior Physicians Association News

29 Sharing the Experience Conference Expands its Reach By Barbara Greene

Career Opportunities

30 In Memoriam

New Members

32 LUMINARY OF TWIN CITIES MEDICINE

Reuben Berman, M.D.

On the cover: Caring for the needs of the elderly can be challenging, but also quite rewarding. Articles begin on page 8. Page 7

Page 32


I N T H I S I S S U E . . .

Geriatric Care — A Prelude

By Marvin S. Segal, M.D.Member, MetroDoctors Editorial Board

THE MAGNITUDE OF CARING FOR the medical needs of our

senior population is immense. Currently, over 13 percent of the

U.S. population is 65 or older. By 2030 that demographic group

is expected to number 68 million. At age 65, life expectancy is

about 19 years, at age 75 it’s 12 years and at 85 is 7 years. Not

only are we dealing with these huge and increasing numbers, but

the complexity and severity of our geriatric folks’ health-inherent

conditions is increasing.

This demographic group is not just representative of average

adults who happen to be some years older; rather, they are unique

in their health status and in the requirements necessary to care

for them in a quality fashion.

It is indeed a privilege to watch over and fulfill the health

needs of our elderly. This issue of MetroDoctors should help us

to even better accomplish just that.

Regarding the first article that discusses the University Medical

School’s geriatric involvement, we’re led to wonder if it’s enough

for the medical community to simply service the care needs of

the geriatric population — or is more to be expected? In the long

run, will focused educational approaches result in accompanying

improvements in both quality of care and fiscal savings? Dr. Ken

Kephart addresses those questions…and more.

In our Colleague Interview where meaningful questions

were submitted by our Editorial Board and community physi-

cians, Dr. James Pacala responds in covering a gamut of geriatric

issues — including preventive care, polypharmacy, psychiatric

care reimbursement — and provides an emphatic and forthright

answer to the “death panel/rationing” question notable in today’s

political rhetoric.

Dr. Richard Golden explores the exploding problem of senior

dementia by practically addressing many of the important aspects

of this complex issue, including risk factor assessment, diagnostic

symptomatology, current treatment status, vehicular operation

and caregiver support.

An economic view of Social Security and Medicare funding

issues is clearly presented by Stephen Parente, Ph.D. along with

future consequences and predictions of these prominent entitle-

ment issues.

Dr. John Mielke relays modern standards and expectations of

long-term care facilities along with a recounting of roles, functions

and practical approaches utilized by their medical directors.

A concern for the future affecting all age categories is ad-

dressed by Deb Newman as she discusses the advantages of pur-

chasing long-term care insurance by individuals and businesses

along with accompanying governmental incentives for doing so.

Jean Wood of the Minnesota Board on Aging provides us

with a striking array of meaningful local services available to our

geriatric population, and the “Own Your Future” initiative stresses

the importance of planning now for the future.

www.ama-assnorg/go/geriatriccare is a link to a helpful new

publication by the AMA, “Geriatric Care by Design.” Check it

out.

What better way to cap this issue than by providing a real

life example of an actual relevant and productive senior citizen?

One of our own, the very special Dr. Reuben Berman is featured

as our Luminary of Twin Cities Medicine.

Enjoy this month’s issue of MetroDoctors…it’s a good read!


President’s Message

A 20/20 Vision for Health Care in 2020

PETER J. DEHNEL, M.D.

What is your vision for ideal health care by the year 2020? What new services,

treatments and medical devices will be readily available eight years from

now that are not available today? What will define “optimal access” for

people, both at a primary care and specialty level? Will there be transformations that

redefine our roles as physicians, such as through “virtual visits” and other telemedicine-

based care? What will it take to get from where we are today to your vision for great

health care? As with any other high quality outcome, this will not happen by itself,

but will take planning, determination and resources. Many of us firmly believe that

without significant physician input and leadership, the outcome will be unsatisfactory.

This topic is especially germane to this edition of MetroDoctors which focuses

on health care for seniors. The opening question morphs into what will optimal care for seniors look like

in 2020? What do we need to start to do today, in a collaborative fashion, to be ready for the challenges

that will confront us as a profession eight years from now?

The challenges are definitely daunting. By the year 2020, the first half of the “baby boomer” gen-

eration will be eligible for Medicare. We collectively have not taken care of our bodies very well. There

will be increasing pressure on Medicare and the Medicare supplemental insurance programs to cover

more and more innovative and highly specialized treatments for an ever-expanding portfolio of disease

processes. Examples are easy to find even today: Two sequential stem cell transplantations are now the

standard of care for a handful of hematopoietic-based cancers. Hepatitis C is a potentially curable infec-

tion, but may require expensive “triple therapy” to eradicate this intracytoplasmic virus. One of the newer

“biologics” — rituximab — works very well on a handful of diseases through the selective reduction of

B lymphocytes, but at a cost of $12,500.00 per month for just the drug, without any of the associated

clinical costs. Knee replacements — while not on the list of extremely high cost procedures — will exert

considerable financial pressure through the sheer volume of eligible individuals who meet the criteria

for replacement surgery.

There will be significant competition for financial resources nationally by 2020 as well. Social

Security will have increasing “distribution pressures.” Retirees wanting monthly distributions from

underfunded pension obligations, especially after retirement from public sector jobs, will add further

financial stress. Subsidies for health insurance for individuals under 65 years will be substantial, given

the likely costs of new and emerging technologies and pharmaceuticals. This is in addition to the very

real costs of unhealthy lifestyles. Just as one example, the FDA recently approved Belviq and Qsymia

for treatment of obesity. These drugs are likely to be expensive when they are finally available on the

market, and with 60-plus percent of us overweight or obese, the impact can be huge by 2020. Finally,

payments to service our blossoming national debt will “come home to roost” by 2020.

So back to the original question: What is your vision for ideal health care by 2020? How do you

propose we get there? Are you willing to jump into the planning and implementation? As I suggested

above, physicians participating in and even leading these health care decisions are crucial for achieving

the best outcomes by 2020 and beyond. This needs to be you and me and the majority of physicians

reading this edition of MetroDoctors. Besides, we all have a personal and vested interest in this. We will

all hopefully make the transition from “provider” to “recipient” as participants in the health care system

as seniors ourselves.


TCMS IN ACTIONSUE A. SCHETTLE, CEO

TCMS NewsSenator Sean Nienow and Senator Michelle Benson attended the July 2012

TCMS Board of Directors meeting.

Both Senators serve on the Governors

Health Care Reform Task Force and

provided the TCMS Board with their

perspectives on a number of legislative

issues. Nate Mussell, our lobbyist, also

provided the Board with a summary of

the implications of the Supreme Court’s

recent decision to uphold much of the

Affordable Care Act.

If you’re interested in obesity prevention

and want to get directly involved in ad-

vocating at the local level, send Jennifer

an email at janderson@metrodoctors.

com.

American Cancer Society PartnershipTCMS will be working with the Ameri-

can Cancer Society on a public aware-

ness campaign on the dangers of tanning

and tanning beds. TCMS has had a

long-standing relationship with ACS

in large part because of the smoke-free

movement that both organizations spent

considerable time and effort advocating

for. Watch for more details of this part-

nership in our online newsletter.

Foundation NewsThe East Metro Medical Society Foundation and West Metro Medical Foundation have philanthropy on their

minds! We have been spending time

over the past year or so working to build

development programs for both foun-

dations. We have hired a consultant,

Andrea Carlson Nelson, to assist us in

this process and she has been working

with both foundations by conducting

interviews and soliciting input from

TCMS members from the East Metro

and West Metro. You will see a more

concerted philanthropic effort from our

foundations in the coming months.

Honoring Choices Minnesota’s 3rd

annual Sharing the Experience Confer-ence was held on Thursday, July 19.

Over 80 people attended the event. Dr.

Craig Bowron provided the keynote

address and focused his presentation on

stories about end-of-life care experiences

with patients and families. Members

of the media also attended the event as

well as a myriad of community mem-

bers. This was by far the most inspiring

Sharing the Experience event. (See

related article on page 29.)

Kris Stevens has joined TCMS as an

intern working solely on the Honor-

ing Choices Minnesota initiative. This

internship will last until the end of the

year and fulfills an educational cur-

riculum requirement for Kris. She has

been an invaluable asset to the Honor-

ing Choices Minnesota team and we

are keeping her very busy. If you know

of others who would be interested in

volunteering their time to the Honor-

ing Choices Minnesota initiative, please

contact us at [email protected].

Stefan Pomrenke, M.D., MPH, MATS

has joined the Honoring Choices Min-

nesota initiative working as a part-time

associate medical director for the faith-

based outreach work unfolding with our

partners from the Minnesota Council of

Churches.

Dean of the Medical School Aaron Friedman, M.D. spoke to the Senior Physicians Association at its July meet-

ing. Dr. Friedman provided an insightful

view of what’s going on at the medical

school and received a lot of questions

from the audience.

Eagan First to Pass Healthy Eating Ac-tive Living Resolution….Away We Go!Now that the city of Eagan has approved

the first Healthy Eating Active Living

resolution, project coordinator Jennifer

Anderson is setting her sights on other

locations across the metro. It is Jennifer’s

plan to have six additional cities adopt

a similar resolution by the end of 2012.

Senator Sean Nienow and Senator Michelle Benson.

Stefan Pomrenke, M.D., MPH, MATS.


Where is Geriatrics at the University of Minnesota’s Academic Health Center?

By Ken Kephart, M.D.

Medical Care Organizations

The Academic Health Center (AHC)

at the University of Minnesota takes

great pride in its composition, bring-

ing together the colleges of medicine, public

health, nursing, pharmacy, veterinary medicine

and dentistry for collaborative education and

training. It is noted as one of the most compre-

hensive academic health centers in the nation.

But, are you aware that geriatrics, as a specialty,

has no clinical presence at the AHC?

There is no clinical geriatrics practice at

the AHC. There is no geriatrics assessment

clinic. There is no geriatrics consult service or

inpatient unit. There is no division of geriat-

rics in the medicine department at the U of

M Medical School. There is no fellowship in

geriatrics at the AHC.

In addition, Fairview, the partner with

UMP at the AHC and owner of the hospital,

does not offer geriatrics assessment or primary

geriatrics clinics and has no geriatrics inpatient

unit or consult service at any of their hospi-

tals. They do have a successful geriatric nurse

practitioner based program for on-site care in

nursing homes and assisted living.

