1

                            TERRY CROWSON

                         September 10, 1996
                        Dr. Fitzhugh Mullan,
                             interviewer



Mullan:    Your date of birth?



Crowson:    5/4/46.



Mullan:    Why don't we start back at the beginning, and tell me a

little bit about you, and where you were born and grew up.


Crowson:    I was born and raised in Rochester, Minnesota, and went

through high school there. Many people have always wondered if

we were associated with Mayo Clinic or not, and we weren't, my
folks weren't.


Mullan:    Must be a rare person in Rochester who isn't.



Crowson:    My father is actually a carpenter, he built houses.



Mullan:    And was he was Rochester, or no?



Crowson:   A long history of being from southern Minnesota.   I

came up to the University of Minnesota and went to medical
school.
                                                                        2

Mullan:        Tell me a little bit about Rochester before we jump to

medical school.        What was it like?
        I should say before we get going, you're in Doctor Crowson's
new office, I gather.        It's been a month or so?


Crowson:        Yes.



Mullan:        In the Heath Partners headquarters, which is a

magnificent off-green skyscraper on the south side of
Minneapolis, near the airport.        It is the tenth of September on
1996, a warm Minnesota afternoon.

        So   we're talking about Rochester and what it was like to
grow up there.


Crowson:        I think it was a great town to grow up in.   When I grew

up, it was about 25,000 people when I was in my formative years,
and it was a great place to grow up.         I worked as a veterinary
assistant and kind of got interested in it, and at one time was
thinking of being a vet.


Mullan:       How did you find your way to the veterinary assistant

job?


Crowson:       Just was looking for a job.   I think I was twelve years

old when I went to work.        I'm sure that violated some child labor
laws.        I started working after school taking care of the animals.
I really found I enjoyed the science and the diagnostics and the
                                                                         3

caring and stuff, although I wasn't doing a lot of that.         I was
just watching it being done.


Mullan:    Was that, indeed, as you started to say, something that

interested you in the possibility of medicine?


Crowson:    Yes.    I think that's where I got the first exposure to

medicine, although veterinary medicine.     That kind of stimulated
me to think about a career in medicine.


Mullan:    Were there others who influenced you about medicine?



Crowson:    There was a biology teacher in high school.    I enjoyed

biology, and he counseled me about all my career planning, what I
would do, encouragement, and that type of thing.


Mullan:    Anybody in or around your family was in medicine or

health at all?


Crowson:    No.    I was the first one to go to college in our

family.


Mullan:    When you went to college, had you yet articulated the

notion you wanted to be a doctor?
                                                                        4

Crowson:    No, I wasn't sure.    I was headed that way.   I think I
went right into premed.     I thought, "I'll give it a shot, see
what happens. ''


Mullan:    And were they supportive?



Crowson:    Oh, very supportive.   The family was supportive, and

both encouraging me to do it and financially with the training.


Mullan:    They stuck with you.



Crowson:    Yes.   And my dad pounded a lot of nails to put me

through school.


Mullan:    As you l o o k back on your youth in Rochester, were there

other influences that you would point to that have had an impact

on what kind of doctor you have become?


Crowson:    No, I really can't tie it back.    In retrospect, I think

my encounter with physicians down there as a patient was mainly
in the Mayo Clinic system, which was very specialized, and I
don't recall ever having a primary care doc.


Mullan:    Personally.



Crowson:    Personally.   I remember having the Mayo Clinic fellows

come out to the house when I was sick.
                                                                      5

Mullan:    To make house calls.



Crowson:    They made house calls.   In fact, they drove these sort

of light brown sedans, everybody knew if you were having a visit
with the doctor, so when that car pulled up in front of your
house, the kids would all run around and knew somebody was sick.


Mullan:    This was a Mayo service, or training?



Crowson:    I think it was service and training.   I think there

were fellows at the Clinic, they'd come out and make the house
call, you'd usually get $ 5 worth of penicillin.    I was growing up
during the polio epidemic, a couple of summers, and there were
some kids with polio in the neighborhood.     But I can't think of
any individual that I ran into in my growing up that I emulated
in terms of a generalist or even a physician.


Mullan:    Do you have brothers and sisters? Any of them take

medical paths at all?



Crowson:   No.


Mullan:    How about religion, church?   Was that one factor in your

youth at all?


Crowson:   Yes, up until about the age twelve or so, and then I

sort of parted ways with a Lutheran background, like the joke
                                                                    6

about a Lutheran minister who couldn't get rid of the mice.    Have
you heard that? A Lutheran minister was having trouble getting
rid of the mice, so the congregation comes in.   "I bought all
these traps, they didn't work," and he got approval from the
congregation to use an exterminating company, and they came in
and still didn't get rid of the mice.   Finally he came back to

report that all the mice were gone, and the Executive Council
asked him how he got rid of them, and he said, "Well, confirmed
them all," and they never came back..


Mullan:    You wouldn't count it an important factor in your

upbringing or your ultimate career?


Crowson:    I think it was important factor in my life, but not the

career.


Mullan:    So you went to university for undergraduate work?



Crowson:    Yes.



Mullan:    And how was that?



Crowson:    It was pretty good, except I think I got locked real

early on this is what I was going to do.    I envied my kids when
they were going to college,    the courses they were taking, and

thought I'd like to go back, because I didn't really get out of
my educational experience what I could have.
                                                                       7

       I got into a program.    At that time, after three years of

premed, I went to medical school, and got my bachelor's degree
after your first year of medical school,       s o you finished in

seven instead of eight years.


Mullan:    So you really were kind of fast-tracked.



Crowson:    I was fast-tracked.    Also,   after my freshman year, I

was married.


Mullan:    Freshman year of college?



Crowson:    College.   So I was also interested, I think, in

finishing school ASAP.


Mullan:    You grew up quick.



Crowson:    Grew up quick.     I had married when I was twenty.   I

think we lived in married student housing through my residency,
on the university campus in St. Paul, for seven years.


Mullan:    Let me ask one of the questions doubling back on the

vet.   Was the vet, himself--1 presume it was a him--an influence,
or was it the practice?      What was it that made the connection for

you?
                                                                      8

Crowson:     I think it was the vet and there was a group of vets.

There were four of them in a group practice, and they encouraged
me, too.     There was encouragement for me to go on and get further
education.     There was a lot of positive feedback working there.
They gave me more and more responsibilities.     They were willing
to teach, let me scrub in with them on things where they may or
may not have needed the help.


Mullan:    They kind of mentored you.



Crowson:     Yes, in a way.



Mullan:    But it was not for veterinary medicine in particular?



Crowson:     No.   I was interested and they were always willing to

help teach and do things and let me participate and try new
things.    Usually my job was to keep the cow from falling down.
But they'd tell me what they were doing, they'd answer questions,

and I say, "What are you doing?     What did you do that for?"   That
was a great experience.


Mullan:    And what was it that appealed to you in that?



Crowson:     I think it was partly the science, the biology of it

all, the wonder of it, how the organisms work and the bodies
work, and how all this anatomy and physiology fit together.      I
think that was part of it.     Part of it was watching, over time,
                                                                        9

to see the change in the physiology of the parameters of the
health of the animal.    I think that was intriguing.


Mullan:    Coming back, then, the university, you spent the years

undergraduate right on to medical school itself.    How was that as
an experience?


Crowson:    As I said, premed was--1 just sort of plodded through

and did the work.    Medical school was fine.   I think the first
two years I wasn't an outstanding student of any kind in medical
school, but I think the first pre-clinical years I didn't enjoy
as much, I don't think I performed as well.     Once I got into the
clinical years, my interest increased, and I started to work.       I
think I felt better about what I was doing, and I performed

better, really fell into the grove of practicing medicine.


Mullan:    At that point in your life, what was your sense of what

you wanted to do?    As you entered medical school and then as you
went through it, did you have an image of what kind of practice,
what kind of practitioner you wanted to be?


