Minnesota Health care News February 2013 by Minnesota Physician Publishing

Your Guide to Consumer Information

Childhood sexual abuse Therese Zink, MD

Bariatric surgery Guilford Hartley, MD

Health-care credit cards Lori Swanson, Minnesota Attorney General

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CONTENTS

4 7 8

FEBRUARY 2013 • Volume 11 Number 2

NEWS

PERSPECTIVE

T H I R T Y- N I N T H

SESSION

By Therese Zink, MD, MPH Paul W. Mattessich, PhD

Ela J. Rausch, MPP Federal Reserve Bank of Minneapolis

CALENDAR National Black HIV/AIDS Awareness Day

HEALTH CARE ROUNDTABLE Health Insurance Exchanges

10 QUESTIONS

Patient engagement

Guilford G. Hartley, MD Hennepin County Medical Center

PUBLIC HEALTH Childhood sexual abuse

MINNESOTA HEALTH CARE ROUNDTABLE

By Stephen S. Hecht, PhD

PEOPLE

Wilder Research

RESEARCH Preventing cancer

INSURANCE Health-care credit cards

LEGISLATION 2013 legislative preview By Jeremy L. Johnson, JD

Lori Swanson, Minnesota Attorney General

Cover photo: Courtesy Hennepin County Medical Center

www.mppub.com

Creating measures that work Thursday, April 25, 2013 1:00 – 4:00 PM • Duluth Room Downtown Mpls. Hilton and Towers

Background and focus: The next step in health care reform involves the patient becoming more actively engaged with staying healthy. New physician reimbursement models reward improved population health but bring new dynamics into the exam room. Incorporating patient attitude and lifestyle choices into health care delivery is necessary, but how should it be done? Creating conceptual and empirical clarity around this question may be best addressed by the term Patient Activation Measure (PAM).

Objectives: We will examine the development of PAM, what it means and how it works. We will explore patient engagement methods that have been successful and the role of health insurance companies and employers in this process. We will explore how PAM may be used across the continuum of care and whose job it will be to implement and track these measures. We will discuss the challenges that are inherent within the concept of PAM and how it may realize its best potential. Panelists include:

PUBLISHER Mike Starnes mstarnes@mppub.com EDITOR Donna Ahrens dahrens@mppub.com ASSOCIATE EDITOR Janet Cass jcass@mppub.com ASSISTANT EDITOR Scott Wooldridge swooldridge@mppub.com

Vivi-Ann Fischer, DC, Chief Clinical Officer, ChiroCare Peter Mills, MD, CEO, nGage Health Sponsors: ChiroCare • nGage Health

ART DIRECTOR Elaine Sarkela esarkela@mppub.com OFFICE ADMINISTRATOR MaryAnn Macedo mmacedo@mppub.com ACCOUNT EXECUTIVE Iain Kane ikane@mppub.com ACCOUNT EXECUTIVE Matt Nichols mnichols@mppub.com Minnesota Health Care News is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone (612) 728-8600; fax (612) 728-8601; email mpp@mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc., or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of this publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $36.00. Individual copies are $4.00.

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FEBRUARY 2013 MINNESOTA HEALTH CARE NEWS

NEWS

DHS Audit Finds Health Plan Finances Are Sound An audit of Minnesota private health plans that oversee state health insurance programs found that although there were a number of problems over the past year, the overall financial management of the plans was sound. The audits were created by an executive order signed by Gov. Mark Dayton in March 2011 and overseen by the Minnesota Department of Human Services (DHS). Further audit regulations were passed by last year’s Legislature, although those audits will not take place until 2014. The DHS audit found several areas of concern, including improper advertising and lobbying, keeping unnecessarily high reserves for unpaid claims, and lack of documentation for administrative expenses and premium deficiency reserves. In addition, an accounting error was found that showed UCare underpaid the

state by $1.57 million. That underpayment has been corrected, officials say. Lucinda Jesson, DHS commissioner, released a statement saying the audit’s findings show the importance of closely monitoring state health plan finances. “The findings released today show that the financial management of publicly funded health care programs by managed care organizations in 2011 was generally sound,” Jesson said in the statement. “Several issues were identified that deserve further action, and demonstrate the wisdom of this increased oversight of public programs. Going forward, strong oversight of the management of these programs will continue and ensure that Minnesotans are receiving the best possible value for their public health dollars.”

Report on Health Measures Ranks Minnesota Fifth Minnesota continues to be one of the top states in United Health Foundation’s America’s Health Rankings, an annual report on health measurements for all 50 states. Minnesota has traditionally been in the top five of the rankings, and ranked fifth this year after dropping to sixth last year. The report says Minnesota’s strengths include low rates of premature death and deaths from cardiovascular disease, low prevalence of sedentary lifestyle and diabetes, and a high rate of high school graduation, which is linked to better health outcomes. The UHF Foundation report says Minnesota’s challenges include a higher incidence of infectious disease, low per capita public health funding, and a high prevalence of binge drinking. In a press conference on Dec. 11, Reed Tuckson, MD, med-

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ical adviser, United Health Foundation, and executive vice president and chief of medical affairs, UnitedHealth Group, stressed that all states faced challenges in the area of health measurements. “It’s a good news story and a bad news story,” he said. “The good news—we’re living longer, life expectancy has significantly improved. The bad news—while we’re living longer, we’re living sicker from preventable illnesses.” Rising obesity, sedentary lifestyle, and smoking are examples of unhealthy factors that are contributing to poor health, Tuckson says, and health-care reform efforts by state and federal governments will be not be effective without a change in lifestyle. “Government alone cannot do what is needed,” Tuckson says, adding that the foundation would partner with states to identify progress being made in states and to promote best practices and prevention.

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MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

HHS Secretary OKs State's Exchange Plan U.S. Secretary of Health and Human Services (HHS) Secretary Kathleen Sebelius gave conditional approval in December for Minnesota’s plan to establish a health insurance exchange. In a Dec. 20 letter, Sebelius told Gov. Mark Dayton that Minnesota has made “substantial progress” in establishing its exchange and that HHS expects the exchange will be able to open for business on schedule in 2014. Although the Dayton administration directed several agencies to begin work on an exchange in 2011, much remains to be done. Last year’s Legislature declined to pass any laws to help establish an exchange. However, the new DFL-controlled Legislature is expected to work with Dayton on the issue as one of their priorities for 2013. Minnesota is one of 20 states that have announced plans to either establish their own exchange or work in partnership with the federal government on one. All states are required to offer exchanges as part of the Affordable Care Act, but a number of states have opted to use a federally created exchange instead of tailoring one to their state’s insurance market. “States across the country are working to implement the health care law and build a marketplace that works for their residents,” said Secretary Sebelius. “In 10 months, consumers in all 50 states will have access to a new marketplace where they will be able to easily purchase quality health insurance plans.”

New Fitness Coalition Promotes Physical Activity A new fitness coalition, “FIT Minnesota,” has been launched by a group of health and fitness companies. The coalition includes Anytime Fitness; Life Time Fitness; Snap Fitness; and the International

Health, Racquet and Sportsclub Association. The group points to programs by insurers and employers that promote wellness as being key to improving health. “FIT Minnesota believes we can continue our state’s leadership role by increasing incentives which encourage physical activity,” says Chuck Runyon, CEO of Anytime Fitness. “Study after study has shown that incentives provided by Minnesota health insurers are working.”