A little history. Geriatrics as a specialty

in the U.S. started in the 70s but didn’t really

spread through U.S. medical schools and prac-

tice until the 1980s. In contrast, the UK has

recognized geriatrics as a distinct and important

specialty since the 1950s and now is the most

numerous of the internal medicine specialties in

the UK. Locally, in the mid 70s, the AHC and

the medical school at the U had some energy

around geriatrics as a specialty and for a while

it flourished, mainly through the department of

family medicine with its research and fellowship

program and through the clinical and teaching

programs at Ramsey and the VA in internal

medicine. The department of psychiatry, in col-

laboration with the VA, developed a fellowship

in geriatric psychiatry. The school of nursing

developed their geriatric nurse practitioner pro-

gram, and the school of pharmacy developed a

geriatric pharmacology program. Compared to

other AHCs at the time, we were competitive

except for one thing — we lacked a division of

geriatrics in our medicine department. Without

that crucial support the geriatric activities in the

medical school withered away. Now our AHC

is an anomaly among other similarly sized and

ranked AHCs in the U.S. with no division of

geriatrics and no clinical geriatrics.

What are the Effects of this Omission? First and most immediate is the effect on clini-

cal care when complex elderly patients go for

care at the AHC. In the outpatient area there is

no geriatrics assessment clinic and no primary

care geriatrics clinic. This means outpatient

assessment and care is split out by a disease or

organ based specialty. A typical complex geriat-

ric patient has five or more chronic diseases and

10 or more medications. Patients go from one

specialty clinic to another all trying to do their

best but without a geriatrics quarterback there

is some duplication of testing, frequent adverse

drug interactions and frustration among pa-

tients, families and clinicians about the lack of a

patient-centered prioritized care plan based on

the patient’s goals of care. This splintering of

care and lack of focus on the patient’s goals of

care also leads to underutilizing palliative care

and avoidance in discussing advance care plans.

In the inpatient setting it can be even

more dangerous. As geriatric patients enter

the hospital for procedures and acute illness

the care is again divided among several disease

or procedural based specialists. They usually

do have a hospitalist to help quarterback their

care but few hospitalists have more than a few

weeks experience in residency and only a few

days education in medical school in specific

geriatrics training. One commonly accepted

approach in good geriatrics care in the hospital

is to use this time to aggressively stop most oral

medications and only very selectively restart a

few old ones and add new ones if necessary

for a new or worsening condition. What I see

frequently is new medicine being added with

each admission and then all of the original out-

patient medications also restarted. It is not un-

common to see these patients in the post acute

setting with 20 or more medications and the

patient getting increasingly adversely affected

with this potentially toxic load of medications.

The second area of concern is in medical

student and resident interest in geriatrics as a

career choice. Without any modeling of the

specialty on campus at the AHC it makes the

Caring for our Elderly


already difficult task of interesting students in

this specialty much worse. The medical school

might argue that they have improved their ge-

riatrics curriculum recently. Its current required

experience is four afternoons of observation in

nursing homes or hospice and two two-hour

lectures in their first two years and NO required

geriatrics in their 3rd and 4th years. This is fol-

lowed by residency training that may include

a few weeks of required geriatrics training in

a three-year primary care residency. Current

emergency medical services. But there is no

clinical geriatrics at the U of M AHC. There is

an acute and growing shortage of geriatricians

with the number of board certified geriatricians

actually dropping compared to a decade ago.

If you combine that with the demographics of

the 75 plus being one of the fastest growing

populations in the next decade you get some

really scary numbers. Current projections put

one geriatrician per 3,800 older Americans by

2030. Contrast this to pediatrics where there

is one pediatrician per 1,300 Americans under

age 18. At our AHC there are three geriatricians

and 182 pediatric providers listed on their web-

site. Continuing the comparison to pediatrics

in Minnesota, there are 38 residency slots in

pediatrics per year — 24 at the U of M and 14

at Mayo. In geriatrics there are four fellowship

spots — two at HCMC and two at Mayo.

A third consequence of no clinical geriat-

rics program and no academic department or

division has been the loss of millions of dollars

in grants that have been available over the years

to help develop a geriatrics program that would

include all three legs of the traditional academic

stool — education, research and patient care.

Several were applied for over the years but none

were funded with the most common reason

being “lack of institutional support.” The few

academic geriatricians we have had at the Uni-

versity have gone on to other academic centers

like John Hopkins, redirected their academic

interest to other areas within the medical school

or school of public health, or left for private

practice or private health care companies.

Well, What Now?It is easy to complain but impossible to re-

verse the past. In this era of scarce resources it

will take a collaborative effort of all interested

parties to create a viable geriatrics presence at

the AHC. There are a group of committed

geriatricians in the Twin Cities willing to help.

There may be interested partners in the health

care systems in the state. What will be needed

at the AHC is commitment from the leaders

to work with the larger health care commu-

nity to establish a visible geriatrics presence at

the AHC. Crucial to this will be establishing

divisions of geriatrics in the departments of

Medicine and Family Medicine. In looking at

successful programs around the country they

are all multidisciplinary, so engaging the schools

of nursing, pharmacy, social work and therapy

will also be necessary. The first and most im-

mediate step is to establish a clinical presence at

the AHC. Teaching and research are important,

but without a visible clinical presence can’t be

sustained on their own. It is certainly true that

there is no procedure, diagnostic or imaging

tied specifically to geriatrics that would help

support it financially. The decision to commit

resources in clinical care, teaching and research

in geriatrics has to come from one’s basic value

that it is the right thing to do for the current

and future care of patients. But isn’t that the

point? Isn’t it the right thing to do?

Ken Kephart, M.D. is board certified in Family Medicine with CAQs in Geriatric Medicine and Hospice and Palliative Medicine. He has been practicing and teaching in the Twin Cities for 30 years and is a graduate of the University of Min-nesota Medical School. He is currently medical director of Senior Services for Fairview Health System and a board member of the Twin Cities Medical Society. The views expressed are his and do not represent Fairview’s position.

Early Registration Discount until Nov. 1! Course Director - Dr. Julie Switzer

Keynote Speakers Dr. Stephen Kates & Dr. Daniel Mendelson

University of Rochester - New York

www.cme.umn.edu/geriatric

NOVEMBER 29-30, 2012St. Paul Hotel, St. Paul, MN

Geriatric Orthopaedic Fracture Conference

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geriatric specialty requirements are: Complet-

ing a one year fellowship [two years if doing

research] accredited through the ACGME, like

all other accredited fellowships. This is after

completing a three-year residency in family

medicine or internal medicine. There is a dire

shortage of academic geriatricians available

for teaching medical students, residents and

physicians out in practice. Because of this short-

age many leaders in geriatrics feel the main

role of geriatrics in the future will be primar-

ily in teaching and research with the clinical

care being consult based for the very complex

frail elderly. There will not be enough trained

geriatricians to do primary care geriatrics [like

pediatrics]. The pay issue is one of the barriers

to attracting students into geriatrics. Unlike

most fellowship trained specialties the pay is

at or usually less than the pay in the primary

specialty, in this case family medicine or inter-

nal medicine.

Data compiled by the American Geriat-

rics Society show that older adults with four

or more chronic conditions account for 80 percent of all Medicare spending. Older adults

account for 26 percent of all physician office

visits, 35 percent of all hospital stays, 34 per-

cent of all prescriptions and 38 percent of all

The decision to commit resources in clinical care, teaching and research in geriatrics has to come from one’s basic value that it is the right thing to do for the current and future care of patients.


Colleague Interview: A Conversation With James Pacala, M.D.

Are there preventive measures that should be utilized routinely in the elderly?

Preventive activities should be tailored individually according to medical

and functional status:

Healthy older adults should receive the same preventive measures as

younger people. Applying the USPSTF/CDC preventive guidelines

are an appropriate strategy for these patients, and would include

activities such as yearly measurement of height and weight, dys-

lipidemia screening every five years (more often in patients with

diabetes or vascular disease), bone mineral density screening at least

once in women over 65, mammography every two years for women

aged 50-74, and yearly screening for depression.

established chronic illnesses such as coronary

disease or diabetes, many of the USPSTF/CDC recommendations

also still apply, but the clinical priority should be on preventing

further adverse manifestations of the patients’ chronic diseases by

treating them as optimally as possible.

Frail older adults with multiple advanced chronic conditions should

work with their doctors to prevent or address what are referred to

as geriatric syndromes — conditions such as functional decline,

immobility, delirium, falls, incontinence, and adverse drug events.

Recommended preventive activities would include inquiring frail

adults and their caregivers about falls in the previous year, vitamin

D supplementation for those who are at increased risk of falls,

inquiring about loss of urine > 5 times in the previous year, screen-

ing for gait disorders by having the patient perform a semi-tandem

stand and the Get-Up-And-Go test (see Arch Phys Med Rehabil. 1986;67:387-389), having a low threshold of suspicion for mental

status testing to detect cognitive impairment, and regular measure-

ment of functional status.

Immunizations and some form of exercise are preventive measures that

are appropriate for virtually all older adults. Other types of preventive

activities are not indicated in older adults. For example, according to

the USPSTF, pap smears are not indicated in women over 65 who have

had previously adequate screening, and prostate cancer screening with

PSA measurement is not recommended in men regardless of age, with

data being particularly supportive against screening in men over 75.

Is there a point when a physician should stop providing preventive care services to the geriatric population?

One has to consider two factors: the life expectancy of the patient and

the time delay between the preventive activity and when it results in a

payoff of improved function or longer life. Certain types of preventive

activities (e.g. aspirin after an MI) have an immediate preventive effect,

while others, most notably cancer screening, have a significant time

lag until the preventive benefit is realized. In the case of most cancer

screenings, it takes at least five years for a patient to benefit from early

detection and treatment. Older adults with a life expectancy of five years

or less should not be screened for most cancers.

Medical Care OrganizationsCaring for our Elderly

James T. Pacala, M.D., MS is the associate head, Department of Family Medicine and Com-

munity Health at the University of Minnesota, and is an associate professor with tenure.

Dr. Pacala matriculated from the University of Rochester School of Medicine and Dentistry,

receiving his medical doctor degree and a master’s of science from Brown University (geron-

tology and chronic disease epidemiology). He completed his residency at the Department of

Family Medicine and Practice at the University of Wisconsin, Madison; followed by fellow-

ships in geriatrics, Traveler’s Center on Aging, University of Connecticut School of Medicine,

and Health Services Research in Gerontology/Geriatrics, Center for Gerontology and Health

Care Research, Brown Institute. Dr. Pacala is board certified in family medicine with added

qualifications in geriatrics. He is president-elect of the American Geriatrics Society.