Crowson:    No, I really didn't.   I had an open mind until I got

into medical school.    I sampled a number of different things and
realized there were certain things I thought I liked or I felt I
was good at, and certain things that I wasn't as good at.    For
instance, I went through pediatrics, I remember taking
pediatrics, and at that time I had young children, and that was
                                                                      10

very hard on me, because we had these very ill children, very ill
tiny kids, that was just very hard.       I think for that reason I
stayed away from pediatrics as a specialty or primary care.      I
think surgery, I found that I wasn't particularly adept at that,

I wasn't good at it.


Mullan:    Cow-holder that you were.      [Laughter]



Crowson:    Yes, I was good at holding stuff, but that was about

it.   That just didn't fit for me.     As I got into the internal
medicine and took rotations, that seemed like what I enjoyed
doing.     I liked the patient contact.    I liked the whole exercise
of diagnostics, figuring out what was wrong, and coming up with
therapeutic and diagnostic     strategies.    I enjoyed it.


Mullan:    So as you graduated, what were you thinking about, and

what did you do?



Crowson:    What I was thinking as I graduated from medical school,

at that time, I think our exposure, at least in this medical
school, to family medicine, was not very emphasized or positive
or thought much of.     It was 1971.   I think family medicine was
getting a foothold, and internal medicine was the one that I
gravitated to.     I think if I were going through today, I don't
know if that would be the same, because I think family medicine
was a lot different than it was.
                                                                     11

Mullan:    Which years are we at?   When did you graduate?



Crowson:    '71.   I took an internship at University of Minnesota,

internal medicine.     I started heading that way in my senior year,

and about maybe halfway through my junior year, I started locking
in on internal medicine courses.     I'd taken cardiology and
oncology, and kind of targeting toward internal medicine.       I did
my internship at the University of Minnesota, which had a
separate program then, separate from the V.A., the Hennepin,
Ramsey, all had separate programs.     I think it was almost the

last year they did that, and then they all started to become more
integrated.    Then did the rest of the internal medicine residency
at the university.     I finished the residency and I signed on as
chief resident at Ramsey.


Mullan:    Which was a separate program at that point?



Crowson:    Yeah, it's a chief residency program.   A year after you

finished your regular training, at that time it was a case of
spending about a half a year very integrated with the educational
programs in serving in the hospital, working very closely with
the residents, making sure the call schedule, making sure things
were covered, making sure conferences were put on.     So it was

sort of an educational administrative position.     And then half
the year you got to do whatever, take some more clinical
experience somewhere and work with the cardiologists, or work in
                                                                     12

clinic, do whatever.     I thought that was a good experience for
me.


Mullan:    Tell me a bit more about Ramsey, because I know it's

important to your career.     It's a hospital in St. Paul?


Crowson:    Ramsey, at that time, was a city/county-type hospital.
It was run by the county.



Mullan:    The county being Hennepin?



Crowson:    Ramsey County.



Mullan:    Ramsey County, which is the St. Paul County, whereas

Hennepin is as you leave Minneapolis.


Crowson:    Right.   And Ramsey, at that time, was truly a

city/county hospital.     There have been several evolutions.   It's
changed quite a bit since then.     But at that time is was really
like a county hospital, it was affiliated with the University of
Minnesota, and most of the care delivered, in fact, all the care
delivered was by teaching services.     The faculty at Ramsey was
just starting to grow.     When I was a resident, I think, I can't
be absolutely sure, we only had a handful of full-time faculty.
The rest were people from the community or the university, and
they were just in the process of growing the faculty and building
                                                                    13

the service delivery system when I came out of residency, when I
came out as chief resident.
     Then I joined the staff as a general internist.


Mullan:    This would have been '76, 77?



Crowson:   '74 I was chief resident, so it would have been halfway

through '74, '75 I started on the staff as a general internist in
ambulatory care.    At that time, the people who were running the
institution had the wisdom to say, "We need to build our primary
care base, we need to build clinics on this campus that will
provide continuity of care for our patients.    We've got to build
a delivery system that includes ambulatory care." A lot of
wisdom and foresight there.    I had nothing to do with it.   I was
just brought on as one of the people to help build that
ambulatory care.
     At that time, the clinic had residents coming down there for
half days, they were supposed to be up on the wards.    The
patients were scheduled for two times.     You had an appointment
for either eight in the morning or twelve noon.     You came, and
you were seen in order that you showed up, and if you weren't
seen, you were sent home to come back tomorrow.     The residents
came down to the clinic usually about ten o'clock, and, of
course, there was a conference    at eleven, so they all left.
There was an inordinate number of cardiac arrests, it seemed,
during clinic hours.    Nobody liked to be there.
                                                                    14

     It was not a good system of care for the patients who had to

wait for long periods of time.    The residents received very
little teaching.    Usually the staff at that time in ambulatory
care would sit and read their current contents and hoped you
wouldn't ask them a question.    There really was a lack of
commitment to thinking that clinic was valuable or important.


Mullan:    You described a milieu, an environment in which there

was an intent to reform this, on primary care principles.       1974-

'75 was fairly early for the articulation of those ideas.     Who
was that coming from?    Where was that coming from?


Crowson:    It came from a number of different sources, I think,

within the community, within the university community.     The
immediate source of it were two people that I worked with, Bob
Mulhausen, Bob was the chief of medicine at Ramsey.    He had come

in a year or two before, and he had a vision.    He was an
academician, a real specialist, but he had a vision about what
needed to happen.    And Mike Spilane was another general internist
that was a year or two older than I, and he was in charge of
General Internal Medicine Section, and Mike is a great visionary.
They saw the importance of having this primary care and building
this primary care.    Ironically, both Mike and Bob still worked
with us.   Bob's back now, running our Medical Education
Institute, which is a new enterprise, it's very exciting, but

that's for another day we can talk about that.
                                                                     15

    At any rate, they had the vision and foresight to say that's

what we needed.   I don't know why I bought on, except I'd worked
with Mike before, I liked general medicine, I liked the whole
scope of things, and I think Mike was probably as big an
influence at that time as anybody.



Mullan:    That was successful?   Did you re-engineer, as we would

say today, the clinics?


Crowson:   Yes.   I always like to say I look back at that as being

something I'm proud of having been part of.    We took it from a
level of function to a new level of function that needs to
continue to improve.   I told you about what the clinics were
like, and what we did was built an educational program.    We put

it in place in 1976, so it's about twenty years ago.    We had
staff heavily involved in seeing patients with the residents,

general internal medicine staff, occasionally bringing in some
specialists, because we didn't at that time have as many
generalists around.
     We built an educational program for the residents.     It was

part of the residency that was a six-month block of time in
ambulatory care, that's all they did.     They covered the inpatient
on a call schedule at night, but basically, they were in the
clinic, and spent a six-month block.    What we did during that
six-month block was we were able to build a curriculum around
ambulatory care that we could deliver.    We had the problem of
trying to deliver a curriculum over three years.    At that time,
                                                                   16

to get any kind of depth, having a conference before clinic and

talk about hypertension in the outpatient setting wasn't very
effective.    For the ambulatory care rotation, we built an entire
curriculum, we had a set of conferences, we had a seminar series.

We talked about what we thought it was to be a generalist.


Mullan:    Were you using that word, do you think, do you recall

back then?


Crowson:    General internist. Well, we talked about it as primary

care doctor, general internist, and what's the role.


Mullan:    But those terms were current?



Crowson:    They were being used.   And the leader there, for me the

person who shaped my thinking about primary care more than
anybody, was Ben Fuller.   He actually had started the Family
Medicine Program as an internist. He started the Family Medicine
Program at the U, and then stepped away from it, and started
working in structuring this tract in internal medicine.    We had a
two-tract system then.    You either went for career in academic
medicine, or to go into practice, and Ben essentially devised and
helped design this curricula, and it was largely his curricula.