HealthPartners, Park Nicollet Merger Becomes Official The merger of HealthPartners and Park Nicollet Health Services became official on Jan. 1, creating the largest health system in the metro area, and the largest in the state after Rochester-based Mayo Health System. The new entity will operate under the HealthPartners brand and will maintain similar executive leadership. Mary Brainerd will continue to be president and CEO of the company. David Abelson, MD, formerly president and CEO of Park Nicollet, will be president of Park Nicollet HealthPartners Care Group. “With this combination, we intend to focus on making people healthier, making health care more affordable, and creating the best possible experiences for patients and members,” says Brainerd. The organization will now serve more than 1.4 million medical and dental members through HealthPartners’ insurance division, and more than a million patients annually through the clinical care division, at hospitals and clinics in the Twin Cities metro area and in western Wisconsin.

State’s Health Task Force Makes Recommendations The Minnesota Health Reform Task Force, one of the major health initiatives launched by

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News from page 5 Gov. Dayton’s administration, has released its final report. “Roadmap to a Healthier Minnesota” outlines the recommendation of stakeholders based on expert testimony and public input, including 65 public meetings held across the state. Officials with the Minnesota Department of Human Services (DHS) say the task force’s new report looks at how to improve delivery of health care while lowering costs and creating healthier communities. The report notes that too many Minnesotans are struggling to afford health care coverage. Those who have coverage face other issues, it adds. “Services are often fragmented and uncoordinated, with a focus on treating individual diseases rather than improving overall health,” the report says. The report presents a number of strategies it says policymakers should consider at a time when both state and federal health care

reforms are being undertaken. According to the report, growing demand for care due to expanded coverage from implementing the federal Affordable Care Act (ACA), an aging population in rural Minnesota, and a decline in primary care physicians all suggest the state should take more steps to support and increase the supply of primary care providers. The report also recommends pursuing evidence-based programs to improve health for atrisk populations, as well as engaging communities to improve health education and decisionmaking through the Statewide Health Improvement Program. The task force calls for the creation of a health insurance exchange and for the expansion of Medicaid eligibility, as well as a call for health insurers to market products and benefits that promote the idea of consumers taking personal responsibility for their health.

MHA Says Program Has Prevented Readmissions The Minnesota Hospital Association (MHA) says after the first year of a two-year patient-safety improvement program, Minnesota hospitals have prevented more than 3,200 readmissions, seen 463 fewer falls by patients, and had 158 fewer patients experiencing pressure ulcers. The MHA’s Partnership for Patients initiative, launched in December 2011 with 26 hospital systems and health organizations participating, builds on earlier efforts such as the association’s Call-to-Action program and the statewide Reducing Avoidable Readmissions Effectively (RARE) campaign. With last year’s grant from the U.S. Department of Health and Human Services, MHA has worked with hospitals both in Minnesota and across the country to identify ways to reduce clinically acquired conditions and to improve patient safety.

MHA now has 104 hospitals involved in the program, with a focus on the top 10 hospitalacquired conditions: adverse drug events; health-care-associated infections (catheter-associated urinary tract infections, centralline-associated bloodstream infections, surgical site infections, and ventilator-associated pneumonia); injuries from falls and immobility; adverse obstetrical events; pressure ulcers; preventable readmissions; and venous thromboembolism. Hospitals in the state report a nearly 32 percent improvement in patient falls since 2010; a 45 percent reduction in pressure ulcers since 2010; and 3,200 fewer readmissions since 2009. “Minnesota has been recognized by other states as a leader in patient safety and quality care,” says Lawrence Massa, president and CEO of MHA. “Our hospitals have demonstrated commitment to transparency and are dedicated to continuous quality improvement.”

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PEOPLE Two Department of Human Services employees, Cecil White Hat and Carol Falkowski, have received lifetime achievement awards from the Minnesota Association of Resources for Recovery and Chemical Health (MARRCH). White Hat, a principal planner/program consultant for Chemical and Mental Health Services’ Alcohol and Drug Abuse Division, was recognized for Carol Falkowski

more than 30 years of work in the field of addic-

tion. White Hat’s career includes teaching in higher education about Native American issues and Native American addiction, working as a licensed alcohol and drug counselor, and serving as chairman on the American Indian Advisory Council and the Cultural Diversity Committee with the Minnesota Department of Health. White Hat was also a 2011 recipient of the Dr. Duane Mackey Waktayanaji Award for distinguished contributions to addiction treatment, education, and advocacy for human rights among Native Americans. Falkowski, who

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retired in September 2012 from her position as drug abuse strategy officer, received the award for her contributions to the addiction field. Over her 25-year career, Falkowski has served as director of the Alcohol and Drug Abuse Division, worked for the nonprofit Hazelden

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Foundation, provided technical assistance and consultation to national organizations, helped release the first-ever State Substance Abuse Strategy, and used her knowledge and communications skills to educate the public and advance the understanding of addiction. Tacjana Friday, MD, has joined the Noran Neurological Clinic. She graduated from St. George’s University School of Medicine and completed her neurology residency at the University of Minnesota. She then pursued her special interest in clinical neurophysiology and epilepsy as a fellow at the U of M, followed by a second fellowship in sleep medicine at Hennepin County Medical Center/U of M. Her special interests include sleep medicine (parasomnias, nocturnal epilepsy, restless leg syndrome, circadianrhythm sleep disorders, sleep apnea, hypersomnia,

Tacjana Friday, MD

and insomnia), epilepsy, and neurological disorders in women and during pregnancy. Rebecca Covington has been named executive director of the Minnesota Consortium for Citizens with Disabilities (MN-CCD). The nonprofit organization, dedicated to improving the lives of people with disabilities, is a broad-based coalition of more than 100 organizations representing people with disabilities, providers, and advocates. Covington’s work in advocacy and coalition leadership includes positions with Minnesota Public Interest Research Group, Duluth Prosperity Agenda, and, most recently, the Flood Homes with Hope Campaign.

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ceived the Mid-career Faculty Award. The conference united residents, faculty, and medical students from a 12-state Midwest region. FEBRUARY 2013 MINNESOTA HEALTH CARE NEWS

PERSPECTIVE

Working “upstream” to improve our health How your ZIP code could kill you ... and what you can do about it

hat matters most when it comes to producing good health? Is it the quality of care that doctors and hospitals provide? Is it the lifestyle choices that individuals make? Or, does it come down to genetics and the hope that one has a good set of genes?

Paul W. Mattessich, PhD Wilder Research

Paul W. Mattessich, PhD, is executive director of Wilder Research, of the Amherst H. Wilder Foundation in St. Paul. Wilder Research is one of the largest nonpartisan research organizations in the nation dedicated to studying the effectiveness of human service, public health, and education programs. Photograph by Stan Waldhauser

Federal Reserve Bank

Ela J. Rausch, MPP (master of public policy), is a project manager for the Federal Reserve Bank of Minneapolis. She analyzes the economic health of low- to moderate-income communities and develops collaborative solutions to community needs.

All of these factors are important. Yet, combined, they account for only about half of what deter- New approach mines your health outcomes, such as how long To stimulate collaboration, the Federal Reserve you will live or your chances of developing chron- Bank of Minneapolis and Wilder Research, in partic disease. Research shows that socioeconomic nership with the Blue Cross Blue Shield of and environmental factors Minnesota Foundation and actually play an equal role the Robert Wood Johnson in determining good Residents in one neighborFoundation, hosted a conferhealth. These factors ence in November 2012 that hood can expect to live include not only your brought together some of up to 13 years longer income and education, but the state’s leaders in public also the neighborhood in than residents in another health and community which you live. development to explore op-

neighborhood.