(Continued on page 12)

Polypharmacy in the geriatric population is a major issue in caring for the elderly as we assess the balancing act between risk and effectiveness in medication use. What is the responsibility of practicing physicians (in counseling toward appropriate and efficacious utilization) when pa-tients enter their office with a brown paper bag chock-full of pills?

As patients age and acquire chronic conditions, the risk of polypharmacy

and adverse drug events increases dramatically. Doctors should regularly

review ALL medications that their geriatric patients are taking and attempt

to discontinue unnecessary medications (or medications that have mini-

mal impact on overall functioning). For more complicated patients who

see a number of physicians, it is advisable to have the primary care doctor

prescribe all the medications. Consulting pharmacists in geriatric team

care have been demonstrated to significantly reduce adverse drug events.

The American Geriatrics Society has just published the updated

2012 Beers Criteria For Potentially Inappropriate Medication Use in Older Adults, an outstanding evidence-based reference for minimizing adverse

drug events. This reference provides recommendations for avoiding use

of selected medications in specified clinical situations due to a high

incidence of adverse effects in older adults. Some of the recommenda-

tions call for avoiding whole classes of drugs such as benzodiazepenes

for insomnia, delirium, or agitation, while other recommendations focus

on single medications such as metoclopramide, which is to be avoided

except in cases of gastroparesis. The 2012 guidelines contain many new

recommendations, such as avoiding the use of sliding scale insulin, which

evidence shows can lead to hypoglycemia without improvement in hy-

perglycemia regardless of clinical setting. The Beers Criteria are available

for free at http://www.americangeriatrics.org/health_care_professionals/

clinical_practice/clinical_guidelines_recommendations/2012.

Increasingly we are graduating residents skilled in either inpatient or outpatient care. For those who will become hospitalists, what part of the geriatrics curriculum would you most want them to learn? Have such objectives or competencies been incorporated yet into any hospitalist preparation residency program? If not, what complica-tions might follow?

The American Geriatrics Society (AGS), with support from the John A.

Hartford Foundation, sponsors the AGS Geriatrics for Specialists Initia-

tive, the goals of which include improving the amount and quality of

geriatric education received by medical and surgical residents. Through

the initiative, the AGS works with 10 specialty boards and societies to

infuse geriatric principles into training and care, similar to what the

AGS is doing in additional discussions with the Society for Hospitalist

Medicine. The AGS is also working to incorporate geriatric competencies

into the new ACGME Next Accreditation System (NAS) for accrediting

residency programs.

www.cmecourses.umn.edu

Promoting a lifetime of outstanding professional practice

2012-13 CME Activities(All courses in the Twin Cities unless noted)

FALL 2012Pediatric Clinical Hypnosis (NPHTI)September 20-22, 2012

Psychiatry Review & Update October 1-2, 2012

North Central College Health Association Conference - Duluth, MNOctober 2-4, 2012

Twin Cities Sports Medicine October 5-6, 2012

Maintenance of Certification in Anesthesiology (MOCA) TrainingOctober 20, 2012Internal Medicine Review & UpdateOctober 24-26, 2012

Cardiac ArrhythmiasApril 26, 2013

Controversies in Cardiovascular DiseaseMay 4-5, 2013

Global Health Training (weekly modules)May 6-31, 2013

ONLINE COURSES (CME credit available)www.cme.umn.edu/online Fetal Alcohol Spectrum Disorders (FASD) Global Health (7 Modules)

Practical Dermatology for Primary Care - Duluth, MNOctober 26-27, 2012

Emerging Infections in Clinical Practice & Public Health November 16, 2012

Geriatric Orthopaedic Fracture November 29-30, 2012

SPRING 2013 WORLD Symposium - Orlando, FLFebruary 13-15, 2013

Lillehei SymposiumApril 4-5, 2013Integrated Care ConferenceApril 12, 2013

Chronic PainApril 19, 2013

Office of Continuing Medical Education612-626-7600 or 1-800-776-8636

email: [email protected]


What is your reaction to recent political rhetoric on the topics of “death panels” and rationing of care?

My reaction is disgust. Engaging an older adult in a sensitive discussion

of care preferences, including end-of-life treatment, is an important

professional duty that respects the patient’s autonomy, individual rights,

and humanity.

Means testing (third party assessments of ability to pay) is now in use in Medicare and likely to be expanded as a method to reduce and apportion its costs. What do you see as the positive and negative consequences for the elderly from Medicare means testing on care access and quality?

The positive consequence is that it helps in a small way to improve the

financial solvency of the Medicare program. Although it has the potential

to motivate seniors not to enroll in Parts B and D (which are subject to

means testing), I am not aware that this has been the case. In the case

of Part B, only about 5 percent of Medicare enrollees (i.e. those with

the highest incomes) have to pay higher monthly premiums than the

standard premium, which is currently about $100/month.

Medicaid eligibility is by definition means tested and often also related to demonstrated disability. Do elderly Medicaid enrollees “graduate” to Medicare when they reach the age of eligibility? Are there dual enrollees in Medicaid and Medicare among the elderly population?

Yes, these individuals have both Medicare and Medicaid status and are

known as “dually eligibles.” Out of about 48 million Medicare enrollees

in the U.S., about 9 million are dually eligibles.

Currently Medicare is funded as a Social Security entitle-ment with both fee-for-service and managed care options. Do we know how health care outcomes compare between (managed care) capitation and pay-for-service enroll-ees? Is there evidence that competition among insurance providers will/can reduce Medicare costs or improve qual-ity? Beneficial effects when doctors or clinics compete for patient loyalty? What is the evidence from Medicare Part D regarding controlling drug costs and ensuring access to medications?

I am less familiar with more recent studies, but on the whole I believe

the research shows that health outcomes between capitated and fee-for-

service models are comparable (e.g. see comparison studies Health Serv Res 2003 Aug;38(4):1065-79, JAMA 1997 Jul 9;278(2):119-24, and

Eff Clin Pract 2000 Sep-Oct;3(5):229-39 measuring outcomes of acute

MI, stroke, and hip fracture respectively). There is some evidence that

competition can improve quality. For example, public reporting of qual-

ity measures as is done with the Minnesota Community Measurement


Colleague Interview

(Continued from page 11)

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program has motivated clinics and systems to improve care. Competition

among providers of capitated models, such as was the case in the HMO

heyday of the late 1980s and early 1990s, was successful at controlling

overall health care costs. But a backlash against HMOs has resulted in

a resumption of spiraling costs since then. For older adults, the Medi-

care Advantage program (which creates competition between private

insurance plans with prepaid Medicare contracts) has not yet realized

its potential to control costs. Overall, Part D has significantly increased

access to medications and lowered out-of-pocket drug expenditures,

helping millions of Medicare enrollees. But the prices of drugs for the

Medicare Part D program are much higher than for Medicaid, due to

the fact that the former are negotiated with private health plans while

the latter are negotiated with the government.

Allowable Medicare payments for outpatient psychiatric services, for example, are now so low that psychiatrists in independent medical practices cannot afford to remain in the Medicare program as providers. Your recommenda-tions to address this situation? Opinions on the wisdom or likely success of the AMA campaign to eliminate the Medicare Sustainable Growth Rate (SGR) physician pay-ment formula? Alternatives?

The situation with psychiatric services is an extreme example of a larger

problem: lowering reimbursement pressures physicians to opt out of

Medicare, threatening access for patients to desperately needed services.

I see no difference between mental health services and other types of

medical care, and they should be compensated similarly. Eventually,

we — doctors and the rest of society — are going to have to come to grips

with the detrimental aspects of fee-for-service care and its propensity

to create overservice waste and spiraling costs. Most lawmakers I know

recognize that the SGR formula is broken and needs to be fixed. Having

the political will, however, to fundamentally change the system, includ-

ing addressing the limitations of fee-for-service care, is another thing.

Presently physicians cannot, by law, bill Medicare patients more than the government will allow. Nor can a patient receive direct government payment if s/he receives services from a Medicare “non-provider.” Should U.S. law be changed to allow physicians to bill Medicare patients the difference between their fees and what the government will allow, i.e. enact a private contracting option as recommend-ed by the AMA? Or, should the government require doctors to treat Medicaid or Medicare patients as a necessary condi-tion of state licensure as has been proposed in Massachusetts?

Personally I disagree with the idea of a private contracting option. While

the Medicare program has its share of warts, it is difficult to dispute

that it has been astoundingly successful in providing older adults with

affordable access to care. I would be in favor of policy reforms that

would provide further access to Medicaid and Medicare services, as long

as those reforms addressed adequate compensation for appropriately

administered medical services.

Tell us about funding physician services in long-term care facilities. Problems? Pilot programs? Recommended solutions?

The problems are similar to other types of Medicare services: discounted

fee-for-service reimbursement that devalues evaluation and manage-

ment (E&M) codes. Mental health services in nursing homes are poorly

compensated and in short supply. Possible solutions would involve

altering the care and reimbursement structures of long-term care. Care

models using teams of advance practice nurses and other non-physicians

working in conjunction with a physician have improved quality and

reduced hospitalizations and emergency room visits. Comprehensive,

prepaid financing models such as PACE (Program of All-Inclusive Care

of the Elderly) have demonstrated similar outcomes. For a review of

the evidence regarding these and other care models, see: Boult C et al:

Successful models of comprehensive care for older adults with chronic

conditions: Evidence for the Institute of Medicine’s “Retooling for an

Aging America” Report. J Am Geriatr Soc 2009;57:2328-37.

Home-based and patient-centered care is on the rise. Please describe innovative care models and results. How can access to home-based care be improved?

There are numerous examples of patient-centered and home-based care

models that improve outcomes, prevent complications, save money, and

increase patient satisfaction. Examples include the GRACE (Geriatric

Resources for Assessment and Care of Elders) model developed at Indiana

University, the Independence at Home model that grew out of work at

Virginia Commonwealth, and the Hospital at Home model pioneered at

Johns Hopkins. All of these models share several common features: team

care featuring a geriatrician as the primary care physician working with

advance practice nurses and other health care professionals, comprehensive

care coordination, and a functionally based or whole-person orientation

to care. You might notice that these features are virtually identical to

those of another care model — the Patient-Centered Medical Home.