Mullan:    He also took lead in setting up the Family Practice

Program prior to that?    Those were two separate contributions?
                                                                           17

Crowson:       Two separate contributions. He had a model that I

think was just outstanding for what the generalists needed to do,
what kind of skills were needed, why the generalist was needed,
and had, I thought, an excellent series of seminars to teach
that.     So   we put that in place starting in ' 7 6 .


Mullan:    You stayed at Ramsey right on through, it that right?



Crowson:       Yes.   I think I was actively involved in that

educational block up until, I think, for maybe ten years or so
that I was real actively involved, and then I started to drift
away into other things.


Mullan:        Tell me a word about the nature of the clientele

population of Ramsey and of the nature of the hospital.             What
kind institution was it?        How did you feel about it?



Crowson : About the institution?



Mullan:    Yes, and its population.       Who was the population?



Crowson:       Population that we were caring for was mainly indigent.



Mullan:    Which in St. Paul terms means what?            Who were the

indigent in St. Paul, in terms of ethnicity, background,
migratory, stable?
                                                                     18

Crowson:     First off, St. Paul, Minnesota, has pretty good

programs for getting medical care to people. I think, regardless
of ability to pay.     Our hospital took patients, regardless, and
still to this day, takes patients regardless of ability to pay.
That's not a criteria for being served by us.    We have an
obligation to care for the citizens of Ramsey County, regardless
of whether you can pay, that's actually mandated by law.
     Ramsey started in the 1 8 5 0 s as a sort of county poor house,
county hospital, and evolved into what's called the Old Ancker
Hospital, which is named after Arthur Ancker.     It was the biggest
hospital west of Chicago at the turn of the century. And the
indigent care mission has been carried forward.
     The patient population that we set up to serve were mainly
the indigent patients who either they had no money at all, or
they were on general assistance medical care, or they were on
Medicare or Medicaid.     Initially, as time evolved, and I don't
know the exact times of this, but the system started to evolve so
that they could go anywhere they wanted, they didn't have to come
to Ramsey.    Now we're getting more and more new Americans, and a
lot of Southeast Asians, black, Hispanic, but the demographics of
Ramsey are mainly indigent.     I don't know the percentages.


Mullan:     So for ten years you were involved largely in the

educational, ambulatory, primary care, delivering programs.


Crowson :   Right.
                                                                    19

Mullan:    Then you evolved?



Crowson:     Still doing that, but then started getting into more

administrative things.     One of the things, I think it was in '86,

we set up, was a prepaid system with the county for providing
care to the enrollees on GAMC, on General Assistance Medical
Care.


Mullan:    Which is Medicaid?



Crowson:   No, Medicaid is state and federal.    This is the local.



Mullan:    Patients who probably didn't qualify for Medicaid, who

were poor.


Crowson:   Who were poor, didn't have resources, usually were in

the system because they had health problems.     The reason they
couldn't work was because they have health problems.     I got
involved in setting up--


[Begin Tape 1, Side 21


Mullan:    This is Doctor Crowson, tape one, side two, continued.



Crowson:   So we set up this prepaid medical plan with the county

for the people out in GAMC.     The county, I think, saved
significant dollars, and we made it work by getting patients into
                                                                       20

a delivery system, whereas before they received care anywhere
they showed up.     I don't know that we studied it enough to know
exactly    all the impacts it had, except that I think it was
successful from this standpoint.


Mullan:    Was this under the conceptual mantle of managed care, or

was this less ambitious than that?


Crowson:    No.   It was a managed care program.   We received a

capitation from the state, and we tried to manage the population
as best we could.


Mullan:    So that an individual who qualified for GAMC--



Crowson:    Would get a card.



Mullan:    And that gave them eligibility to you, but they had to

come under certain circumstances in terms of seeing a set
physician, I presume, etc.?


Crowson:    Well, part of it, the challenge was that the average

person was only on the program for a few months, so that
continuity idea, while ideal, not necessarily did the best.        I

think we were able to do some things with setting up alternatives
to showing up at the ER and helping people so they didn't feel

they had to use the ER.
                                                                       21

     I     got more involved in sort of medical administrative
issues, started looking at our whole ambulatory care setting.          I
said a while back that when I first started at Ramsey, we were
just starting to pull the clinics together and make them work,
and try to make them work better, meet the needs of the
population to build a primary care business.      By    1990 we were

one of the largest hospital-based outpatient facilities, and
today we're still fairly large.      We'd see over 250,000 visits a
year, right on the campus, not including our other outlying
sites.     So   it really was a successful strategy that was put in
place through the vision of many people at Ramsey.


Mullan:    And it remained, throughout this period, a county

hospital?


Crowson:    Well, in the 1970s, about the time I came on, it was

becoming apparent that Ramsey County could not continue to
support the hospital to the degree that would be ideal, mainly
because Ramsey County doesn't have that big a tax base.        It's
geographically a small county, it's got a lot of government land,
and by comparison, it's got one-sixth the tax base of Hennepin.
     We realize that in order to provide the service to the
county, we had to have a different model, and so we started
moving further and further away from governance by the county and
funding from the county, and in 1986, we made the split with the
county and became a public benefit corporation; a not for profit
corporation that would carry the mission, i.e.,        forward for
                                                                      22

providing care to the citizens regardless of ability to pay.     The

hospital gets,less than 1 percent of the budget from county tax
revenues.    So   it's an interesting model, because, I always like
to say, we're fulfilling a public mission through private
initiatives, which I think is one of the ways it can work.



Mullan:    And who governs?



Crowson:     There's a board of the hospital.   Things are evolving

now, but at that time we formed a corporation called Ramsey
Health Care, which was the public benefit corporation, which had
three subsidiaries.     One was the hospital, St. Paul Ramsey
Medical Center, the second was Ramsey Clinic Associates, which is
a not-for-profit, multi-specialty group practice.


Mullan:    That's called Ramsey Associates?



Crowson:    Ramsey Clinic Associates.   And Ramsey Foundation.



Mullan:     So the Clinic Associates were essentially the medical

group?


Crowson:    Yeah, its a doctors' group.   We have about 180 to 200

docs.


Mullan:    And the third was the Foundation?
                                                                    23

Crowson:    Ramsey Foundation.



Mullan:    And what was its role?



Crowson:    Its role was fund-raising, which is new.    When we were

with the county and perceived as the county, you know, people
don't want to give you money, if you get their tax dollars, so we
started building that fund-raising, and that has grown
significantly.       It's the vehicle through which we receive grants
for research and administer research efforts.


Mullan:    What year was this?



Crowson:    1986, '87.



Mullan:    And the public benefit corporation, this is when it came

into being?


Crowson:    Yes.



Mullan:    Under the aegis of the public benefit corporation, there

were the three subs?


Crowson:    Right.    And the Ramsey Health Care, essentially it was

a PHO, a physician-hospital organization, that started working
very closely together to be successful, but it was under the
                                                                        24

governance of a board that is a representative of the community.

There are three physicians on it, otherwise it's all community.


Mullan:    What I'd like to do is quickly walk through your story

up to the present, and then go back, since it is intertwined with
the organization in specific, and developments in Minnesota in
terms of evolution managed care, as I understand it, in general.
So let's just quickly do the personal side, and then come back
and look at it in the big picture.


Crowson:     So in '86 I started looking at other things.    I became

director of ambulatory care, which was a deputy medical director,
and then by--1 can't remember the dates, it was '89 or '90 or
something, I became medical director of the hospital.       At about
the same time, we had sort of a double crises in the clinic:       a
financial crisis, and also our leader died relatively suddenly of
cancer.


Mullan:    Your leader being?