In fact, Twin Cities residents in one neighborhood can expect to live up to 13 years longer than residents in another neighborhood just a few miles away, according to a 2010 Wilder Research study. Similar studies of other cities have also demonstrated neighborhood-based differences in life expectancy. Does this mean that your ZIP code could kill you? Well, not literally, but major differences in health outcomes across geography do exist, and they exist across racial and income groups, too. Upstream factors

Ela J. Rausch, MPP

and transit, though not necessarily with an eye toward health improvement. We have since learned that the environments in which we live, work, and play have a huge influence on our health. Yet, there has been little collaboration between community development and public health.

How do the characteristics of neighborhoods influence health? Communities often provide the infrastructure that makes good health possible. If a neighborhood lacks safe places to exercise, that can negatively influence residents’ health. If a neighborhood lacks stores with fresh produce, that can adversely impact health. Experts call these influencers of health “upstream” factors. Other upstream factors that produce good health: quality housing, clean air, and access to good schools and jobs. To improve these factors, we must work collectively through organizations, institutions, and government. Old approach In the past, public health and community development organizations have worked independently to improve communities. Public health focused on promoting healthy behaviors (for example: eating nutritious food, exercising, and not smoking), developing policies that protect the public from harm (food-handling laws, fluoridated water, smoking bans, etc.), and increasing access to health services. Community developers focused on economic development projects such as housing, commercial development, childcare centers,

MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

portunities to align efforts to build healthier communities.

Since the conference, organizations across Minnesota have begun to take action: • City of Minneapolis Department of Family Health and Support and Minneapolis Consortium of Community Developers are exploring opportunities to increase access to healthy foods through the improvement of neighborhood corner grocery stores. • The Institute for Agricultural and Trade Policy launched a Farm to Childcare initiative to connect families to locally grown foods through 55 metro-area childcare locations. Together with La Crèche Early Childhood Centers, Inc., the Institute is exploring opportunities to increase community engagement by offering culturally appropriate foods and education, and by working with urban farmers in north Minneapolis. • Minnesota Department of Health and Minnesota Housing Finance Agency are collaborating on healthy homes and lead abatement. What can you do? Raise awareness among family and friends about social and environmental determinants of health. Support each other in making lifestyle changes that improve health. Support public officials, of any party, who understand the importance of good health. With them, advocate for projects and policies that promote health. By working together, we can make changes upstream that will vastly improve the health of our families and our communities. And, if we take the right steps, every one of us can live in a healthy ZIP code. To learn more, visit www.wilder.org www.minneapolisfed.org.

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Dramatic benefits possible for the committed patient Guilford G. Hartley, MD Dr. Hartley is board-certified in internal medicine and is the medical director of Hennepin Bariatric Center at Hennepin County Medical Center, Minneapolis. He is a member of both the American College of Physicians and the North American Association for the Study of Obesity. What can you tell us about the history of bariatric (obesity-related) surgery? Some of the earliest work was done in the 1950s by surgeons at the University of Minnesota and at Metropolitan Medical Center (now closed). These included procedures to reduce the capacity of the stomach to hold food. Please tell us about the different kinds of bariatric surgery. The most common procedure is the Roux-en-Y gastric bypass. It divides the stomach using staples to create a new stomach pouch about the size of an egg. This makes someone feel full sooner, so they don’t eat as much. This procedure has been used since about 1970 and combines safety and effectiveness in controlling overweight and the many medical problems that may arise from overweight, including type 2 diabetes, high blood pressure, high cholesterol, and certain cancers. Adjustable gastric banding, or lap banding, enjoyed great popularity in this country starting about 10 years ago, but its effectiveness has been disappointing and patients with bands often experience irritating, though rarely dangerous, complications. A relatively recent procedure, the vertical sleeve gastrectomy, removes much of the stomach without bypassing the intestine. Results with this procedure thus far have been encouraging, but we don’t have enough experience with it to know how well it will work long term. Studies show that bariatric surgery has a dramatic effect on type 2 diabetes. What can you tell us about this? Anything that helps overweight type 2 diabetic patients control weight improves their diabetes control. Gastric bypass surgery produces significant weight reduction in most patients. In addition, gastric bypass has specific hormonal effects on insulin that other bariatric surgery procedures do not. This helps produce even better diabetes control. Some diabetic patients experience long-lasting remission of diabetes after bariatric surgery. Other patients’ diabetes persists but with improved control that requires less medication. How does bariatric surgery affect diet after surgery? Patients eat much less than they did before surgery and need to choose foods that are tolerable, take small bites, and chew thoroughly. It is important to avoid concentrated sweets, to drink only calorie-free beverages, and to avoid drinking beverages at mealtimes. This means no liquid dairy products, sugar-sweetened soda, or fruit juice. It’s fine to eat an orange, for example, but we recommend against drinking orange juice.

Photo credit: Bruce Silcox

MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

How would someone know if he or she is a candidate for this surgery? I recommend you become familiar with your body mass index (BMI). It’s like another “vital sign” and tells you the relationship between your weight and height (underweight, healthy, overweight, obese, severely obese). You can calculate your BMI with this tool: www.hcmc.org/a_z/obesity/bmi1.htm. If your BMI is greater than 40, or if it is greater than 35 and you have obesity-related medical problems like diabetes, you are likely a candidate for bariatric surgery.

Bariatric surgery programs

after surgery; dealing with concerns about What are some of the issues are very successful at weight loss and analyzing post-surgery exeraround insurance coverage for cise and diet; following the status of obesitybariatric surgery? A few insurance carhelping people navigate related medical problems like diabetes; and riers do not cover it. Many erect artificial insurance requirements. looking for low iron levels and vitamin defiobstacles to make it hard for patients to ciency, which can be complications after get approval for the insurance company to bariatric surgery. Generally, patients need about four visits during the pay for the surgery. Your best bet is to contact your medical insurfirst year after this surgery. After that, annual visits are usually enough ance carrier, primary doctor, or a bariatric surgery program for help unless there have been complications. navigating insurance requirements. Bariatric surgery programs are very successful at helping people navigate insurance requirements and Please share a dramatic success story you have seen. get the treatment they need. A 6-foot 3-inch patient was 35 years old and weighed 630 pounds at the time of surgery (BMI = 79). Despite this very, very severe obesity, What questions should a patient ask a bariatric surgeon the patient was physically active and commuted by bicycle to work. before scheduling surgery? The most important criterion is to This patient lost weight rapidly after surgery but didn’t achieve lowfind a surgeon you are comfortable talking with. Don’t let yourself est weight, 332 pounds (BMI = 41), until about eight years after surfeel or be rushed. Think about the decision to have or not to have gery. The patient has remained very active. The patient had multiple bariatric surgery very carefully. In general, you get one good chance obesity-related medical problems, including obstructive sleep apnea, at making this surgery work, so you want to go into it as well which have disappeared or improved with weight control. This informed as you can be and already accustomed to following the patient is still severely obese, but with health much improved because improved diet and exercise habits you’ll need to follow for the rest of of the weight control made possible by the surgery. your life. You may want to ask your surgeon about how much experience he or she has, how successful her or his patients have been at What does the future of bariatric surgery hold? Research long-term weight control, and how many and what kinds of complicontinues to improve bariatric surgery. The ideal future would see cations his or her patients experience. bariatric surgery disappear completely. That could happen if we can prevent obesity from developing or treat it with nonsurgical means. What does follow-up after this surgery entail? It’s very Unfortunately, there is no sign that effective prevention strategies or important for patients to commit to regular follow-up visits at their medications for treatment are on the horizon, so we will need to rely bariatric surgery program for the rest of their lives. Visits involve seeon bariatric surgery for the foreseeable future. ing if the amount of weight lost is appropriate for that point in time

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FEBRUARY 2013 MINNESOTA HEALTH CARE NEWS

INSURANCE

Health-care credit cards

itizens are struggling with the high cost of health care and gaps in insurance coverage, and in response, many national lenders have begun to market health-care credit cards as a way for people to pay medical bills. While these credit cards may sound enticing at first, patients who fail to follow all the rules in the fine print may face interest rates of up to 29.99 percent on their health care bills and late fees of $30 or more. The Office of Minnesota Attorney General Lori Swanson offers the following guidelines to help citizens avoid the pitfalls of health-care credit cards.