“Engaging Patients/Improving Outcomes”

Tuesday, October 2, 2012Ramada Plaza Minneapolis

6:00 p.m.—Registration/hors d’oeuvres

6:30–7:45 p.m..—Jan Schuerman will lead a discussion on ICSI’s Collaborative Conversation model

7:45–8:30 p.m..—Larry Morrissey M.D., Stillwater Medical Group, Engaging patients from theory to practice to results

Cost: Free for MMA/TCMS members; $35 non-members and guests

Register at: http://www.mnmed.org/collaborative

Co-sponsored by Minnesota Medical Association and Twin Cities Medical Society

SAVE THE DATE


Boiling Down the Basics of Cognitive Impairment and Alzheimer’s Disease

for Family Practitioners

By Richard Golden, M.D.


As a neurologist in private practice with the

Noran Clinic, I see many patients at various

stages of dementia. Here are some of the most

common questions I hear from my patients,

their caregivers, and their family practitioners.

What are the Major Risk Factors for Cognitive Impairment?There are many important risk factors to con-

sider when diagnosing and treating patients

with cognitive impairment. Having a full and

clear picture of a patient’s medical history will

help define the nature of the impairment and

may point to possible courses of treatment. It’s

important to remember that cognitive impair-

ment does not necessarily mean a diagnosis of

Alzheimer’s Disease (AD), as there exist several

other causes of dementia which merit addi-

tional discussion.

Of the many risk factors for cognitive im-

pairment, the most important is age. Dementia

specialists often say it is normal for cognitive at-

tributes to slow as part of the aging process, but

the important difference is that with “normal”

memory issues, desired information may still

be recalled, though it may be several hours, or

perhaps even the next day, before the desired

name or word comes to mind. For a patient

with dementia, the process of recollection re-

mains incomplete.

Additionally, the discovery of genetic bio-

markers Apo lipoprotein E in the allelic form

E4 has been linked to earlier and more aggres-

sive AD. Patients who have one E4 gene have

two to three times the risk of those without the

E4 allele, and those with two E4 genes (homo-

zygous) have a 13-20 fold risk. Having an E4

pattern does not, however, mandate a course of

memory decline, but rather, it seems as though

E4, in a manner similar to high cholesterol in

heart disease, serves as a warning for increased

risk.

There are still other factors associated with

increased risk of cognitive impairment. Lower

levels of educational attainment as well as a

previous history of head injury (with or without

loss of consciousness) are markers for increased

risk. Therefore taking note of recent or remote

head trauma should be a part of the pertinent

history taken by medical professionals. Vascular

risk factors including hypertension, hypercho-

lesterolemia, smoking, lack of exercise, as well

as hyperglycemic states also increase the risk of

dementia.

What Symptoms Should Make Us Suspicious of Dementia?1. Does the patient’s cognitive impairment

interfere with their ability to function at

work or during his/her usual activities?

2. Does the patient’s cognitive impairment

represent a clear decline from previous

levels of functioning?

3. Can the patient’s cognitive impairment be

explained by another factor (i.e. delirium

or major psychiatric disorder)?

4. Are at least two of the following

domains impaired?

The ability to acquire and remember new informa-tion. (Does the patient en-

gage in repetitive questions

or conversations, misplace

personal belongings, forget

events or appointments, or

get lost on familiar roads?)

The ability to reason. (Does the pa-

tient demonstrate impaired reason-

ing or poor judgment, inability to

handle complex tasks, exhibit poor

understanding of safety risks, seem

unable to manage finances or to plan

complex sequential activities?)

The ability to discern/make use of visual stimuli. (Does the patient have

impaired visual spatial abilities, in-

ability to recognize faces or common

objects, inability to sight objects de-

spite good visual acuity, or inability

to use simple implements or have

problems getting dressed?)

The ability to use language. (Does

the patient have trouble speaking,

reading or writing, suffer from the

inability to find the right word, hesi-

tate while speaking, or have problems

spelling or errors in writing?)

The ability to be socially active. (Does the patient exhibit personal-

ity and/or behavior changes, demon-

strate decreased interest in previously

pursued hobbies, show a loss of inner

drive and motivation, appear apa-

thetic or exhibit a loss of empathy?)


If more than two of the above bring a yes,

then suspicions of Dementia is heightened.

How Useful are the Cholinesterase Inhibitors and Glutamate Modulating Medications in Treatment of Dementia?Many physicians mistakenly believe cholin-

esterase inhibitors and glutamate modulating

medications only work for very short durations

and should be discontinued after a few months

to a few years time. However, studies have

shown that cholinesterase inhibitors increase

the amount of acetylcholine in the brain and

are effective throughout the entire course of

illness. The clear changes in behavior, cognition

and the ability to function which these drugs

afford are clinically significant throughout the

course of the illness. Unfortunately, as the dis-

ease worsens, an observer may find it harder

to quantify the benefit. But the question that

needs to be asked by the practitioner, patient

and family members is, “How much worse

would the patient be if they weren’t taking

these drugs?”

That said, there are still no hard and fast

rules on how long someone should use cholin-

esterase inhibitors. While it might seem like a

simple idea to stop and “test” the benefit, there

are some risks involved. Discontinuation has

been associated with worsening of symptoms,

and restarting the medications may not bring

the patient back to the previous level of func-

tion. For this reason any decision to discontinue

cholinesterase inhibitors should be carefully

considered.

Glutamate modifying medication should

be considered when there is rapid deterioration.

It is also helpful in patients who have developed

behavioral symptoms related to agitation or

aggression. For these reasons, this type of drug

is generally used in the mid-to-later stages of

the disease.

Cholinesterase inhibitors and glutamate

modifiers can be used in combination with

one another and both classes of drugs are rela-

tively well tolerated in patients. Having said

that, interactions with other medications are




possible, and side effects exist, so it is important

to clarify all medications for possible inter-

actions. Finally, with the changes in medical

coverage some insurance plans will, unfortu-

nately, make the decision financially. Time will

tell how guidelines for coverage will develop,

and it is important to note that neither class

of drugs produce a slowing in the progression

of disease, they are simply the most effective

at helping patients live with its symptoms.

Is There Anything Promising on the Horizon For a Cure?Nothing appears to be the cure yet. Slowing

progression of the disease process — i.e. Amy-

loid protein and other depositions which may

play a role — using intravenous immunoglobu-

lin, seems to come the closest so far.

The Driving Question As many of you know, most clinicians would

rather have a colonoscopy prep than discuss

patients’ driving privileges. Unfortunately,

though, there comes a time when a patient’s

driving abilities must be discussed. This be-

comes more urgent when a patient’s cogni-

tive abilities are impaired. The Academy of

Neurology has put forward a set of guidelines,

which, although far from perfect, are at least

an attempt to bring some sanity and reason

to this topic.

There are some signs that prove particu-

larly important when assessing a patient’s ability

or declining ability to drive safely. The obvi-

ous indications for considering a revocation

of privileges include accidents and tickets (for

speeding or reckless driving). The presence

of either aforementioned indication signals it

might be a good idea to further assess a patient’s

driving skill. Aggressive or impulsive behaviors

are another issue — especially in someone who

has not had those tendencies prior to changes

in their cognitive ability. Sometimes individuals

“restrict” their own driving even before their

loved ones or physicians do — by refusing to

drive in certain circumstances (during rain or

after nightfall). This indicates the patient senses

the loss of some abilities and fears their driving

would endanger themselves or others.

Boiling Down the Basics

(Continued from page 15) There is strong evidence that people with

dementia who report they “can drive just fine”

pose a greater risk than those who are aware of

their shortcomings. In the case of the former,

their dementia simply doesn’t allow them to

realistically judge their abilities, so caregivers

and family must help identify the issues. Keep-

ing track of stories where the patient got lost

or “lost the car” in the parking lot will help

families make their case in a more formidable

but less emotional manner. Sometimes it is

actually harder for families to let go of the

idea of their loved one’s independence and

self sufficiency — that is until they step back

and take an objective look at the situation, or

once they are forced to answer pressing ques-

tions like, “Would you let your children ride

with the patient?” Suddenly the gravity of the

situation is presented in a different light and

their true feelings come forward.

As a Practitioner, What is My Role With Regard to the Caregiver? Do I Need To Counsel or Consider Their Needs? I simply cannot say this more plainly. Without

a doubt, no medical intervention is as impor-

tant to the successful treatment of the patient

as helping caregivers coexist with this disease.

When caregivers are not part of the treatment

planning, the grind of providing care makes

them five times more likely to experience sig-

nificant depression, and their risk of suffering

major medical problems of their own goes up

nearly six-fold. If as a result of a caregiver’s de-

cline in health, or for any other reason, he or she

is no longer able to provide care, this absence

causes the degree of difficulty in managing the

patient to rise dramatically.

Five to ten minutes spent one-on-one

with the primary caregiver on whatever is top-

most on their list, telling them something you

read in a recent journal article that might help

them, or giving them tips on behavior modi-

fication may seem simple to us as physicians,

but those minutes can mean the world to the

person taking care of our patient. There is no

end to the topics you can research to help aid

your patient’s caregivers (the use of light and

quiet music, touch or massage therapy, how to

communicate with people suffering cognitive

impairment, how to relieve their own stress

and anxiety so they don’t lose their patience,

the list goes on).

What is most important is that the care-

giver sees you as their partner in the care of

their loved one. Spending just a few minutes

to make sure they realize you truly are seems

like a small price to pay.

At a certain stage in the disease there will

be hard questions to discuss. Things like, “Is it

still safe for my loved one to be home alone?”

It is at these moments when true assessment

of the capabilities of both patient and care-

giver will need to be evaluated, and you will

be glad for the time spent building a trusting

and cooperative relationship with your patient’s

caregivers. Our practice also uses allied health

professionals to direct people toward resource

outlets, both non-profit and for profit.

Making the arduous journey with a pa-

tient and their caregivers through the course

of cognitive impairment can be a challenging

responsibility. Insightful identification of risk

factors and symptoms, partnered with medi-

cation that may help symptomatically, as well

as the development of an understanding and

supportive relationship with the patient and

caregiver will enable the patient and his or her

family to maximally enjoy their time together

and will help the patient live graciously and

meaningfully.