Crowson:    Doctor Taddeini, who was head of the doctors' group at

that time.    So we had a vacancy in leadership, and I ended up
taking that role, and I served both as president of Ramsey Clinic
and as medical director for the hospital.     So we've had

essentially one medical hierarchy system that worked for both the
clinic and the hospital, and so I filled those roles.
                                                                     25

Mullan:    You became the medical director of the hospital,

preceded becoming--


Crowson:    Yes.   I don't know, some months, shortly also became

president of the clinic, of Ramsey Clinic.


Mullan:    And that lasted for a while?



Crowson:    Yes.   Actually, I'm still holding those two roles,

although the roles are evolving.     Two years ago we merged with

the Health Partners organization.     I served in those two roles up

until just this July. I still hold those titles, although the

roles are changing, and I became co-medical director with Health
Partners.    We're the Health Partners Medical Group, which is a
merger of the old Group Health Medical Group and Ramsey Clinic.


Mullan:    Have you stayed active clinically?   Do you see patients

still?


Crowson:    Up until last Friday, that was my last day.   That was

hard.      When I took on the   administrative roles, I maintained
clinical practice, I'd attend on the wards, and I'd do all this,
and I just found that I couldn't do it, and I'd start cutting

back.     Finally, last couple of years I've only had one half-day
of clinic.    As a primary care doc I couldn't do it.   There are
two issues that I had to confront.     One was maintaining my

competence, which over time you start losing unless you're doing
                                                                     26

more of it than--1 don't know where the line is, where you're
doing enough to maintain your skills and to keep up.      I felt that
I wasn't, so I had to make that decision.
       The other was, as a primary care doc, I couldn't be there

when patients need me.     You have a contract with the patient to
be their doc, and then they can never get hold of you, and the
nature of that contract I found unsuitable, I didn't feel I could
deliver.    So   I found myself telling patients, "Well, 1'11 try to
be available, but you've got to understand I won't be."      I think
it got to the point that I just couldn't do it, so I made the
decision, probably last spring, to start weaning out of patient
care].


Mullan:    Again pursuing the personal theme, for many people, I

suppose in all walks of life, but certainly in medicine, by the
time they reach their latter part of their forties or their
fifties, they have "done it" in the sense of become the clinician
that they wanted to be, or established a level of specialty

proficiency, or what have you, and I found that it's often a time
where people kind of rethink what they want to do with the
balance of their career.     Did that enter into this evolution for
you?


Crowson:   Well, I think it did.    I guess I've looked at it as

doing something that I find interesting, and, personally, I like
starting up stuff, getting it rolling, and then after it's
rolling for a while, I kind of like to go start something else
                                                                      27

up.   And if I look back at my career, that's kind of how I've
done things.    I love getting stuff up and started and run it for
a while, and then turn it over to somebody else.      I'd rather go
on and do something else.     I facetiously, maybe not so
facetiously, tell me colleagues that I surpassed all my career
goals when I graduated from high school.     So I've never had that
"This is where I want to be at the end of my career."       I've never
set a goal like that.     So it's been whatever's in front of me,
what's interesting, what are the opportunities, maybe head in
this direction.    So   it wasn't a stage of calculated moves, it was
more of what opportunities were in front of me at various times
that I saw that were an interest to me.      That's sort of how it
evolved.


Mullan:    Let's go back and pick up the sociopolitical health care

developments both in the Twin Cities and with Ramsey.       We were in
the late eighties, talking about the new currents were blowing,
were affecting the institution.     Tell me a bit more about the
environment. Minnesota, as I understand it, has had a somewhat
more progressive tradition in terms of health care, in terms of a
lot things, but health care in particular.     You referenced it
before with the "Ramsey mission.'' Tell me more about that, and
then how did the managed care currents intersect with that?


Crowson:    I don't know that I have a good explanation for how

that all fits together, other than it seems like this setting was
ripe for development of managed care to develop as a way of
                                                                     28

delivering care, as an alternative way of how we could get the

services to people.     I guess I just don't know enough about what
was going on at the time.     At that time, when I think back to the
early eighties and '86, I was somewhat cocooned, frankly. We
were in an academic-based practice focused on our mission, and
really not in touch with the market, and I think that's part of
the story of how things played out.     So I don't know that I can
shed a l o t of light on that.   I wish I could.


Mullan:     Managed care was a force in this city before it was

elsewhere?


Crowson:     Yes.



Mullan:     Going back to the early seventies and Paul Elwood

[phonetic] being here, and the concepts were at least in play
early on.



Crowson:    Yes.



Mullan:    As a practitioner, if you can think back to the mid-

eighties or earlier, were you skeptical about that, or that might
have been okay for some other segment of the market, but it
didn't have anything to do with what you were doing?


Crowssn:    Yes, I think that's kind of--1 guess I'd go back and

say, first of all, if you look at Group Health had its foundings
                                                                   29

as a cooperative, as a traditional group health cooperative.     It
started and it was in the community and received a lot of
criticism, and went through a real rough time of the medical
community   .

Mullan:    How far did it go back?



Crowson:    I think it started back in the forties.   But I remember

when I was going through medical school, they were growing, and
there was a Group Health right on Como Avenue.   The medical
community and provider community was not at all enamored with
that approach, and they went through some really rough times back
then, but I remember that it progressively grew in the community.
As a practitioner at Ramsey, I think we were isolated from that
because of our special place in the market, or at least viewed
ourselves isolated. We were not isolated.    We viewed ourselves
isolated, that we were in an academic-based practice, providing a
special service to the community, and we didn't have to go out

and play in that market.
     Now, as things evolved, obviously in 1986, we started to see
that the state and some of our traditional populations were going
to be cared for differently, and we started to realize that we
had to do things differently. Also I think we started to realize
that in order to build a patient population base that would
support the organization, that we were going to have to get more
involved in managed care.
                                                                   30

     From a practitioner's standpoint, a lot of us felt we were
sort of isolated, but when you look back at the history, we
started an HMO, don't quote me on the year, but we had Ramsey
from shortly after the time I got there, it must have been the
late seventies, early eighties, we started our own HMO, Ramsey
Health Plan, in order to participate in that market.


Mullan:    So by the mid-eighties, these developments were rolling?



Crowson:    Oh, yes.



Mullan:    And you described the public benefit corporation

transition.    Walk me forward then, from a Ramsey perspective,
that as it began to merge with Group Health and Partners and so
forth, how did that unfold?


Crowson:   We looked at what was happening in the market, and at

that time the Minnesota care legislation had gone through.    That
was legislation passed a couple of years ago that started to
address the care of the uninsured, and started to look at how the
health care system was going to be designed.    It was clear to us
that one of the things that was developing was the whole concept
of--1 think at that time they were called integrated service
networks, which, in essence, were going to be networks of
providers, both physicians, other health services, hospitals, and
insurance function, all being in a package, put together in a
package, and that that was how the market was going to evolve,
                                                                   31

and that the purchasers--our read was that when we looked at our
strategic planning, that the market was evolving, that the
purchasers were going to be looking for these ISNs.     They're
going to be looking for a broad geographic distribution,
integration of all these services, rather than this piecemeal,
putting together--


Mullan:    The Minnesota care legislation, that was designed to

enable integrated service networks?


Crowson:     Yes, and particularly mechanisms to provide for the

uninsured.


Mullan:    What year do you think that was?



Crowson:     It was probably four years ago, I think, that was

passed, three or four years ago.


Mullan:    The way that it was going to provide coverage for the

uninsured was to enroll them in Integrated Service Networks?