Read the fine print!

New market niche Many national lenders have begun to issue health-care credit cards as a way to capitalize on the high cost of health care and lack of insurance coverage faced by many citizens. Consumers currently charge about $45 billion in out-ofpocket medical expenses on credit cards, and that number is predicted to reach $150 billion by 2015.

By Lori Swanson, Minnesota Attorney General

t Eat more fruits, vegetables, whole grains and less fat t Be physically active every day t Do not smoke t Eat smaller portions and lose 10 pounds if you are overweight t Know your ABCs: A1C, Blood pressure and Cholesterol t Take your medicines as directed

Do you still believe losing weight will change your emotional need for food?

t Talk to your doctor

You need emotional eating rehab. Call 952-920-8644 www.vivifydietrehab.com 12

MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

Minnesota Diabetes & Heart Health Collaborative

ÂŠ 2012 Minnesota Diabetes & Heart Health Collaborative

Some clinics aggressively promote health-care credit cards to make more money.

future services on their card, only to see the provider go Banks often encourage dentists, medical clinics, out of business. The The Minnesota Attorney General’s Office chiropractors, cosmetic and eye surgeons, patient was then on received a complaint from a 91-year-old woman weight loss programs, hearing aid dispensers, the hook for expenwhose hearing aid dispenser convinced her to take and other providers to offer health-care sive debt for services out a health-care credit card to pay for her hearing aids. credit cards to their patients as a way to they did not receive. The woman—who lives on $12,000 per year in Social generate income for the clinic. When a Other patients Security benefits—made all her monthly payments of around patient charges services on a healthreport that they $110 on time and thought that the credit card company care credit card, the clinic is paid became unhappy would bill her for her final payment. When she didn’t immediately by the credit card with the services receive a bill, she made the final payment just a few days company, even if the services performed by the after it was due. The credit card company then billed won’t be delivered until a future clinic or lost a job her for interest of $1,200—charged retroactively to date. Some patients report feeling and could no longer the date of the original charge. This became a pressured by their clinics to enroll afford the monthly payvery expensive way for a senior citizen in health-care credit cards to pay ment, but that they were on a fixed income to finance for care that they do not need or trapped into receiving treathearing aids. want or cannot afford. ment because they had already Patients should remember that clinplaced the amount of the future ics have an incentive to aggressively promote treatments on their credit card. these credit cards as a guaranteed way for the clinic to Think twice before you finance yet-to-be-delivget paid promptly but that the cards may not always be ered services on a credit card. in the patient’s best interest. Do not let your clinic Credit cards affect your credit pressure you into taking out a credit card you do not want. Do not sign up for anything with- Some patients report that they were not aware they were taking out a health-care credit card, but instead thought they were simply out asking to read the fine print. obtaining a payment plan from their clinic. Beware interest-free promotions Health-care credit cards to page 34

Telephone Equipment Distribution (TED) Program

Health-care credit cards are now offered by many of the nation’s largest lenders, including GE Money Bank, JP Morgan Chase, CitiGroup, and Capital One. UnitedHealth Group and Humana have started offering credit cards too. Many lenders try to entice patients into signing up by offering credit cards that have a zero percent interest rate if the balance is paid off within a promotional period (often 12 or 18 months) and if, during the promotional period, the consumer makes all monthly payments on time. If the balance is not paid off within the promotional period or if the patient misses a monthly payment, however, interest rates can quickly jump to as much as 29.99 percent retroactively. Before agreeing to a zero-interest Do not let offer, be absolutely sure that you can your clinic pay the balance in full during the pressure you interest-free period and that you can make all your monthly payments in into taking full and on time. If you can’t, you may out a credit end up being responsible for paying off card you do your health care bills at double-digit not want. rates that you cannot afford and may also be responsible for hefty late fees.

A 91-year-old’s experience

Do you have trouble using the telephone due to hearing loss, speech or physical disability? If so…the TED Program provides assistive telephone equipment at NO COST to those who qualify. Please contact us, or have your patients call directly, for more information.

1-800-657-3663 www.tedprogram.org Duluth • Mankato • Metro Moorhead • St. Cloud

Financing future treatments Some clinics convince patients to use a health-care credit card to pay for services to be delivered in the future. The Attorney General’s Office has received complaints from patients who placed charges for

The Telephone Equipment Distribution Program is funded through the Department of Commerce Telecommunications Access Minnesota (TAM) and administered by the Minnesota Department of Human Services FEBRUARY 2013 MINNESOTA HEALTH CARE NEWS

RESEARCH

any experimental studies have identified dietary compounds that protect laboratory animals against certain cancers. This is an early step along the path toward identifying compounds in food that may someday provide the same protection for humans. Research goal

Preventing cancer Does diet play a role? By Stephen S. Hecht, PhD

When considering cancer prevention, it is important to consider the lengthy process by which cancer develops. It typically takes up to 30 years of exposure to cancer-causing agents (carcinogens) such as tobacco smoke before clinically detectable symptoms of cancer appear. This process is carcinogenesis, a series of steps that convert normal cells to cancer cells. These steps are often initiated by damage to genes that is inflicted by common lifestyle agents such as tobacco smoke.

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Preventing common cancers Consequently, the goal of cancer prevention is to prevent or slow the steps in carcinogenesis. One approach to this is chemoprevention, which involves deliberate exposure to certain substances, or compounds, that can prevent cancer. Some of these compounds occur commonly in the diet, particularly in fruit and vegetables. Chemoprevention in the laboratory Foods found to contain chemopreventive compounds include: Cruciferous vegetables. Studies show that a human diet high in consumption of cruciferous vegetables is associated with decreased rates of breast, lung, and pancreatic cancer. Cruciferous vegetables—cabbage, broccoli, watercress, cauliflower, kale, and others—release the compound I3C after being crushed or chewed. I3C prevents breast cancer in rats treated with a mammary carcinogen and prevents lung cancer in mice treated with carcinogens from tobacco smoke.

Most cancers are caused by lifestyle factors. • No. 1 is tobacco, in all forms. Tobacco products cause at least 18 types of cancer, including lung cancer. Secondhand tobacco smoke also causes lung cancer, increases the risk of death from heart disease, and is responsible for approximately 50,000 deaths annually in the U.S., according to the Centers for Disease Control and Prevention. No amount of exposure to secondhand smoke is safe. Smoking also increases the risk of colon cancer. • Obesity increases the risk of colon, uterine, breast, and esophageal cancer. • Overexposure to the sun causes skin cancer. • The best way to prevent cancers from known exposures is to avoid those exposures. The American Cancer Society (www.cancer.org) and the U.S. National Cancer Institute (www.cancer.gov) provide sensible suggestions for decreasing your risk of cancer and for detecting cancer early.

PEITC from watercress prevents lung cancer in rats. When rats are treated with a tobacco smoke carcinogen called NNK, they almost always develop lung cancer. But, when PEITC from watercress is added to their diet, 100 percent of NNK-caused lung cancer is prevented. A clinical trial (research using willing humans) is currently being conducted to see if PEITC prevents lung cancer in human smokers. Myo-inositol, or MI, prevents lung tumors in mice treated with tobacco smoke carcinogens, and is found in many vegetables, nuts, and fruits. It has the advantage of being completely nontoxic to humans. Clinical trials of MI in lung and colorectal cancer are underway.