ConclusionThis disease is so disabling on several levels

that its complexity may cripple our ability to

respond adequately if the current trends con-

tinue. Medications and care organizations can

and will be of great help, but certainly will not

be the total answer. Society’s response to the

HIV epidemic, which was multidimensional,

e.g. pharmaceutical, governmental, spiritual

and — in my humble opinion — well-funded,

provides a framework to use. The question

is — can we be just as successful in this type

of dementia affecting our senior population?

Richard Golden, M.D. has been a practicing neurologist at Noran Clinic since 1985, with a special interest in neurodegenerative disorders. He currently serves as the director of the Memory Disorder Clinic at Abbott Northwestern Hospital and is a former board member of the Alzheimer’s Association.


By Stephen T. Parente, Ph.D.

Baby Boomers Reckoning on Medicare


Health economists and demographers

have been concerned about the wave

of baby boomers hitting the “Shore

of Medicare” and Social Security for decades.

What is the primary concern? Impending

program bankruptcy that imperils the U.S.

economy is the issue. To understand why that

is possible, it’s important to understand what

Medicare is. The program was created by law

in 1966 to be financed by the taxing powers

of Congress. The federal government would

then administer this program that functions

as a multi-generational insurance contract. It

was designed so that people younger than age

65 pay a share of their federal taxes into the

program and expect a health insurance program

when they reach the age of 65.

The baby boom population is a unique

demographic bubble where the fertility rates

in the United States, immediately after World

War II from 1946 until 1964, were significantly

higher than normal. The first baby boomer to

become a Medicare recipient was in 2011. The

last baby boomer will enter Medicare in 2029.

Before 2020, Medicare’s program payments

will be greater than the amount collected by

Medicare taxes, at which point the program will

be financed by taking on more U.S. debt. This

is the driving concern of fiscally conservative

economists who believe that additional debt on

a massive scale is acceptable for infrastructure

or national defense but not long-term social

assistance programs.

It is important to clarify Medicare’s fiscal

revenues and obligations. Currently, Medicare

operates as two separate trust fund accounts

held by the U.S. Treasury. These funds can

only be used for Medicare. The first is the

Hospital Insurance (HI) Trust Fund that pays

for Part A services such as inpatient hospital

care, skilled nursing facility care, home health

care (some), and hospice care. The second is

the Supplementary Medical Insurance (SMI)

Trust Fund which pays for Part B benefits,

such as doctor services, outpatient hospital

care, home health care not covered under Part

A, durable medical equipment, and Medicare

Part D prescription drug benefits. Medicare

Advantage health plans are financed by a joint

allocation of HI and SMI funds. The HI Trust

Fund is financed by payroll taxes and the SMI

Trust Fund is financed by funds authorized by

Congress and premiums from people enrolled

in Part B and Part D as well as interest earned

on the trust fund investments. If over time

payroll taxes for HI and general taxes for SMI

are insufficient, Congress can deficit finance the

program. As of April 2012, the HI and SMI

Trustees Report1 projects that HI tax income

and other dedicated revenues will fall short of

HI expenditures in all future years under cur-

rent law. Furthermore, they find “The HI Trust

Fund does not meet either the Trustees’ test of

short-range financial adequacy or their test of

long-range close actuarial balance.” However,

they find the Part B and Part D accounts in

the SMI trust fund are adequately financed

under current law, since premium and general

revenue income are reset each year to match

expected costs. This will remain the case as long

as the additional tax revenue required does not

adversely affect the long-term growth rate of

the U.S. economy.

The Medicare program today is unlike

the one in 1990 and will also be unlike the one

offered in 2022. In 1990, less than 5 percent

of the Medicare population was in a Medicare

Managed Care plan or HMO and there was no

prescription drug coverage. Today, the Medi-

care program has prescription drug coverage

and over 20 percent of the beneficiaries are

in Medicare Managed Care. By 2022, many

expect Medicare Managed Care to have well

over half the program participants and perhaps

have as many as 80 percent of the population

in managed care.

From the viewpoint of a health economist,

the demand of the population will likely be

determined by expected benefits. Culturally the

baby boom population is quite different from

the World War II generation and the millen-

nial population born in 1990s. For example,

World War II generation patients generally took

direction from physicians without question.

Baby boom generation patients looked to have

physicians be co-equal members of their treat-

ment team. Millennial patients would want

to use social networking and the internet to

customize their solution and then direct their

care team if possible.

The baby boom population may actually

be best seen as two cohorts: the early and the


late boomers with break point being the late

1950s. The early boomers grew up in a post-

war America where the economy soared and

trust in technology and government were high

because both were seen as critical to winning

World War II as well as enabling a giant export

boom. This early boomer population grew up

in a world where their parents had full benefits

and growing salaries. This is likely to affect the

expectation of what the Medicare program

should provide to them as they enter it. The

most prominent representative of this cohort

coming of age is President Bill Clinton.

The late boomers into the Generation-X

population, born between 1965 and 1980,

entered into a more cynical world with the Viet-

nam War in full swing, the assassinations of the

Kennedy’s and Martin Luther King Jr. as well

as the Watergate scandal. Technology was less

valued since it brought the world to the brink

of a nuclear exchange with the Cuban Missile

crisis. The expectations of this population are

likely to be more measured and even cynical

because they grew up with parents who were

more likely to be ravaged by recessions in the

1970s as well as a federal government that was

clearly seen to betray the trust of the public. It is

likely that this cohort will look to the Medicare

program as something less likely to be available

to them. This group would more likely prefer a

voucher to supplement their own contribution

to make sure they have adequate medical care

in 2023 to 2026 when they start entering the

program. This may be why Rep. Paul Ryan’s

(WI-R) proposal to have Medicare become a

voucher program in 2024 with outlays matched

to projected HI and SMI long-term revenues

and expenses may be more politically tractable

than many people think. The most prominent

representative of this cohort is President Barack

Obama.

The central factor driving cost increases

is the increasing longevity of the U.S. popula-

tion. When the Social Security program was

created in 1936, approximately 10 percent of

the population was likely to live to 65. Today,

the expectation is that well over 60 percent

of the population will live past the age of 80.

Furthermore, the costs associated with end of

life, when palliative care is still in its infancy for

cultural acceptance, will likely lead the nation

to still prefer care to generate a cure into age

80 than accepting one’s age and physiological

limitations. Another concern is the expectation

that the use of technology to enhance mobility

through orthopedics may be a large cost driver

for baby boomers who are fine tuning limbs and

mobility under the Medicare program. From a

standard of care perspective, this is fine. From

an actuarial perspective, it is a set of unexpected

benefits to be paid by the program that either

needs more tax receipts to pay in ahead of time

or more cost sharing from current beneficiaries

to make sure the Medicare program does not

reach a point of bankruptcy. If bankruptcy did

occur, it would most simply be an exhaustion

of benefits paid by the trust funds and reduc-

tion in program staff from sudden or gradual

shutdown of Medicare.

While it is impossible to predict the fu-

ture with any clarity, it’s almost certain that

the baby boom population will experience a

Medicare transformation. The question is not

if, but when. If changes take place for the early

cohort of boomers, they will be very apprehen-

sive because of their expectation of generous

benefits accorded to them throughout their

lives. Certainly this has been the case for higher

education prices as well as home prices from

1970 to 1985 when the early boomer cohorts

came of age to economically thrive as adults and

professionals. If it changes for the late cohort

of the boomers, their expectations have already

been tempered, throughout life, to lower their

expectations. Thus, the Medicare program may

pivot to a Ryan-like voucher program to achieve

better long-term sustainability that emphasizes

greater personal beneficiary responsibility to

achieve long-term health.

Stephen T. Parente, Ph.D. is Professor of Finance, Minnesota Insurance Industry Chair of Health Finance, and Director of the Medical Industry Leadership Institute in Carlson School of Man-agement at the University of Minnesota. He was a senior health adviser to Senator John McCain (R-AZ) in the 2008 Presidential election and a legislative fellow for Senator John D. Rockefeller (D-WV).

Notes:1. To examine the Medicare Trustees report for 2012,

see: http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Reports TrustFunds/Downloads/TR2012.pdf.


Baby Boomer’s Reckoning on Medicare



The Role of the Long-Term Care Medical Director

(Continued on page 20)By John W. Mielke, M.D., CMD

A Little HistoryThe history of medical direction dates

back to 1970 when a Salmonella out-

break caused the deaths of 36 nursing

home residents in a Baltimore nursing

home.1 This led to increased federal scru-

tiny of substandard nursing homes. The

AMA became involved and lobbied for

the requirement for medical direction at

all long-term care (LTC) facilities. In 1974

the federal regulations included medical

direction as a condition of participation. A

1984 revision of the nursing home regula-

tions threatened to leave out the medical

direction requirement, but this time many

other organizations (AMA, American Ge-

riatrics Society, the new American Medi-

cal Directors Association (AMDA) and

others) weighed in and the position was

subsequently retained. Dr. James Pattee

and Dr. Thomas Altemeier, here in Min-

nesota, researched the role of the medical

director (the results of which were used in

a book authored by Drs. Pattee and O. J.

Otteson2) and began teaching a nine day

course for medical directors that became

the impetus for the Certified Medical Di-

rector program through AMDA. I was

privileged to take this life-changing course

here in Minneapolis in the early 1990s.

The IOM 2001 report, Improving the Quality of Long Term Care, recommended,

“One approach to improving the quality of

nursing home care would be for facilities

to vest greater authority and responsibil-

ity in medical directors for medical care

services and require attending physicians

and nurse practitioners to follow facil-

ity medical policies and procedures.”3 In

November 2005 CMS updated the expec-

tations of medical directors in the F501

portion of the “interpretative guidelines.”

This document can be accessed by search-

ing the AMDA website for f501 or at the

CMS website.4

It should be clear from the historical

perspective that the medical director role is

to assure quality of medical care in nursing

homes. It should also be clear that the his-

torical quality of care has been inadequate

at times, even abusive and negligent. The

medical director is therefore viewed as an

essential component in preventing abuse,

neglect, and substandard quality of care.

How is this best accomplished?

The Definitive Document “The Nursing Home Medical Director:

Leader And Manager”

I encourage you to access this docu-

ment at the following website: http://

wwwlivepage.apple.com.amda.com/gov-

ernance/whitepapers/A11.cfm.

Four Main Roles, Nine Essential FunctionsThe AMDA white paper identifies four

main roles for the medical director:

— Physician Leadership

The medical director serves as the

physician responsible for the overall

care and clinical practice carried out

at the facility.