Crowson:   Well, that was going to be one of the strategies that

was going to be used.    We saw that buyers, the business community
and government purchasers, were all going to be looking for these
networks. We did not think that Ramsey Health Care was big enough
to survive in that kind of a market.
                                                                      32

     We had a number of integrated pieces, we had a hospital, we

had a physician group, and we had, actually, some insurance
vehicles, but we just weren't big enough.      We couldn't cover the
entire metro area, and we didn't think that we going to be able

to be an independent service network.      The other thing that we
saw, the networks were starting to form and not everybody was
being allowed to participate.      So in a couple of cases, we were
having contracts canceled.      We were just told "We are shrinking
our network, and you're no longer going to play, and you're not
allowed to be in the network."
     So    when we looked at all those forces, we thought we needed
a partner.     So   we went out and went through a process of talking
with a number of different entities.      We didn't think that
horizontal integration made sense to us, because there's already
too many hospitals beds, and we thought that it made more sense
for us to become part of the health plan.      So that led to our

discussions with Health Partners, who was interested, and seemed
to fit.


Mullan:     The point there being that integrating or linking up,

partnering with another entity that looked a lot like you that
had hospitals was not particularly advantageous.


Crowson:     No.
                                                                   33

Mullan:    Whereas linking to an entity different from yourselves,

one which had a population base, but not bricks and mortar, was
more appealing, and Group Health constituted that?


Crowson:    At point, Group Health had been merged with Med

Centers, and they were now called Health Partners.    But, yes,
that made more sense to us than--we did talk to other hospital
systems, but we thought our best bet was to try to work with the
network.


Mullan:    And again, Group Health had linked with Med Centers.

What was Med Centers?


Crowson:     Med Centers was a health plan that was a contracted

network, whereas the Group Health was a staff model, an HMO.
They felt that merging those two brought advantages to them.
Together they could have advantages in the market.


Mullan:    And when was it did you merged with them to make Health

Partners?


Crowson:    1993.   Health Partners was formed about two years

before we merged.    We merged in 1993, the end of '93.


Mullan:    And that brought your hospital, your medical staff into

this larger network?
                                                                     34

Crowson:    Yes.   We're a division within a larger corporation that

had the group health delivery system and insurance functions.


Mullan:    And that has stayed intact without major changes since?



Crowson:    The last two years.    I think there haven't been many

structural changes, but there have been a number of operational
changes, and we're in the process of merging the two physician
groups.    Just did that.


Mullan:    That would be the Group Health and Ramsey Clinic.



Crowson:    Yes.



Mullan:    And when you say "merge them," that means?



Crowson:    Become one group.



Mullan:    That they admit to the same places?



Crowson:    We act like one.    Prior to this summer, basically we

had Ramsey Clinic as a separate physician entity, and Group
Health as a separate physician--


Mullan:    So the running rules from all different perspectives

would have been different, recompense, referral patterns, etc.,
etc., would have been different?
                                                                     35

Crowson:    Yes.   By merging, what we're doing is saying, "We are

now going to behave as one group."    We don't want to be two
competing groups under one umbrella, that's not a very efficient
way to do things, and that we want to become one group to carry
out the missions that we both have.


Mullan:    HOW'S that going?



Crowson:     It's been two years we've been at it, and we went

through a lot of planning together.    We're coming from very
different spots, pure staff model HMO and academic-based multi-
specialty practice, you have differing cultures and different
views.     We've, I think, been quite successful in the last two
years at planning, bringing the groups together, forming the

vision of what we want to be as a combined group, and then going
about the steps to implement it.     This summer was when we named
the leadership, the combined leadership of the group, and we're
in the process of putting that structure into place.     We
anticipate that by 1998, we will be just completely one group.


Mullan:    What I'd like to do is explore a little bit both what

it's been like as a physician manager in these various stages of
evolution, and then I'd like to talk a little about managed care
and how it plays out in the population in its various flavors
here in Minneapolis.     But focusing for the moment on what it's

been like to be a physician manager, you had an identity that was
based at Ramsey with all of the attributes that that had, both
                                                                        36

with foresight, and, I'm sure, with some degree of market
buffeting.     That organization has melded into a larger one, and
it continues to meld, witness the recent consummation, as you
describe it, as a physician group merger.      What sort of role have
you played?     What has it been like for you?   What is it to become
a physician manager in one of these new integrated entities?


Crowson:    Well,     first off, there are several key differences

between clinical medicine and management.       First, is how you get
your rewards.       In clinical medicine, you do get relatively timely
feedback.     You do something, and within, hopefully, in some
cases, minutes, and other cases, days, weeks, months, you start
to get some feedback about what your interventions have done,
your patients are getting better, there's some response to what

you're doing.
      In management, it's very indirect.     You try to put into
place a system of processes that somehow will improve the
outcomes, but by the time the outcome rolls out, you don't have
quite the connection you do as you do in clinical medicine.        So

that's one important difference is the reward that I had to adapt
to.
      Second thing is the degree to which you're working in teams,
teams of different disciplines.      I think medicine is evolving

more and more toward teamwork and working with different
caregivers.    We've always had team work, but I think it's the
working in teams with different disciplines, that we haven't in
                                                                        37

medical practice traditionally worked with such as finance, human
resources, legal.      The team work is much more complex


[Begin Tape 2, Side 13


Mullan:    This is Terry Crowson, tape two, first side.



Crowson:    Mentioning the complexity, part of that relates to

autonomy.    I think in clinical practice there's a little bit more
autonomy in the decision-making and that kind of autonomy in
decision-making doesn't work as well in administration.        I think
you need    different decision-making strategies to make sure you
get the good decisions and get it done in any kind of timely
fashion.    So   those are significant differences, j u s t generically.


     I think one of the challenges that I suspect any
administrator, physician administrator, right now is facing is
trying to help people through the change of what's going on.        I
look at it that we are in the third revolution in medicine this
century.    We went through an education revolution early in this
century with the Flexner Report.       This is actually Ben Fuller's
wisdom, and he also said that with World War 11, the
technological revolution started, and it goes on.       We're now
going through a socioeconomic revolution in the United States,
and it's still playing out.



Mullan:    Socioeconomic?
                                                                      38

Crowson:    Yes, revolution.   It's probably been happening, and

managed care is part of that.     It's probably been going on for
maybe a decade or so, but we're still in it, and it will evolve.


Mullan:     The first two come through clearly to me.    The third,

certainly there's a lot of changes in the society of medicine and
the economics of medicine.     Is this from the physician
perspective particularly?


Crowson:     Yes, I think the roles of physicians and what they

traditionally played have been changing.     How they do their work
is changing.     How it's financed is changing.   It's a major, major
change.     How physicians work, we're working more on teams, we're
working more in groups, and the solo practitioner, who is
basically on a fee-for-service model is really just about
completely gone.    As we go through that, I think one of the
things, dealing with the physicians, that is helping them
understand that this change is going on and what's driving it,
and understanding what changes we have to make to be successful
in carrying out our mission.
        I tell my colleagues that I wish it were 1974.    I loved that
year.     It was great, you know? And I wish it could be like that
from a standpoint of what I felt my role was and what I did, but
it's not.     That's not one of the options on the table.   We can't
go back to the way things used to be.    We've got to figure out
new ways in the new realities to do it.    And that's probably the
biggest challenge, is helping to make that transition.
                                                                     39

Mullan:    You must have engaged multiple positions on both the

clinical, the quasi administrative, and the administrative levels
dealing with these changes over the last decade or so you've been
involved in this.     In the more recent period, when it's become

pretty intense, you see people making it, people not making it?
How do you characterize how you see physicians responding?


Crowson:    My experience has been that the people who are probably

within five years of retirement are just hanging on.     That's been
true for the last five years or so.     They're in their last stage
of their career, a lot of them are just hanging on, so they won't
change or see the need to change.     Some of them are just happy to
be getting out and not have to go through it.     The young people
adapt.     They're adaptable, coming out of training, adapt pretty
quick.     I think it's the doctors in my cohort who are most
trouble, because we have twenty years or so of our careers in a

system that's seen a significant amount of change, and I think
that's probably the group that's having to go through the most

change.