It typically takes up to 30 years of exposure to cancer-causing agents (carcinogens) before clinically detectable symptoms of cancer appear.

Other compounds. When rats treated with a colon carcinogen were given curcumin, a constituent of the spice turmeric, they showed a significant decrease in the incidence of colon tumors. Gingerol, a constituent of ginger, also has preventive activity against colon cancer.

Resveratrol in grapes and red wine prevents a number of different cancers in laboratory animals. Although someone could not drink enough red wine to obtain its protective effect against cancer without suffering the effects of excessive alcohol consumption, resveratrol can be isolated from grapes or chemically synthesized, so one day it may be possible to use it in purified form for chemoprevention. Cyanidins in freeze-dried black raspberries provide some protection against esophageal and colon cancer in rats treated with carcinogens. Green tea and its constituent EGCG help protect against lung cancer and breast cancer in laboratory animals. Clinical trials are currently assessing green tea and EGCG protection against human cancer.

From laboratory to humans There’s no doubt that chemoprevention works in laboratory animals. The big question: Will it work in humans? To answer that question, we need to carry out clinical trials. There are many challenges to successfully completing a clinical trial. Preventing cancer to page 29

In the next issue.. • Reducing medication costs • Spring allergies • Malignant melanoma FEBRUARY 2013 MINNESOTA HEALTH CARE NEWS

PUBLIC HEALTH

Childhood sexual abuse

Far-reaching medical consequences, and what to do about them By Therese Zink, MD, MPH

My patient, Melanie (not her real name), weighs nearly 300 pounds. She enters the exam room protecting her left leg, which she had injured while working at her new job. She had been excited to start the new job because she needed the money and was looking forward to the stimulation of something beyond childrearing. Unfortunately, her job duties were unrealistic given her lack of physical fitness. She was disappointed that she’d hurt herself within the first week on the job and would not be able to return for several weeks, if at all. During her exam, I diagnosed her with prediabetes and suggested losing weight; less weight would help both her leg injury and the prediabetes. Doctors had been telling her to lose weight for years. But food was her comfort for the disappointments and challenges in her life and, as a single mother of a disabled child, her life was not easy. We talked about her relationship with food and I inquired about childhood sexual abuse, which is often experienced by people who grow up to be morbidly obese (the condition of being very over-

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MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

Help weight). She responded—yes. She had lost weight multiple times, but always regained it. She’d never had any therapy to deal with her childhood trauma. Widespread problem

• Information for adult victims and adult abusers: www.health.state.mn.us/ injury/topic/svp/help.cfm • Resources for child victims are available through the Midwest Child Resource Center, St. Paul: www.mrcac.org, (800) 422-2955, (651) 220-6065

In 2007, the Centers for Disease Control and Prevention identified sexual abuse as a major public health problem. As many as 62 percent of adult women and 15 percent of adult men • report having experienced some type of inappropriate sexual exposure during childhood, such as someone touching them inappropriately or exposing their genitals. When sex abuse is • defined more narrowly to include sex organ contact, 17 percent of women and 8 percent of men report being victimized sometime during childhood. The perpetrator is likely to be someone the victim knows and trusts. Studies of brain development suggest that children develop adverse physical Victims changes in their brains in response to abuse. often have These changes in brain structure appear to be significant enough to negatively affect multiple IQ and to result in psychological and emohealth tional problems. Abuse in childhood often results in physical and mental health probproblems. lems in adulthood and victims often have multiple health problems. These include depression; misuse of alcohol or drugs; obesity, especially excessive overweight; and a variety of other health problems such as headaches, pelvic pain, and abdominal pain. Many of these post-abuse conditions seem resistant to treatment. Symptom severity is affected by the length of time the

Family Advocacy Center of Northern Minnesota, Bemidji: www.facnm.net, (218) 333-6011 Child Sex Abuse Prevention and Protection Center: www.stopitnow.org, (888) PREVENT, (888) 773-8368 abuse lasted, the invasiveness of the abuse (for example, whether or not intercourse occurred), whether or not there was more than one abuser, and the amount of force used by the abuser. Whether the perpetrator is a male or female or is the same or a different gender from the victim does not seem to make a difference in the degree of residual harm to the victim. Costs of abuse A decade ago, the Minnesota Department of Health examined the costs of childhood sexual abuse. It found that both victims and perpetrators suffer from similar physical and mental symptoms, have occupational and academic losses due to missed days, and have an inability to perform or learn adequately. While the costs of childChildhood sexual abuse to page 19

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February Calendar 12

In Our Own Voice NAMI Minnesota presents a free public education program featuring two guest speakers’ compelling stories of living with mental illness and their road to recovery. Register at www.eventbrite.com. For more information, contact Brian at (888) NAMIHELPS (or (888) 6264-43577), ext. 116. Tuesday, Feb. 12, 10–12 p.m., Normandale Community College, 9700 France Ave. S., Bloomington

Baby Café This free, weekly drop-in center helps with breastfeeding. Get help from health professionals; feel free to bring your partner and other children. Call (651) 241-5088 for more information. Wednesday, Feb. 13, 12–2 p.m., St. Luke Lutheran Church, 1807 Field Ave., St. Paul

Cancer Caregiver Support North Memorial offers a free support and education group for caregivers of those who have cancer. For more information, contact Jewel at (763) 581-2804. Monday, Feb. 18, 6–8 p.m., North Memorial Outpatient Ctr., Humphrey Cancer Ctr. Waiting Rm., 3535 W. Broadway Ave., Robbinsdale

Young Parkinson’s Support Allina Health’s free support group for women 60 years of age and younger with Parkinson’s disease teaches resources for living a healthy lifestyle with this disease. Call Ruth to register: (952) 888-1734. Tuesday, Feb. 19, 7–8 p.m., Byerly’s Community Rm., 13081 Ridgedale Dr., Minnetonka

National Black HIV/AIDS Awareness Day Did you know that African Americans are the ethnic group most affected by HIV? Though they composed only 14 percent of the U.S. population in 2009, African Americans accounted for 44 percent of all new HIV infections. At some point in their lifetimes, an estimated one in 16 black men and one in 32 black women will be diagnosed with HIV infection. In 2007, HIV was the ninth leading cause of death for all blacks and the third leading cause of death for black women and men aged 35–44. To combat these disturbing statistics, February 7 has been designated National Black HIV/AIDS Awareness Day. Originally funded by the Centers for Disease Control and Prevention (CDC), this day was established to encourage all African Americans to be tested for HIV. Approximately one in five adults and adolescents in the U.S. living with HIV are unaware of their HIV status. This translates to approximately 116,750 people in the African American community. The sooner an individual is diagnosed and linked to appropriate care, the better the outcome. For more information and for testing sites, visit www.cdc.gov.