— Patient Care-Clinical

Leadership

The medical director applies clinical

and administrative skills to guide the

facility in providing care.

— Quality of Care

The medical director helps the facil-

ity develop and manage both quality

and safety initiatives, including risk

management.

and Communication

The medical director provides infor-

mation that helps others (including

facility staff, practitioners, and those

in the community) understand and

provide care.

The nine essential functions inherent in

these roles are:

— Administrative

— Professional Services

— Quality Assurance and

Performance Improvement

— Education

— Employee Health


Long-Term Care Medical Director


— Community

— Rights of Individuals

— Social, Regulatory, Po-

litical, and Economic Factors

— Person-Directed Care

The article further lists tasks under

each function, dividing them into essential

and optional categories. This list can be

overwhelming and discouraging. I can tell

you at a practical level it is impossible to

accomplish all these tasks. So the follow-

ing is an attempt to make these high level

goals possible at a practical level.

At a Practical LevelIt is important to consider each of the

functions with every visit to the facility.

How am I functioning as a physician lead-

er, overseeing physician services, providing

quality review and education to the staff?

Many of these functions can be combined

into your routine visits, if we are mindful

of these roles.

Become part of the leadership team: Visit with the administrator and Director

of Nursing (DON) at least monthly. Find

out about strategic planning. Ask to be

included in decision-making, especially

clinical decisions such as radiology pro-

viders, dental services, new service lines.

Discovering decisions after the fact means

you are not considered part of the leader-

ship team, and this severely limits your

effectiveness.

Round on each nursing unit regular-ly: There is nothing more important than

hearing from the front-line staff. Peters and

Waterman5 described this as “Management

by Walking Around” in their 1982 best-

seller, In Search of Excellence. This MBWA

activity can accomplish all four roles. You

gain informal leadership by showing in-

terest and solving problems for front-line

staff. You hear about provider-nurse in-

teractions, patterns of care, and concerns

about medical care issues. Use your senses:

smell, hearing, sight to discover quality

care problems. Are there urine odors, too

many pages/alarms/loud talking, poor

quality interactions between staff and

residents? And, look for excellence and


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annual survey. I specifically ask them to call

me for any questions regarding medical

care issues. I always review the findings,

help investigate questionable tags and at-

tend any “informal dispute resolution”

hearings. I frequently add a medical direc-

tor note to charts when an adverse incident

requires investigation and comment. These

notes have been invaluable in explaining

the steps taken by staff in providing good

care, even when the outcome was negative.

Unique NeedsEach home has its own unique style and

needs. Smaller homes deal with quality

at the front desk. It seems that everyone

knows all the patients, families and their

medical care needs. The administrator

likely answers the phone. The small home

doesn’t need a data gathering tool, but

they do need a wide variety of expertise

because they can’t afford a full-time infec-

tion control nurse, or wound specialist.

So, in a small home the medical director

reward it with an immediate, “you’re doing

a great job here!” When issues come up,

use the time to educate staff.

Quality Committee engagement: The

traditional role of eating donuts, drink-

ing coffee and signing our name countless

times to unread documents is gone. If QA

meetings are boring, change them. They

must be relevant to our goals as medical

directors. I need an overview of how we

compare to state and federal benchmarks.

Then we need to identify quality deficien-

cies to process improvements. The new

terminology “Quality Assurance/Process

Improvement” (QAPI) emphasizes this

pattern. Dr. Sontagg advises us to bring

the latest articles and research to these

meetings to stimulate quality improve-

ment initiatives. I review late physician

visits, INR values, infection control and

antibiotic utilization, use of antipsychot-

ics for “dementia behaviors” and other

issues at various nursing homes. It is the

time for my primary interaction with the

consulting pharmacist. The QA meeting

is vital to accomplishing all four roles of

the medical director.

Always, always be available for emer-gency back-up: Long-term care nursing

can be lonely and isolating. It shouldn’t be

without a life-line. I tell the nurses at ori-

entation that they should never leave their

shift with a bad feeling in the pit of their

stomach. They should always call for as-

sistance. Emergency availability is a crucial

role for the medical director in assisting

with critical patient care decisions. It also

stabilizes the work force. They must feel

supported and protected. Of course these

after hours phone calls can accomplish

many of our other goals: quality moni-

toring, education, and physician services

oversight. We are always doing more than

one thing as a medical director. (If we can’t

be available — establish a credible back-up

plan.)

Policy and Procedure: The previous

suggestions have involved developing in-

formal leadership. Policy and procedures

allow for formal authority to be exercised

by the medical director. This includes

many important medical care policies

to be reviewed and revised. In addition,

admission policies are increasingly criti-

cal. Will your facility admit chest tubes,

nasogastric tubes, BIPAP for ventilatory

insufficiency, or certain behavior chal-

lenges? This is a critical area for medical

directors to assess the management and

nursing skills of the facility and match

them with the referrals for admission. It

is part of our role to limit admissions that

we are not medically capable of managing.

Medical provider credentialing falls under this authoritative leadership and should be considered as a means to estab-lish leadership within the medical staff. At one home we have a one page attend-

ing physician agreement that establishes a

basic code of conduct for practicing phy-

sicians in the facility. The medical care

committee reviews deviations from this

code of conduct and supports my role in

overseeing provider care and conduct.

Survey and compliance issues need the presence of the medical director. I make every effort to stop and introduce

myself to the survey team early during the

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needs to supplement the staff limitations.

Larger homes have a broader range of staff,

but it is harder to see where quality may

be breaking down. A more robust quality

data approach is needed. There may be

more need for provider staff monitoring

and intervention/education.

ConclusionFlexibility is a key attribute of medical

direction. While the roles and functions

remain stable, the tasks will change based

on the need of the organization. It is a

rapidly changing landscape. Our facili-

ties and the residents are dependent on

our engagement with the medical director

role. If we strive to assure the best quality

of care for this frail population we will

fulfill the roles of the medical director with

excellence.

John Mielke is an internist/geriatrician who specializes in care of the elderly in nursing and assisted living facilities. He is a certified medical director and past president of the Minnesota Medi-cal Director’s Association. He is the Chief Medical Officer of Presbyterian Homes. In that role he is working with a team of care givers called Optage House Calls, a primary care clinic of Presbyterian Homes. They are a certified Health Care Home intent on delivering patient-centered care in the elder’s home environment.

The original article, entitled “The Role of the Medical Director,” was published in TOPICS, a Peer Review Journal of the Minnesota Medical Directors Association, Vol. 32, Issue 5, June 2011. It is re-printed with permission and edited by the author, John Mielke, M.D., CMD.

Endnotes:1. Elon, Rebecca D., Medical Direction in Nursing

Facilities: New Federal Guidelines accessed on April 30, 2011 at http://www.annalsoflongtermcare.com/article/4782.

2. Pattee, JJ, Otteson OJ. Medical Direction in the Nursing Home—Principles and Concepts for Physi-cian Administrators. Minneapolis, MN: Northridge Press, 1991.

3. IOM report accessed on April 30, 2011 at http://www.nap.edu/openbook.php?record_id=9611&page=201

4. https://www.cms.gov/transmittals/downloads/R15SOMA.pdf.

5. Peters, Tom and Waterman, Robert, In Search of Excellence: Lessons from Americas Best Run Com-panies Harper and Row, New York 1983.

Long-Term Care Medical Director



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Long-Term Care Insurance—Preventive Medicine for Your Retirement?

By Deb Newman, CLU, ChFC, LTCP

Mortality is down, morbidity is

up. As medical professionals,

you are acutely aware that al-

though people are living longer, they often

live with chronic, debilitating illness that

in the past would have been fatal. The

good news is that those illnesses are now

manageable; the bad news is, of course,

that they often necessitate years of care.

Most of us know someone who is

receiving long-term care. However, few

of us stop to think of the ramifications

that a need for extended long-term care

would have for either our own family

member or a member of our medical of-

fice. In this regard, consider the statistics

provided in the state of Minnesota’s “Own

Your Future” public awareness campaign,

which urges state residents to prepare for

long-term care: it estimates that at least

30 percent of Minnesota boomers will not

have sufficient resources to pay for health

and long-term care when they retire.

In order to lessen or even eliminate the

burden of caregiving imposed on family

members caring for their loved ones, many

people prefer to hire caregivers. Paid long-

term care, whether provided in-home or

in a facility, is what long-term care insur-

ance (LTCI) is designed to cover. Without

LTCI, the bill for paid caregiving is covered

either by the individual, or (needs-based)

means-tested government programs such

as Medicaid. One of the deficiencies of

most government programs is that they do

not cover the most desirable care in the set-

ting of your choice. As fiscal pressure rises

on these programs, qualifying has become

tougher in many cases. Governments have

responded to this new reality with both

state and local incentives to purchase LTCI

(see shaded box on the next page).

This year, the median cost of a private

one-bedroom unit at an assisted-living

facility in the Minneapolis area is almost

$47,000. In 30 years, that cost is pro-

jected to be over $200,000, according to

Genworth Financial’s 2012 Cost of Care

Survey. The cost of home care services can

also be daunting; the median annual rate

for a home health aide in Minneapolis is

currently $63,492 [44 hrs/week]. Because

the possibility of needing long-term care

is so very real, it makes sense that, in the

same way that we traditionally insure our

bodies with life, health and disability in-

surance, we must plan ahead for the pos-

sibility of needing extended care.

While long-term care insurance used

to be considered a policy purchased at

retirement age, that is no longer the case.

Partly due to the awareness that illness or

injury necessitating long-term care services



can befall anyone at any age, the average

issue age has dropped over the years, and

is now 57. While most LTCI claims occur

in post-retirement years, it makes good

sense to include this coverage as part of

pre-retirement planning.

No one can predict if or when a need

for long-term care will arise. If it does,

people without coverage are often forced

to make the difficult decision of choosing

which of their assets to liquidate in order to

pay for care. Long-term care insurance is a

viable way to avoid being forced into mak-

ing those tough decisions. You could say it

is preventive medicine for your retirement.

Long-term care coverage also gives

consumers the freedom of choice and con-

trol over the care they receive. Whether

individuals wish to stay in their own

homes, in an assisted living community

or other facility, this type of insurance lets

the policyholder stay in control, which

means more flexibility and better care.