Mullan:    One hears stories of physicians' extreme angst, anger,

frustration, and obviously there are many who have adapted well.
Do you see people just on the negative side, other than the folks
at the terminal stage, or people who cut and run and take early
retirement, do you see people being broken by this?    Do you see

people who can't adopt, who are being extruded by this system?
                                                                      40

Crowson:     I don't think so.    I'm sure there are people who are

just throwing in the towel and saying this isn't what they signed
up for.    In general, I think in health care, we didn't go into it
because we saw it as a rapidly changing field.       I sure didn't,
and I think this is true of a lot of different providers, not
just physicians, that there was going to be this much change.
But I don't see a lot people broken, just throwing in the towel,
and saying, "I don't want to do this anymore."
     What I found interesting, when we started talking with our
docs about what we wanted to do, and we started talking to our
groups about what's the ideal group that we want to form, this
new group.     How do we want it to work, what do we want it do, how
do we want it to continue?       What you saw is, you saw it coming
back with those kind of core values that drove us.       You kept
seeing that.    We had these two very disparate groups in terms of
cultures but when we get down to talking about what you value,
there's a lot more there that's alike than there is different, a
lot more alike than they are different.

     I see it as sort of a redirecting, kind of stepping back and
redirecting in the current realities of what we're dealing with,
how we best carry out what we set out to do in the first place
with medicine, and I think it presents all kinds of opportunities
that weren't there before.       I see some of the things we're doing
here, and it's just exciting.       The population-based health
initiatives that are going on this organization.



Mullan:    Which means what, exactly?
                                                                       41

Crowson:    Looking at saying we have this group of members now in

our health plan.    How do we improve their health?     It starts
right where the missions did.      Health Partners' mission is to
improve the health of our members in our communities.       Pretty
simple.     It's to improve the health.   Now let's get serious about
this.     What do we do to improve the health? And there are a
number of initiatives that have come out within a program called
Partners for Better Health, that have targeted things, and
saying, "Let's do some specific things that we can look to as
improving health, and let's target certain areas," and we've got
specific goals that have been set out for reducing cardiac
events.    We've got goals that look at immunizations rates.     We've
got goals that look at maternal infant health.       We've got goals
that relate to diabetes, identification and early treatment and
maybe even initiatives that would identify people at high risk
and hopefully prevent some of them from developing types of
diabetes. There are also initiatives related to domestic
violence, breast cancer, early detection and treatment.       Let's go
out and set some goals, put some initiatives in to improve how we
preform in those areas.     I think that's exciting stuff.


Mullan:     In terms of this theme of adaptation of the new

environment, any observations about the adaptability of primary
care physicians versus specialists?


Crowson:    It'll all be biased.    I have biases.   I just told you
I'm biased.     In general, I think the primary care docs are more
                                                                     42

flexible in being able to adapt. Maybe that's a generalization,
and I can't give you any data, it's just my impression.    I think
they tend to adapt better to changes.


Mullan:    I would think there might be even a more elementary

level in which primary care doctors are sought by, or retained
by, a system as it forms up, whereas the specialists are much
more at risk in terms of what I presume is the downsizing of the
specialist fleet most organizations have.    Is that a fair
observation about this?


Crowson:    I think, in general, if you look at Twin Cities market,

I think that's a fair observation, that the specialty market
here, depending upon what figures or what assumptions you want to
make, there probably are more specialists, particularly in
certain areas of what we need to serve the population.     I think
that's true, that, in general, right now, I think the specialists
are feeling more threatened and there may be more angst.


Mullan:    I tried to look at the figures that you've been good

enough, or I think George Isham had been good enough to send me a
snapshot of Partners in the various merged groups, the
composition of specialists versus generalists, and, of course,

that's just one point in time, I don't how that's evolving.      What
is the strategic balance between generalists and specialists, and
are you trying to downsize one and upsize the other?
                                                                      43

Crowson:    We brought together the two groups, and Group Health

was maybe two-thirds primary care and one-third specialty,
whereas the Ramsey Group was just at two-thirds specialty and
one-third primary care.     I think what we're trying to do is we

want to make sure that we've got the right balance.       There are
some specialties where we think we may have maybe some work to
do, but I think there are options in terms of how we deploy our
people.     So I don't think we're envisioning any massive changes.


Mullan:     Back to the primary care theme.   As the systems, in

general, have formed, and as this one in particular has formed
and reformed, tell me a bit about the role of the generalist,
going back to your roots, struggling in those ambulatory clinics
in the mid-seventies, trying to make sense of them.     Has the hour
of the generalist arrived, or, as I hear in some sectors people
sort of saying, the generalist is being abused and misused, and
has been become a policeman, or a variety of other things.     How
has the life of the generalist evolved in your systems here?



Crowson:     I don't think I ever felt like a policeman for the

system, and I don't think the docs in Group Health have either,
the primary care docs.    I don't feel they've been put in that
position.    When I first started as a generalist, that was not the
thing to do.    I think the attitude was that if you were in
general medicine, then you were too dumb to get a fellowship.        I
remember one of my former professors came over to give grand
                                                                    44

rounds at Ramsey, I hadn't seen him for a couple of years, and he
said, "Gosh, hey, Terry what are you doing?"
      And I said, "Well, you know, I'm in general medicine at
Ramsey," and you would have thought I said I'd been in jail for
two years.    The look on his face told me that somehow failed.     I
think that was sort of a prevailing attitude, that there wasn't

much merit in generalism.
       I happen to think there's a lot of merit in generalism,
obviously, and I think it's exciting.     I think it's
intellectually challenging.    When you think about it, when you're
the first person to hear the person's story, you're not the
fourth person, you're the first one to hear what's bothering him,
and you start with an infinite number of possibilities, and
through listening, hopefully through listening, and examination,
you're able to narrow it to a small number of possibilities of
what could be wrong, and that's an incredible, incredible
exercise.    Whereas I think sometimes I don't find it as
challenging when you get into some of the technical specialty
areas.    It's almost rote.   It's not as exciting.
      The other thing is that I found was that in regard to the
illnesses and the diseases, I    lose interest.   But the illnesses
always come in such interesting packages.    Every individual's
different.    In primary care, you really get to appreciate that.
It's sort of a privilege, a professional privilege to be able to
see how the same physiology, i.e., a ruptured disk, plays out in
different people, and I think that's fascinating and interesting.
So   from a personal standpoint, the rewards are exciting.
     I think the role is very important role in the decision-
making, the decision-making role of the primary care doc.
Somebody has to collect enough information to be able to either
nail the diagnosis, or get close enough to know what to do next.
When you figure that there's, what, probably less than twenty
complaints, I mean generically, i.e., weak and tired, but there
are 4,000 diseases.   That's an exercise.   How do you get from,
\\I'm weak and tired," to what's the right treatment?   That's why
I think it's important. And the other thing is that subtlety
makes a difference.   The majority of information is coming from
listening to the people.   I think that the primary care doc, the
work has to be structured in such way that the primary care doc
has the skills and the time to do that well.
     My experiences as a primary care doc, about 50 percent of

the people who come in the office are there specifically because
of something that's going on their life right now, and it's not
due to a typical illnesses that we are all taught so well to
diagnosis.   The majority of the headaches I see are not brain

tumors.   The majority of the bellyaches I see are not ulcers or
ulcerative colitis.   The majority of the diarrhea I see is
functional bowel, it is not inflammatory bowel disease.     You've
got to know the difference.   It's not to trivialize it.    It's
that that's very important.   Just think of having to sort through
what "Am I dealing with the person who has functional bowel,"
versus somebody who's got ulcerative colitis.
     I think it's very important.   The primary care doc uses
history and physical in appropriate use of diagnostic tests by
                                                                       46