11 HIV Testing Annex R.E.A.C.H. Community Office offers free and confidential HIV community-based testing for males and females 15 years of age or older. Call Theresa to schedule individual testing or for more information: (763) 235-1986. Monday, Feb. 11, 1–7 p.m., Annex R.E.A.C.H. Community Office, 2404 Plymouth Ave. N., Minneapolis

Seniors Insurance Counseling The Hennepin County Library and Metropolitan Area Agency on Aging offer seniors free help with health insurance. Bring prescriptions and insurance questions, and get help from a certified state health insurance counselor. To register, call (612) 543-8375. Wednesday, Feb. 20, 12:30–2 p.m., Hennepin Cty. Library–Washburn, 5244 Lyndale Ave. S., Minneapolis

Down Syndrome Parent Group Down Syndrome Association of Minnesota offers this group to provide information and support for parents of children with Down syndrome. Share the joys and challenges with others who understand. Call (651) 603-0720 for more information. Monday, Feb. 25, 6:30–8:30 p.m., McAuliffe Elementary School, 1601 W. 12th St., Hastings

Bariatric Surgery Park Nicollet sponsors this free information session for individuals struggling with severe obesity. Learn about weight loss surgery, follow-up care procedures, and all surgical options available from Park Nicollet. To register, call (952) 993-3454. Tuesday, Feb. 26, 2–3:30 p.m., Hampton Inn–Shakopee, Shakopee Conference Rm., 4175 Dean Lakes Blvd., Shakopee

Anyone Can Fall Metropolitan Area Agency on Aging offers a presentation on the risks for falls, how to prevent them, and resources available to those living independently that can help minimize risk. Free. Call Kim at (651) 578-0676 for more information. Thursday, Feb. 28, 3–4 p.m., Oak Meadows Senior Living, 8131 Fourth St. N., Oakdale

Mar. 4

Buying a Hearing Aid Lakeview Health presents Stillwater Medical Group audiologist Mary Kochendorfer, AUD, discussing benefits and drawbacks of different types of hearing aids. Free. Register by calling (651) 430-4510. Monday, Mar. 4, 10–11 a.m., Lakeview Hospital, 927 Churchill St. W., Stillwater

Send us your news: We welcome your input. If you have an event you would like to submit for our calendar, please send your submission to MPP/Calendar, 2812 E. 26th St., Minneapolis, MN 55406. Fax submissions to (612) 728-8601 or email them to mmacedo@ mppub.com. Please note: We cannot guarantee that all submissions will be used. CME, CE, and symposium listings will not be published.

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MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

Childhood sexual abuse from page 17

Abuse in childhood often results in physical and mental health problems in adulthood.

hood sexual abuse are difficult to estimate, a research study called Adverse Childhood Events (www.acestudy.org) showed an association between childhood trauma and physical problems like heart disease, lung conditions, depression, and other mental illness in a large population of middle-class adults. The study examined the history of adverse events during childhood of more than 17,000 California patients, including those who had experienced childhood sexual abuse. Researchers found that the more adverse events a person experienced as a child, the more physical and mental health problems he or she had as an adult. Patients with adverse childhood events were also more likely to smoke, misuse alcohol, use drugs, and participate in unsafe sex. Management of these health conditions adds millions of dollars to health costs each year. What can victims do?

Melanie took a step toward examining her childhood sexual abuse by making an appointment with a counselor. Treatment of child sexual abuse is a complex process. It takes time to understand that childhood sexual abuse can be at the root of health problems because sometimes, memories of the abuse are hidden to the victim. Melanie, for example, remembered the abuse but had not linked it to her obesity and inability to lose weight until she started counseling. Her excess weight had been a protection for her. In order to permanently shed that weight, she needed counseling.

Protecting young people

Our culture’s discomfort with teaching children about sex creates barriers to having open discussions about the positive and negative aspects of sex and sexuality. Since our skin is a large sensory organ and we all need touch, how do we distinguish between good touch and bad touch? It is important to begin talking about that with children when they are young. It is important to teach boys and girls that their bodies are theirs alone and that no one should touch them in the areas covered by a swimming suit (except for medical reasons). Pay attention to your child’s discomfort. If they don’t want to sit on someone’s lap, they don’t have to. If they don’t want to hug or kiss someone, they can shake hands instead. Tell them that if someone tries to touch their private areas they should tell an adult. If a would-be abuser tells them not to tell, they should tell anyway. Studies show that protective factors can limit long-term problems caused by abuse. These factors include the child having good self-esteem, feeling that he or she can ask adults for help, and having positive peer relationships. The family can offer protection if the household has structure with rules and regulates unacceptable behavior, and if there are parents or other caregivers who supervise and listen to the child.

Therese Zink, MD, MPH, is a family physician and a professor in the department of family medicine and community health at the University of Minnesota who does research in the areas of injury and trauma.

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M I N N E S O T A

MR. CHRISTENSON: What do we mean when we say “health insurance exchange?” MR. MUNSON-REGALA: A health insurance exchange is a facilitated marketplace where purchasers and sellers conduct transactions that connect folks with insurance coverage. It’s a place to shop for insurance products and public health programs like Medicaid in order to access insurance subsidies or tax credits. It provides consumers with information such as the quality, value, and cost of plans, whether or not they ever choose to purchase from the exchange. It is a place where the cost of connecting people to coverage gets reduced.

H E A L T H

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R O U N D T A B L E

About the Roundtable Minnesota Physician Publishing’s 38th Minnesota Health Care Roundtable examined the topic of accountable care organizations. Six panelists and our moderator met on Nov. 1, 2012, to discuss this issue. The next roundtable, on April 25, will explore the subject of patient engagement.

MS. MCMULLEN: Anyone employed by a large employer who is self-insured will not be eligible to purchase through an exchange.

MS. MCMULLEN: From the business perspective, the most important part of what an exchange can and should be is a place for consumers to have the ability to compare different products and enroll in them. DR. SAWYER: It’s a potential stepping-stone toward improving access to care because more consumers will be able to more effectively shop in a sophisticated electronic marketplace. We need to remember that insuring more people does not necessarily lead to universal access. It does not necessarily remove obstacles to receiving care. Will it be a good step forward? Potentially, yes, depending how it’s implemented and how the public receives it. DR. DEHNEL: Everyone wants more health care for a broader segment of the population at a better cost. It’s important to make a distinction between health, which is something we all want, and health care, which is something paid for by health insurance. You can have the world’s greatest health with very few health care services; likewise, you can have the world’s greatest health insurance without necessarily having access to health care services. In talking about the exchange, focusing on insurance is only part of the discussion. Access to care, that’s part of a broader discussion. MR. CHRISTENSON: What do we hope to accomplish with health care exchanges? MR. MAYNARD: To insure the uninsured. An exchange should be a one-stop shop for determining eligibility into government programs like Medicaid and CHIP (Children’s Health Insurance Program), alongside commercial products that can be funded partially

thousand will be small employers and their employees, defined as groups of 50 or less. Some of those groups could change, dependent on policy decisions made next session. For example, should we expand “small employer” to include groups of 100 or less? Fundamentally, an insurance exchange is intended to serve individuals and small employers.

Health insurance exchanges Assuring they are meaningful through subsidies. The complexity of this is the complexity of all the different programs, plan designs, and products that have to be brought together to accomplish this. MR. SCHUYLER: An exchange will increase transparency around cost and quality, especially in comparing benefits. You’re comparing plans based on price, but in an exchange, you’ll also be able to compare plans and carriers by quality based on different metrics. Increased transparency will be valuable to consumers. MR. CHRISTENSON: Who will be eligible for coverage in health care exchanges? MR. MUNSON-REGALA: A study on the Department of Commerce website projects enrollment in a health insurance exchange to be 1.2 million Minnesotans. Of those, 700,000 are expected to be in Medicaid based on the assumption we’re going to expand Medicaid. We’ll see in the next legislative session if that assumption is accurate. Three hundred thousand individuals are expected to purchase health insurance products, potentially with the assistance of an advance premium tax credit. Two hundred

MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

DR. SAWYER: Every two years, the Minnesota Department of Health publishes a report on insurance coverage. I think the last one reported over 500,000 uninsured Minnesotans. That’s larger than the population of St. Paul, and it’s been increasing steadily over the past several years. More shocking is that of those 500,000 uninsured, 70,000 are children. That’s double the enrollment of the entire Minneapolis school district. Those people often get care in the most expensive clinics we have—hospital emergency departments. Costs are being incurred, yet access to care is a challenge for these people because they lack affordable coverage. And these numbers don’t include people who have high-deductible insurance plans. They have coverage, but it’s not of much practical value to them. MR. CHRISTENSON: What important elements must be included in the health insurance exchange if the benefits that we’ve been speaking of are to be realized? DR. DEHNEL: First, make insurance more understandable to everyone by providing consumers with a much better understanding of what health insurance can and cannot do for them. Second, make it as transparent as possible. We want to make sure those choices lead to decisions that are as well informed as possible for people participating in the exchanges. MR. MAYNARD: A critical aspect for it to be successful is to have choice. To have choice, participation of the plans, employers, and consumers is critical. MS. MCMULLEN: I agree, a variety of options for consumers is important, as is ease of navigation. People assume that this may be like Travelocity, and you’re going to be able to go online and easily buy your ticket for health insurance like you do for travel. Insurance is

H E A L T H

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going to continue to be a complicated decision-making process, so we need to focus on ease of navigation for consumers, whether they’re individuals or businesses.

employees pick that default plan because it’s what they were accustomed to. In the second year, we saw employees start to choose outside that default plan.

MR. SCHUYLER: Consumer decision tools and plan selection tools are the most important components of the exchange. If tools aren’t intuitive enough for consumers to make a choice that’s best for them, the exchange will fail. Plus, states like California include vision plans in their exchange, and I think you’ll see other states including other plans—vision, dental, pharmacy benefits—and making sure those are transparent and segregated.

MR. CHRISTENSON: Can a health insurance exchange encourage competition between health plans?

MR. MUNSON-REGALA: Choice and removing the nuisance factor of procuring insurance are important to consumers. The No. 1 concern consumers have is cost. An exchange should be designed to help moderate and manage cost. DR. SAWYER: There’s the argument for the exchange to have many insurance plan options in hopes that use by consumers would be straightforward, easy, and transparent, and another argument that the exchange should include a narrow range of options to ensure consumers can shop effectively. MR. MAYNARD: Technology under consideration will be able to narrow choices. As analytics are developed and the exchange matures postlaunch, use of the exchange will drive ability for plan selection to narrow and remove complexity. Plan designs offered on the exchange will mature, too. Over time, consumer purchases will drive change. DR. DEHNEL: For some people who are in the exchange for the first time, maybe those coming from an environment where their employer covered at least part of their premium cost, it’s going to be sticker shock when they’re suddenly responsible for the entire cost of the premium. For a lot of people there’s going to be a higher cost than they anticipate when they get into the exchange, regardless of the plan they choose. MR. SCHUYLER: That’s a great point. The Utah exchange allows the employer to pick a default plan to cover employees who don’t select a plan. Normally employers select a plan that their employees are most familiar with, a plan that they’ve chosen in the past. In the first year of the Utah exchange, we saw

DR. DEHNEL: Yes, if it is set up well. Competition has always been a good thing. It will put some burden on the payer community to provide information to attract and keep customers. MR. SCHUYLER: Unless there’s a good mix of plans in the exchange, I don’t know that you will get that competitive pressure. There has been some consideration to allowing countybased purchasing units in Minnesota to be members of the exchange. These units carry risk but are not traditional insurance companies or HMOs. They operate with a lean overhead and therefore can keep premiums low but still have robust options for the consumer. Unless they’re in the game, there may not be pressure on other payers. It would be like a discount airline not being able to operate in the Twin Cities. MR. CHRISTENSON: Should Minnesota allow for-profit companies to participate? MR. MUNSON-REGALA: Limiting participation to not-for-profit companies limits choices available to consumers. There are pros and cons to that decision. DR. DEHNEL: There has to be a level playing field for all participants in the exchange. If they are under the same set of rules, have the same state or federal fees and taxes, and as long as requirements for covered benefits are basically in the same area, then you’ll have a level playing field. The concern is that the playing field may not be level for both forprofit and not-for-profit companies. MR. MAYNARD: Participation is key. If there’s choice and participation by all health plans in the marketplace, it will create a competitive marketplace and drive costs down. One of the biggest concerns I hear from states is that not all plans will participate or will participate only in part. Employers and consumers alike won’t want a marketplace where there isn’t choice. It’s key, regardless of nonprofit or profit.

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A B O U T T H E PA N E L I S T S Peter Dehnel, MD, is president of the Twin Cities Medical Society and medical director for utilization management, Blue Cross and Blue Shield of Minnesota (BC/BSM). Trained as a pediatrician, he formerly served as the medical director of Children’s Physician Network of Children’s Hospitals and Clinics of Minnesota. In the latter capacity, he collaborated with other pediatric clinicians to improve care for children and teens in the Twin Cities area. His ultimate goal on behalf of BC/BSM is to optimize the interface between the insurance world and provider community, helping BC/BSM members get the right benefits and services within the context of their plan in order to deliver the best possible outcomes. Dan Maynard is president of Connecture, the leading provider of Webbased information systems used to create health insurance marketplaces and exchanges. The company grew from one he started in 1997, which was the first online broker for health insurance plans that allowed consumers to comparison-shop health plans. Connecture’s solutions are provided to health plans, state insurance exchanges, private exchanges, and insurance brokers. More than 25 million Americans shop for their health insurance through systems built by Connecture, and more than half the nation’s 20 largest plans rely on Connecture systems to sell, administer, and manage their plans and products effectively. Beth McMullen is health policy director for the Minnesota Business Partnership (MBP), an association of CEOs of Minnesota’s 100 largest employers. Since joining MBP in February 2002, she has worked with business executives and government officials to shape health policy in Minnesota through lobbying efforts at the state capital. Prior to MBP, she worked for Associated Builders and Contractors, Wisconsin Manufacturers and Commerce, and then-Congressman Scott Klug (R-Wis.). She has been honored twice by the Minneapolis-St. Paul Business Journal: In 2011 as one of its “25 Women to Watch,” and in 2005 as one of its “40 Under Forty.” Manny Munson-Regala, JD, is the assistant for health reform for the Minnesota Commissioner of Health. He was formerly deputy Exchange director at the Minnesota Department of Commerce, where he was responsible for business functions of the Exchange, including eligibility, enrollment, navigators/brokers, premium management, outreach, and marketing. His career includes public service with state agencies and the private sector, including service as vice president of strategy and partnerships at Ceridian; deputy commissioner at the Minnesota Department of Commerce; director of legal, regulatory, and government affairs at United Healthcare; vice president of government affairs at GeoVera Holdings, Inc., and Discover Re; and assistant vice president, senior corporate counsel at Travelers Insurance and St. Paul Companies. Charles Sawyer, DC, is senior vice president of Northwestern Health Sciences University, Bloomington, Minn. In that role, he serves on the Minnesota Chiropractic Association’s legislative committee and represents the university as a member of the Minnesota Provider Coalition, 15 diverse provider groups working together to affect change. At Northwestern, he has served as an associate clinic director, assistant dean of clinic development, dean of academic affairs, founding director of Wolfe-Harris Center for Clinical Studies, vice president for academic affairs and research, academic dean, and provost. In 2010, he and two Northwestern colleagues established the Center for Healthcare Innovation and Policy to advance complementary and integrative health care. Daniel Schuyler is a director at Leavitt Partners, a health-care intelligence business in Salt Lake City, where he helps to guide the firm’s health-insurance exchange practice. Prior to joining Leavitt Partners, he was the director of technology for the Utah Health Insurance Exchange, where he was responsible for defining technical goals and business processes associated with the exchange, the second of its kind in the United States when created in 2009. Prior to that position, he managed the department of environmental quality, National Environmental Information Exchange Network. There, he helped bring Utah from the bottom third in environmental exchanges to the top 10 percent in less than one year. Robert Christenson, with 40 years’ experience in health care policy and consulting, helps solo and small-group practitioners build a full practice of ideal clients and improve their net revenue.