Long-term care insurance can be offered in

medical groups as an employer-paid ben-

efit, a voluntary employee-paid benefit or a

combination of both. Medical groups seek


benefits that offer flexible coverage, dis-

counted rates and reduced underwriting.

A properly-designed multi-life long-term

care insurance program can offer all these

elements to even small offices with as few

as three individuals. Additionally, spouses

and other qualified family members are

eligible for coverage with considerable

premium savings under these multi-life

programs. There are no requirements that

every employee be covered.

The tax advantages to a business are

tremendous. The premiums of employees

and their spouses are 100 percent deduct-

ible to the business, cannot be included

in an employee’s income and are tax-free

when the benefits are received. Addition-

ally, there are no requirements that every-

one be covered. This is a great benefit to

enhance a retirement plan where the physi-

cians, for example, have already maxed out

their contributions.

Deb Newman, CLU, ChFC, LTCP, is the founder and president of Richfield-based Newman Long Term Care, focusing solely on long term care planning solutions. For more info, please visit www.newmanlong-termcare.com

Government Incentives for Long-Term Care Insurance

The Minnesota Long Term Care Insurance Partnership Program allows people to

protect assets that otherwise would need to be spent before qualifying for Medicaid in

the event of a prolonged care need that exceeds the limits of their policy. A partnership-

qualified policy enables people to protect one dollar of personal assets for every dollar

their policy pays out in benefits.

Minnesota State Tax Credit Policyholders receive a tax credit for the lesser of 25 percent

of premiums paid, or $100, per person/year.

Health Savings Accounts, or HSAs, can pay for qualified medical expenses tax-free,

including tax-qualified long-term care insurance premiums.

Federal Tax Deductions* Like traditional major medical insurance, LTCI is tax deductible

by businesses. While C-Corporations may take a 100 percent deduction (policies paid

for employees, their dependents, spouses and retirees), the deduction available to other

entities (and their shareholders) may be limited to an age-based maximum. Employees

receive benefits from the policy tax-free.

*Refers to the typical tax-qualified, reimbursement policy, as well as almost all other policies.

Long-Term Care Insurance


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The Minnesota Board on Aging: Your Link to an Expert in Local Services

By Jean K. Wood

Minnesota’s aging network is the first

place to start when your frail older

patients need to connect to local

services. The Minnesota Board on Aging — a

state agency — oversees a statewide network

of Area Agencies on Aging (AAAs) that can be

reached easily through the phone, the internet

and live chat. The AAAs provide easy access to

an array of core social services for older adults

and their family caregivers. These services help

older adults recover from acute illness, manage

chronic conditions and prevent injurious falls

and at the same time, help them and their

caregivers identify ways to make their homes

appropriate for aging well and safely.

The aging network’s Senior LinkAge

Line® is toll-free and available statewide at

(800) 333-2433. Senior LinkAge Line® (SLL)

staff have for over a decade helped patients

bridge the gap between getting a prescription

and paying for it by providing training and

support to help connect doctors and patients

to the patient assistance programs. The linkage

line also provides help with the annual open

enrollment period by supporting thousands of

callers to select the most appropriate Medicare

Part D plan. This assistance is available free of

charge to all callers — older adults, family mem-

bers and providers — including hospitals and

clinics. The SLL welcomes calls from hospitals

before a patient is discharged in order to begin

planning for a successful transition home.

The home and community-based ser-

vices delivered by the aging network are criti-

cal to health status following an acute illness

and for successful chronic care management.

These services are available through networks

of publicly subsidized, private and voluntary

service providers. Engaging these networks in

a coordinated strategy through a partnership

with the Minnesota Board on Aging and Area

Agencies on Aging offers great potential to help

older adults live well at home. This is particu-

larly true after a hospital stay when assistance

at home can make the difference between be-

ing readmitted to the hospital or successfully

managing at home.

These home and community-based ser-

vices are available to individuals of any income level and most offer a sliding fee scale. The

sliding fee scales are based on self-reported

income. Services include:

teaches older adults to take action to better

manage their chronic conditions.

-

tions that help older adults address their

fall risks and be safe at home.

prescription drug payment issues, as well

as medication management assistance, to

help older adults maintain medication

compliance at home.

diet and ethnic meals, to support adequate

nutrition.

older adults are able to follow through on

referrals and access community services.

home modifications to create an accessible

and safe environment.

The Senior LinkAge Line® provides easy access to connect to these in-home

and community services. The Senior LinkAge Line® is available toll-free

across the U.S. on weekdays at 1-800-333-2433. Senior LinkAge Line® is

on the internet through live chat with access to 30,000 services statewide at

www.MinnesotaHelp.info. When connecting to the Senior LinkAge Line®,

clinic staff will link to an expert who:

supports

caregiver consultants


Minnesota Board on Aging


These home and community-based ser-

vices are just as important over the long haul as

they are immediately following an acute episode

to reduce the overall risk of hospitalization and

complications when age and chronic disease

combine to increase frailty.

Family caregivers play a critical role in

supporting their loved one at home. Many

caregivers offer intense levels of support and,

as a result, need help in maintaining their own

health. Respite services provide a caregiver with

a much needed break. Evidence-based training

and education programs, such as Powerful Tools

for Caregivers, equip caregivers with the skills

that they need to help their loved one manage

chronic illnesses. One-on-one caregiver consul-

tation, through the use of an evidence-based

assessment process, focuses on the needs of the

caregiver and helps the caregiver take action to

maintain their own health while fulfilling their

caregiving role. These services are especially

helpful for caregivers who are supporting a

loved one with Alzheimer’s Disease or other

dementias.

Area Agencies on Aging can assist in con-

vening community providers and participate

in planning efforts to develop comprehensive

community approaches to care transitions and

other efforts that improve outcomes for older

adults. The Area Agencies on Aging have a

long track record of convening a broad range

of public and private partners to address critical

issues affecting older adults. The AAAs have

facilitated the development of numerous falls

coalitions to address the multiple risk factors

that lead to a high rate of falls in older adults.

Health and community professionals, older

adults and family caregivers can learn how they

can take action to prevent falls at www.mnfalls

prevention.org.

To learn more about the Minnesota Board

on Aging, go to www.mnaging.org.

Jean K. Wood is the executive director of the Min-nesota Board on Aging and director of the Aging and Adult Services Division, Minnesota Depart-ment of Human Services. In these roles, Ms. Wood oversees the management of state and federally-funded home and community-based services for older Minnesotans, of which the Senior LinkAge Line® is the most utilized.


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Own Your Future

“Do you have a plan for your long-term care?” This is the question that the State of Minne-

sota will be asking its residents over the next

few months as part of the Own Your Future

initiative.

The purpose of Own Your Future is to

urge Minnesotans to have a plan for their long-

term care, including how to pay for it. The

campaign addresses the dramatic increase in the

number of Minnesotans who will need long-

term care by 2030 and the need to increase the

numbers of individuals using private financing

options to pay for their long-term care. With-

out additional private financing, the state could

see significant — and unsustainable — increases

in Minnesota’s public long-term care budgets

in the future. Physicians know the risks for

long-term care: Over 70 percent of persons

65+ will need long-term care at some point in

their remaining lives and increasing numbers

of young persons need long-term care. Many

individuals also mistakenly believe that Medi-

care covers long-term care costs. It does not. It

only covers this type of care under very limited

circumstances.

Minnesota’s Own Your Future initiative

was created to educate and encourage individu-

als to get the facts and plan for their long-term

care. It includes three components:

throughout the state.

products for use by individuals who are

not poor enough to quality for public

programs but are not wealthy enough to

self-fund their long-term care.

-

sions to better align with and encourage

private payment for long-term care.

The objectives of Minnesota’s Own Your

Future campaign over the next year are:

the importance of planning now so they

have personal and financial options to

meet future long-term care needs.

have taken action to address and provide

for their future long-term care.

In June Lt. Governor Yvonne Prettner

Solon and Minnesota Department of Hu-

man Services Commissioner Lucinda Jesson

convened a 28-member advisory panel that

Because the effort will focus on helping

individuals create a plan for long-term care,

there is a clear message to physicians.

“As authority figures in the areas of health

and long-term care, physicians can assist in pro-

moting Own Your Future educational messages

to their patients,” said Greene. “We know that

advance care planning has a significant role in

one’s health and wellbeing. Other important

conversations are needed such as where patients

want to receive long-term care, who they prefer

as their caregivers (family members, assisted/

skilled living nurses and aides, others), and

whether they wish to remain in their home

or prefer another kind of housing and care.

A variety of long-term care conversations are

needed so our wishes are known to our loved

ones and our physician. Once these conversa-

tions take place, most people feel a sense of

relief in knowing that their preferences are

clear and understood by their family and care

provider.”

Physicians can also provide information,

including the website for Own Your Future

and brochures that describe more about the

risks for long-term care and what actions can

be taken to address those risks.

The campaign will launch in early fall

and will include a website and other written

materials, community meetings around Min-

nesota and other grassroots efforts suggested by

panel members. Through a partnership with

the federal government, Governor Mark Day-

ton and Lt. Governor Prettner Solon will send

a letter to all Minnesotans this fall urging them

to plan.

More information will be available this fall

at the Own Your Future website,www.mn.gov/

ownyourfuture, as the campaign is launched

and gets underway.

includes Barbara Greene, director of commu-

nity engagement for the Twin Cities Medical

Society’s Honoring Choices Minnesota initia-

tive, and other key stakeholders.

“We need to engage all Minnesotans in

thinking about how they will plan for and pay

for the care they are likely to need as we, as a

society, are living longer and growing older,”

said Prettner Solon. “We are grateful for the

assistance in this campaign of Minnesotans

representing key sectors of labor, business,

health care, the faith community and non-

profit organizations.”

“Employers have a stake in this issue be-

cause long-term care planning can help ease

demands on family caregivers and give em-

ployees a greater sense of security about their

futures,” said Jesson.


Patience Breeds Success

As with any new idea, it takes time to get

to the end goal. Along the way, twists and

turns are part of the hard work that’s invested to

make a goal attainable and successful. Since the

Twin Cities Obesity Prevention Coalition was

created in November 2010, we have worked

diligently to craft a strategy that would allow

us to be effective and successful in providing

leadership to improve public health through

the creation of healthy eating/active living

strategies.

Patience has been an important factor in

rolling out the work and building the partner-

ships with cities across the metro. In a perfect

world, our work would be seamless, void of

any snags and there would be 10 to 12 com-

munities boasting about their newly crafted

healthy eating/active living resolutions by now.