setting apart probability of disease. And that's where, just

from a decision-making standpoint, that's what the primary care
doc needs to do, as accurately as possible.        say, "What is the
prior probability of disease that I'm testing?"          If we use
Bayesian logic, you're going to get the most information when
you're about 50 percent sure before you test. And if you think
about some of the testing strategies you end up with a low prior
probability, and then after the test, you haven't really made
much progress in certainty of whether they've got         the disease or
not.
       I think understanding all that, and being able to use it and
have the work structured so you can use it, I think that's very
important.      I think it really makes a difference.     You see it
with the cardiologist. Maybe 50 percent of the people or more, a
cardiologists sees with chest pain may have coronary artery
disease.      If I took all the chest pain that walked into my
clinic, it's probably going to be about 5 percent, where coronary
artery disease is the cause of their chest pain.         Makes a
difference in your mind-set, depending on what you think the
prior probability is.
       So   I think that's an important diagnostic issue. It's
important that you have skilled people who are knowledgeable as
the first contact.     Ben Fuller taught that we   (   ea1 with two kinGs
of data.     We deal with primary data, which is everything that is
unique to the patient, and we deal with secondary data, which is
sort of the fund of medical knowledge, everything that's known
                                                                     47

about medical knowledge, and we have to integrate those two, to
come up with a rational diagnostic or therapeutic strategy.
        That means that your primary care doc has to be good at
certain things.     They ought to be darn good with communicating.
They've got to be real good at interviewing and in listening to
patients, because that's where the majority of information comes.
They ought to be knowledgeable and skilled about decision-making,
rational decision-making.     I keep going back to Ben, because I
sat through his lecture series twenty-five times, so I've never
forgotten.     I've got it hammered in.   I needed to sit through at
least ten to get it.    But he pointed out the importance of the
primary care doc and the decision-making skills.     He says that
basically the primary care physician's commodity is the decision.
We have technology, we have other things, but basically it's a
decision, an informed decision that we present to the patient in
the form of recommendation, and they can either accept or reject
it.     I believe that is the fundamental commodity that we provide,
and that's what people come to us for.
        It's not to say that patients aren't the ultimate decision-
makers at all, but I think we do have an obligation.     We just
don't turn the data over to the patient and say, "Well, what do
you think we ought to do?    Here's the data I collected.   What do
you think ought to do?"    We take that primary and secondary data,

put it together in a series of recommendations for the patients,
and we should be good at that.    We should really trained for
that.
                                                                    48

     I think there's always room for improvement. When I went

through training, I essentially unlearned anything I learned
about appropriate medical interview, because of the system.      The
system was such that you were the fourth person to work somebody

up, and you just had to collect the data so that you could report
it to an attending physician for decisionmaking.     It really

wasn't used.    I spent very little of my training time in clinic.
My first years of practice I    learned more than I learned in my

residency about what was relevant.    I wasn't well trained, I
don't think, for what I ended up doing.      I shouldn't say well
trained, I should say optimally trained.     That was one of the
things we set out with this educational program, was that was one
of the things we wanted to do was to take it and say, "Let's go
in this direction.   We'll build on this."


Mullan:    This very eloquent discussion of what the essence of

primary care practice is, would that be appreciated, both
understood and also valued, by the majority of the primary care
physicians that you have collected in your network, many clearly
educated in other ways, and not at least with their basic
education, subjected to this kind of both systems thinking and
particularly primary care philosophy?    Would that be appreciated,
and to the extent that it isn't, what could be done about that,

or what are you doing about that?


Crowson:    I don't know that I got a great assessment of that.

From what I've see, I suspect that is appreciated.     You see it
                                                                    49

surfacing in various ways as people look at, "Let's figure out
better ways, more rational ways to take care of people."     You
listen to the discussions that go on between the generalists and
specialists about how you ought to approach certain problems, and
you start looking at practice guidelines that are best practices.
You start developing what our best practice is, and you start
having discussions between the specialists and generalists, and
you start seeing, you start understanding those things.      I think
there is an appreciation for that, the difference amongst the
primary care docs.    I can't say I've gone out and really assayed
it, I'm just saying I think it's there.


Mullan:    When you talk to the leaders or proponents of some

managed care systems, they lament the primitiveness, or the ill-
appreciated skills of even graduates of very good primary care
training programs coming into their systems.   They're not
decision scientists, they're not good communicators, etc.     A
major issue for them is retraining or recrafting or doing
remedial training for people who have excellent minted, newly
minted, internists or pediatricians or family docs parchments.


Crowson:   That is still an issue.   That is an issue.   I think the

docs who've been in the system, it's sort of like, like myself, I
guess, for the first two years, I didn't have a clue.     I don't
know how I learned what I needed to know but I think I got both a
fair amount of mentoring from Mike Spilane and some of the others
                                                                   50

who were working with me, and kind of started learning the real
importance of this.
     I think that the education program has a significant ways to
go in turning a lot of people who are going to function in that
kind of role.    I think that's both locally and nationally, but
I'm not as familiar, I've not been in touch with what's gone on
with primary care training as close as I was ten years ago, when
I was involved with SGIM.   But I certainly think that that's been
a problem certainly locally, that we do not feel that the
trainees have received the kind of experiences they need to
practice optimally as primary care physicians.
     As a managed care organization, we have a lot to offer the
educational system.   Ramsey has traditionally had an academic
background.   At any given time at Ramsey Hospital there are
probably 130 residents and probably 50 to 75 medical students.


[Begin Tape 2, Side 21


Mullan:    Second side of tape two, Doctor Crowson.



Crowson:   Ramsey has a longstanding relationship with the

university for involvement in education.   Group Health has also
been involved for some time, probably not quite the same degree
as Ramsey had.   One of the challenges is how to carry our
education mission forward within the new Health Partners
relationship.    One of the things that we decided we needed to
structure was the separate entity within the Health Partners
                                                                      51

organization, a separate corporation, which we called the Medical
Education Institute.     It has a separate board of directors and
Bob Mulhausen, my former mentor, is medical director.     We're just
in the process of establishing this as the vehicle through which
we, the Health Partners Organization participate in education.
We restructured an affiliation with the University Minnesota so
that the Medical Education Institute will be that vehicle.        I
think it has a lot of potential for being a new way of educating
health care providers.


Mullan:     Because that's been a rap against managed care, that

they aren't carrying their weight in terms of education.


Crowson:     This organization is stepping up to the plate, and

saying, "This is important.    We think it's important.   It's
something that we need to be involved in and we want to help the
process."     I think we want to be part of the process of how
education is conducted.     I think we've created the appropriate
relationships, we've laid the groundwork for the relationships
and the structures to be able to carry that forward in a new way.
So   I'm optimistic about education and our educational programs.


Mullan:     If someone were looking at the plans for the Medical

Education Institute in its fullest extent, from the outside,
would they conclude that this was a robust part of both the work
of Health Partners and medical education within the Twin Cities,
                                                                    52

or would they say, "Oh, this is just a fig leaf they're doing so
they can say they can say they're involved in medical education?"


Crowson:   I think when you look at what's involved, I think they

would see a significant involvement, because, like I say, we're
still got 130, just if you take what Ramsey's doing alone, it's

130 residents, that we're providing training for.   We're
expanding residencies for which we are the sponsoring
institution.   Since Health Partners took over, our family
medicine program has gone from twenty-four to thirty students.
We've expanded significantly.
     We've started a new emergency medicine residency since they
came on.   We started a new psychiatry residency in collaboration
with Hennepin.   We have not cut back on any of our residencies.
So I would say that we have a very substantial involvement.     I
think one of the things we wanted to make sure was that we had a
mechanism within the Health Partner family of organizations, a
method of managing our education program.
     I think the future of our educational endeavors is really
going to be dependent on our ability to understand our costs and
to understand the quality of our product.   One of my biggest
fears about the future of education is that the costs are so
buried in the operations of most educational institutions, and
there's not a good understanding of it, and because of that,
things are going to happen by default, that are going to hurt
programs as the money gets less.   I think that in order to
                                                                     53

effectively manage it, we've got to understand what that is and
know what it is.


Mullan:    The costs need to be explicit.


Crowson:    Yes.   You can't manage it if you don't understand it.



Mullan:    You can buy more, or you can buy less, but at least you

know what you're buying.


Crowson:   Yes, at least it's up there where you understand.   What
I'm concerned about is that the system would just evolve, there
would be less and less money, and as less and less money came
into the system, people would start making decisions about
programs or make decisions about delivery systems, or make
decisions in their budgeting process that would harm the
educational programs, not through a plan that everybody
understands, but just because it's so hard to understand it, and
people are going to have to make cuts. Most educational
institutions are facing financial problems, and are going to be
starting to make some cuts.     That's one of the other things that
I think is a benefit for us to understand.


Mullan:    I know the medical school has been at risk here.   The

simple-minded outside story is that the market was divided up
between managed care companies, the university didn't position
itself well, and their patient base, or their economic base was
                                                                     54

rapidly and dangerously eroded.     Is that accurate, and what has
happened, and where does the medical school stand?


Crowson:    I think you've got to separate out the medical school.

You can think about them differently.    It's fair to say that I
think throughout our community amongst everybody and the
providers, we want a very strong medical school.    Now, what we
need to have that very strong medical school, and how much is
linked to the University Hospital and the delivery system is a
whole different discussion, but suffice it to say I think it
would be a mischaracterization to blame it on managed care.

     I think the market dynamics were such, the market dynamics
in this community are such, that the university did not position
itself to survive, whether it was managed care, whatever was
going on.    I think it's true of a lot of institutions. We faced
that a bit at Ramsey, and I don't think we positioned ourselves
as well.    Had we taken a different course, we may not have ended
up merging, because we would have had other alternatives, but
basically the course we took became the best strategy for us.
The university is finding that.    It is now merging with Fairview,
because that's its best strategy.


Mullan:    University Hospital.



Crowson:    University Hospital is merging with Fairview System.

So I think it's fair to say that the university found itself not
                                                                     55

having a sustainable market presence unless it did something
different.


Mullan:    And it is running to catch up by doing that, by merging?



Crowson:    Right.   I think just to say, "Well, managed care came

in and ruined everything," that it ruined it for the university,
it's not a--


Mullan:    Right.    It's a simplistic explanation.   It has been held

up often as an example of what universities shouldn't do, or as
managed care becomes a more forceful presence in cities all over
the country, universities need to position themselves to absorb
that or deal with that, which they haven't in the past, or at
least University of the Minnesota hasn't.


Crowson:    Right.   And I think that gets back to, how do we

position ourselves? What is the best positioning for an

institution? And I don't know.      I can't say for the university.
I think there could have been some things they did differently,
or approaches that they may have taken over the years.


Mullan:    As I understand the law in Minnesota, for-profit managed

care is not legal.     Put differently, managed care health
organizations need to be not for profit.



Crowson:    For HMOs, yes.
                                                                     56

Mullan:     So that there are no for-profit organizations in the

field.     Has that made the field different?   For instance, when
you talk about setting up the Educational Institute, are you
given more latitude to move in that direction because you don't
have a fellow across town, or an organization across town that's
cutting costs eight different ways, trying to get the money to

the bottom line?


Crowson:    It's hard for me to say.   I haven't been in the for-

profit market, so I don't know how it behaves, so I have
questions about how that would behave.    I think that the not-for-
profit really has advantages of being able to utilize resources
to improve the health.    If you go back to the mission of Health
Partners, it's to improve the health of members of the community,
and we can use resources with different initiatives to do that.
     One of the ways that I think we do improve the health of our
members in our communities is by training medical professionals,
and we're involved in training with all medical education.     I
think that's one of the ways we do it.    I think because we do not
have a competing interest of having to meet the needs of
shareholders, we have resources that we can put back into the
system to make it better.    Now, I haven't experienced that, but
at least my belief is, if you've got to meet the needs of
shareholders, which is what for-profit enterprise, that's their
responsibility, is to maximize the wealth of their shareholder,
that's what they're there for.
                                                                       57

        So   the question in my mind is always what happens to those

resources that go out of the system into shareholders' pockets.
I think that margin is what we can, to a the degree that they're
similar, we can put back into the system and make it work better.
So that's my view on it.      But I don't know what it's meant to
this market, and it maybe that will be short lived.        I don't how
long that law will hold.


Mullan:      Was that part of the law that you cited before?



Crowson:      Don't quote me on it, because I'm not an expert on it,

but I think it's been a longstanding law from when HMOs were
first formed.


Mullan:      Is there anything else you'd like to comment on?   Tell

me some more about your family, back on the personal.


Crowson:      I've been married thirty years.    Got a daughter who

just turned thirty.      She's a wonderful daughter.   And a son who's
twenty-five.      Both married, and don't have any grandkids yet, but
that's fine.      My folks are still around.


Mullan:      What do your daughter and son do?



Crowson:      My daughter lives in Wisconsin, works outside a small

town.     They live on a farm.   She and her husband both work in the
town.     She works for a manufacturing company, operations
management.


Mullan:    And your son?



Crowson:    He's working for an electronics company, a Motorola

distributor up in Duluth.


Mullan:    And how does your wife feel about your career in

medicine?


Crowson:     I think she thinks it's great, but she's got her own

business now she's working on, so I think she takes it pretty
much in stride.


Mullan:    That's good.



Crowson:    She's really my balance.    She keeps me centered.



Mullan:    You made a good choice early.



Crowson:     I think so.   She really does.   There are days I wonder

why she puts up with me.       I come home and I'm pretty strung out.
She's been very supportive.



Mullan:    Thank you, Terry.     It's been great, and I appreciate all

you've told me.
                                                                 59

Crowson:    Wish we could talk more.



Mullan:    Well, we'll do it again.



Crowson:    Yes, it's a lot of interesting history there, you know.

Gene Rich--talk about training, Gene was one of the people who
went through the training.


Mullan:    At Ramsey?



Crowson:    Yes, we had him in our clinics for si months, then h:

became one of our chief residents, and he joined us on the staff.
Eventually, I turned the educational program over to him, and he
moved it on a new level.


Mullan:    We have him to thank for this interview.



[End of interview]
                                                                        60

                                      Index



Isham, George 30
Elwood, Paul 2 0
Family Medicine 8
Fuller, Ben 12, 27, 33
Generalists vs. Specialists 30, 3 5
Group Health 21, 23, 25, 31, 36
Health Partners 2, 23, 24, 29, 35,              36,    37,    40
Health Partners Medical Group 1 8
Heritage System 3 9
HMOs 21, 39, 40
Integrated Service Networks          22,   23

Managed Care 15, 18, 20, 21, 26, 27, 35                  38        39
     For profit 3 9
Mayo Clinic System 3
Med Centers 24
Medicaid 13, 1 4
Medical Education Institute 11, 36, 37
Medicare 1 3
Minnesota Care Legislation 22
Mulhausen, Bob 10, 36
Partners for Better Health 2 9
PHO (Physician-Hospital Organization) 1 7
Primary Care 12, 19, 31, 32
Primary Care Physicians vs. Specialists 30
Ramsey   Clinic 1 8 , 21, 2 5
Ramsey   Clinic Physician Associates 16
Ramsey   Foundation 1 6
Ramsey   Health Care Corporation 1 6 , 23
Ramsey   Health Plan 22
Ramsey   Hospital (St. Paul, MN) 8-10, 12, 13, 15, 16, 18,
            35, 37,   38,   42
Rich, Gene    42

Spilane, Mike    10, 11, 35

Tredini, Dr.    18

University of Minnesota          1, 5, 7-10,     12,    36,    38