As we have learned, we don’t live in a perfect

world and although the goals of the project

are being met, it’s been a slower process than

we anticipated. It isn’t necessarily a bad thing

however. We have had the good fortune to be

able to partner and strategize with multiple city

staff including mayors, council members, city

planners and park and recreation staff who have

taken a genuine interest in looking at all the

strategies that can move their community to-

ward a healthier future. In March 2012, Eagan

was the first Minnesota city to pass a healthy

eating/active living resolution. Another metro

community will unveil their new resolution in

late August.

Over the

coming months,

be on the look-

out for more cit-

ies to craft and

pass their own

healthy eating/

active living res-

olutions — each

meeting the

unique needs of

its community. As a coalition, we’re confident

we’ll have a successful 2012 and even better

2013 while we continue to create healthier

communities for all.

Jennifer Anderson, project coordinator, Twin Cit-ies Obesity Prevention Coalition.

Senior Physicians Association NewsThe Senior Physicians Association held their

summer luncheon on Tuesday, July 10, 2012.

Aaron Friedman, M.D., dean of the University

of Minnesota Medical School, and vice presi-

dent for Health Sciences spoke on the Vision of

the Medical School. His presentation was very

insightful and was followed with an engaging

question and answer session.

Mark your calendars and join us at our upcoming events!

September 4, 2012Senior Physicians Association Annual EventWeisman Art Museum Tour & Lunch

October 9, 2012Fall LuncheonGreat Lakes and Threats to

Minnesota Waters

Doug Jensen,

U of MN Sea Grant Program

Additional information is online at www.Me-

troDoctors.com. Click on Senior Physicians As-

sociation in the menu on the left hand side.

By Jennifer Anderson

Aaron Friedman, M.D., dean of the Univer-sity of Minnesota Medical School, was the featured speaker at the July meeting of the Senior Physicians Association.

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Sharing the Experience Conference Expands its Reach

C A R E E R O P P O R T U N I T I E SSee Additional Career Opportunities on page 30.

What happens when you share advance

care planning perspectives with health

care system providers, community leaders, faith

organizers, and multicultural representatives?

The July 19, 2012 Sharing the Experience

Conference, sponsored by Honoring Choices

Minnesota and the Twin Cities Medical Society,

demonstrated that important conversations,

learning and new strategies happen quickly

when stakeholders are gathered together.

With an audience of 80 participants in-

cluding attendees from Wisconsin and Michi-

gan, this year’s event focused on collectively

sharing growth, sto-

ries and vision. High-

lights included Craig

Bowron, M.D., Ab-

bott Northwestern

hospitalist and Hil-

lery Smith Shay, fea-

tured in the HCM

documentaries, who

shared keynote ad-

dresses on their

personal and pro-

fessional end-of-life

care experiences.

Barry Cohen, Ph.D.,

Rainbow Research,

provided a compel-

ling overview on the

power of evaluation

and establishing re-

alistic outcome mea-

sures. Faith panel

participants Helen

Jackson Lockett-El,

Minnesota Council

of Churches Community Organizer, Scott

McRae, director of Spiritual Care & Clini-

cal Pastoral Educator, Park Nicollet Health

Services, and Ann Ellison, director of Com-

munity Health, Fairview Health Services shared

By Barbara Greene, MPH

Craig Bowron, M.D., conference keynote, Abbott Northwestern Hospital.

Hillery Smith Shay, conference keynote, HCM documentary participant.

Multicultural presenters José González, MN Dept. of Health and Aida Strom, HCMC.

spiritual perspectives in beginning ACP con-

versations founded on core values and beliefs.

Multicultural panelists José González,

Office of Minority and Multicultural Health,

MN Dept. of Health, and Aida Strom, patient

advocate, HCMC, described how age, gender

and acculturation impact conversations around

advance care planning. Health care system lead-

ers and representatives shared successes and

progress in reaching patients and their families

on end-of-life care decision-making.

This year’s conference was successful in

bringing together community members and

health system staff in an interdisciplinary, in-

tergenerational and culturally rich way.

Barbara Greene, MPH, Honoring Choices Min-nesota director of Community Engagement.


C A R E E R O P P O R T U N I T I E SSee Additional Career Opportunities on page 31.

In MemoriamROBERT HEETER, M.D., age 70, passed

away recently. Dr. Heeter attended the Uni-

versity of Minnesota Medical School. He was

an orthopaedic surgeon at Ridgeview Medi-

cal Center for 35 years. Dr. Heeter became a

member in 1976.

DUDLEY HILKER M.D., passed away on

June 7, 2012. Dr. Hilker graduated from the

University of Minnesota in 1942. He was a

World War II Veteran who rose to rank of

captain, and then served as a field surgeon re-

ceiving a bronze star before discharge in 1945.

Dr. Hilker practiced OB and family medicine

in Minnesota for over 60 years. He became a

member in 1948.

ALEXANDER E. RATELLE, M.D., passed

away at age 87 on Sunday, June 10, 2012. Dr.

Ratelle graduated from the University of Min-

nesota Medical School in 1951. He founded

the Anesthesiology Department at Methodist

Hospital and practiced there for 38 years. Dr.

Ratelle became a member in 1955.

STANLEY STONE, M.D., age 96, passed

away on July 5, 2012. Dr. Stone graduated from

the University of Minnesota Medical School in

1941 and practiced family medicine at North

Memorial Hospital and Golden Valley Clinic.

Dr. Stone became a member in 1994.

Marc C. Osborne, M.D.Colon & Rectal Surgery Associates

General Surgery/Colon and Rectal Surgery

Youssef A. Sawers, M.D.Anesthesiology, P.A.

Anesthesiology

Angela D. Siwek, M.D.Southdale Pediatrics Associates, Ltd.

Pediatrics

Christa L. Waymire, M.D.Glencoe Regional Health Services

Family Medicine

New Members

SAVE THE DATE: EMMS Foundation Fall Event

Wednesday evening, November 7, 2012

Twin Cities Public Television Studios, Saint Paul

Yup.

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

Internal and Family Medicine Physician Opportunities:Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN.

Mahtomedi, MN? (Ma-toe-me-dye)So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education.

For further information please contact:Patti Lewis, Director Human Resources1500 Curve Crest Blvd, Stillwater MN(651) 275-3304, [email protected]

Internal Medicine?

Family Medicine?

Internal and Family Medicine Opportunities

NEW clinic inMahtomedi, MN?

We’ll make it all better.


C A R E E R O P P O R T U N I T I E S Please also visit www.metrodoctors.com

Recruit With

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Betsy Pierre, ad sales(763) 295-5420

[email protected]

Rates starting as low as $185—call today!

Options for website listings available as well.

www.metrodoctors.com

With just one click

you will find information

on the latest TCMS news,

events and legislative issues;

Board and committee actions;

past issues of MetroDoctors;

and new career opportunities!

Visit TCMS at www.metrodoctors.com


B y M a r v i n S . S e g a l , M . D .

LUMINARY

REUBEN BERMAN, M.D.

of Twin Cities Medicine

This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like consid-ered for this recognition to Nancy Bauer, managing editor, [email protected].

A cardiologist approached the frail patient’s hospital bed and introduced himself. “Your doctor asked me to see you in consul-tation. I’m Dr. Reuben Berman.” The startled patient sat bolt upright and exclaimed, “Oh no … am I that sick?”

The clinical reputation of our popular Luminary was obvi-

ously far reaching — beyond the medical community and

well into the general population — both in his chosen field

and in a myriad of other pursuits by this ultimate Renais-

sance man.

Reuben was born of Eastern European immigrant par-

ents and reared in Minneapolis. An outstanding student at

North High, he obtained his bachelors degree and in 1932

a medical degree at the U of M. After a Minneapolis Gen-

eral Hospital residency, he joined Dr. Moses Barron, a lead-

ing Twin Cities internist, in private practice at the Medical

Arts Building. He served in the Civilian Conservation

Corps during the depression and was called out of private

practice to spend 4+ years as an Army Flight Surgeon at the

height of WWII. His heroic battlefield European service

was rewarded by the presentation of a Bronze Star and the

French Croix de Guerre. At Dachau, he witnessed first

hand the chaotic aftermath of the holocaust and described

the inhumanity he observed in a written narrative currently

housed at the Minnesota Historical Society.

His beloved Isabel and their six extraordinary children

shared with him a life chock-full of accomplishments:

a founder of and chief of staff at Mount Sinai Hospital;

editor of Minnesota Medicine; acknowledged leader in the

American Heart Association and the American College of

Cardiology; president of the Minnesota Medical Founda-

tion; recipient of the Charles Bolles Bolles-Rogers Award;

founder of the Minneapolis Society of Internal Medicine;

and professor of medicine at the U of M. Prior to becom-

ing the driving force of Mount Sinai’s Clinical Research

Center — which continues today at Hennepin County

Medical Center as the Berman Center — he closely col-

laborated with noted research physicians, Drs. Paul Dudley

White and Ancel Keys. Reuben reluctantly agreed to the

naming by others of the Berman Center and generously

saw to it that a huge amount of money intended for him by

grateful patients went entirely to

support that research program.

He was an Eagle Scout at

age 15 — somehow passing the

rigorous array of badge require-

ments despite the fact that his

time for running a 100-yard

dash — as he stated — was “only

slightly faster than that of a

quick turtle.”

In between Reuben’s pro-

fessional exploits, he somehow

found time to bake delicious

bread, take expert photos,

sound the Shofar (ram’s horn) at his synagogue, hunt and

delectably prepare wild mushrooms, regularly pilot an

airplane, play superb music — first on his clarinet and later

a bassoon — and exercise by riding a bicycle on the streets

of Minneapolis into his 80s.

He was generous and directive in nature. To the

admiring young physician just leaving the Army in the 60s,

who expressed interest in following his lead in teaching, re-

search and patient care, he quietly though forcefully stated,

“You’ll be starting with us in July, we’ll exceed any offers

you receive from others, and caring for our patients will be

the focal point of all we do!”

Reuben Berman was a gentle man whose every pore

exuded wisdom. A favorite quotation of his after complex

experiences — both good and bad — was, “There’s a lesson

to be learned from all of this.”

And of his most beloved pursuit he said, “Medicine is

a combination of art and science — don’t belittle the art…

without which the science fails.” During his nearly 96 years

of a full and energetic life, Reuben found and followed the

perfect combination of both.

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