MR. CHRISTENSON: Do physicians expect detrimental effects from a health insurance exchange? FEBRUARY 2013 MINNESOTA HEALTH CARE NEWS

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M I N N E S O T A DR. DEHNEL: There’s a distinction between health care services and health insurance. If the benefit and product design of your insurance plan has a strong detrimental effect on the delivery of health care services, physicians won’t like that. It’s going to disadvantage many good providers in this community if you have an insurance product design that excludes either the care they can give or participation with patients. DR. SAWYER: I don’t know that it’s a detriment per se. All providers are dealing with the challenges of a multipayer environment. The exchange won’t resolve that. When the Affordable Care Act (ACA) was being debated, a noted health economist testified in Congress that Duke University Medical Center, an acute access hospital with 900 beds, had 900 billing clerks. Not 900 physicians, not 900 nurses, but 900 billing clerks in a 900-bed hospital. We’re going to perpetuate complexity on the provider side of dealing with that multipayer environment. And not just multiple payers but multiple levels of benefit access within that payer. We have a huge administrative burden across the system that is unmatched in the world. We have to wrestle with that.

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DR. SAWYER: Might the exchange evolve over time to fulfill higher aspirations in the context of health reform? Right now, I think the temptation is to overpromise and not reach those expectations. MR. CHRISTENSON: States can create their own exchange or they can allow the federally traded exchange to go into operation. How would a state benefit from having its own exchange instead of participating in a federally operated exchange? MR. MUNSON-REGALA: Minnesota’s decision to build its own exchange gives us the opportunity to tie our exchange to the broader range of health reform initiatives that Minnesota has been working on for some time. That’s less likely to occur in a federal exchange. Another benefit of a Minnesota-based exchange is that exchanges will need to provide

spective, a lot of my members have employees in all 50 states. While it’s important for Minnesota to take advantage of advances we’ve made in health care, we need to pay close attention to what’s happening across the country so we have continuity in how employers communicate with exchanges. For example, we don’t want General Mills, based here but with employees all over the country, having to figure out how to communicate with exchanges in 50 different ways. It’s important for Minnesota to have its own exchange, but we need to make sure that we have some continuity across the country. DR. SAWYER: Control of the exchange should be at the state level, but there’s a price to pay for that control. Like-minded states, especially those that are contiguous, could collaborate and get economies of scale. Minnesota will probably spend $100 million just to get this thing built. Ongoing maintenance is another expenditure. MR. MAYNARD: Sustainability of the exchange will be borne by the exchange and the state, whether it’s a federal or state pro-

There has to be a level playing field for all participants in the exchange.

MS. MCMULLEN: For employers, one of the biggest concerns about the exchange as it is under the ACA is the amount of communication that must occur between employers and the exchange regarding human resource information. For example, how much an employee earns, in order to determine if they qualify for a subsidy or a public program. MR. MAYNARD: It’s daunting, the education and the timing associated with all of this. The program rollout is a fixed time frame, so we basically have a year to completely educate the entire population on how to purchase insurance. MR. SCHUYLER: Beth and Dan make a great point about outreach and education and how important it is to communicate how the exchange is going to work. This is a new way for employees and individuals to purchase insurance. Outreach and education are critical to ensure people understand how the exchange works and how they can make informed choices. The way we approached the Utah exchange was via a limited launch, addressing concerns that arose during that launch. That exchange is in its third iteration, learning from past mistakes and consumer feedback.

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a lot of customer service, and I’d prefer customer service relationships with folks in the state than with those outside Minnesota. That’s partially because there’s a connection to the marketplace that matters. Ultimately, states want a state-based exchange so that they can continue to control their markets and their health care environment. MR. MAYNARD: Every state would like a statebased exchange. If you take politics out of it, whether it’s a blue state or a red state, what it comes down to is taking control and having that access, as Manny said. I would be hardpressed to think that there are many states that would say, yeah, I would like to give that all up to the federal government. MS. MCMULLEN: From a large employer per-

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gram. Some forward-looking states are collaborating to create consistency in how programs will operate. MR. CHRISTENSON: When Utah made the decision to create their own exchange, what was in their minds? MR. SCHUYLER: Utah chose to build a small group exchange because employers were seeking ways to mitigate rising health care costs. Several stakeholders proposed defined contribution, which allows an employer to provide an employee with a set dollar amount every month. The employee could go into the Utah Health Exchange and purchase any product from any insurer in the exchange. In the first year of the exchange, we had 66 products and three insurance carri-

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M I N N E S O T A ers. Defined contribution allows the employer to forecast and predict costs on an annual basis because they can control the defined contribution that they allocate as part of their budget to the employees. It gives the employees greater choice instead of picking only one plan provided by the employer. They can go into the exchange and choose from what are currently 198 different plans. It builds loyalty between employee and carrier because now these products are portable. It doesn’t matter if the employee leaves and goes to work for another employer. As long as that employer is in the exchange, the employee can carry that health plan with them. Before, you didn’t have that. Defined contribution has been a big success with the Utah Health Exchange. MR. CHRISTENSON: If Minnesota has a statebased exchange, not a federal one, can we design our own essential benefits set?

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acute and chronic pain. They also provide that in an outpatient, ambulatory context. Will these providers be included in those benefit packages? MR. CHRISTENSON: The Affordable Care Act requires the financing of health care exchanges to be self-sustaining. Where should the money come from to operate Minnesota’s exchange? MR. MUNSON-REGALA: Exchanges need to be self-sustaining starting in 2015. Before that, Uncle Sam pays for design, development, and operational costs of an exchange. In 2015, we have several options. One is the Medicaid match. Some funding could come from our partner agency, DHS. Another source of funding could come from user fees, either on top of the premium or from the premium itself. In other words, consumers, insurance

MR. MUNSON-REGALA: Yes, until the feds implement one nationwide in 2016. If we choose to add additional benefits and/or

If there isn’t choice, if it isn’t affordable, you’re not going to get participation. Dan Maynard

mandates on top of that core set, the state of Minnesota picks up the cost associated with requiring additional benefits to be sold throughout the entire marketplace. DR. SAWYER: The Affordable Care Act requires 10 categories of essential benefits, including ambulatory patient services, rehabilitation, laboratory services, and preventive and wellness services. Which providers of those services will plans include in their benefit package? For example, chiropractic doctors are in many respects primary care physicians, certainly for musculoskeletal problems, and they do that in an ambulatory service capacity. They also provide preventive and wellness services. Second example: Acupuncturists are increasingly sought after, particularly for patients with

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companies, navigators, and brokers using the exchange may pay some fee to access it. General revenue—highly unlikely—could fund. Other possibilities include naming rights and advertising. It’ll probably be a blend of some of those rather any one mechanism. DR. SAWYER: Manny’s right; it’ll have to be a blend. According to documents from the Insurance Exchange Task Force, as of last week, it had not reached a conclusion about how this will be operationally paid for. MS. MCMULLEN: We believe there should be a market outside the exchange. You have to consider the impact of the cost of that exchange. You don’t want it spread across the whole market. It should be paid for by the users of an exchange.

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MR. MAYNARD: If you’re going to use user fees, I’d make them transparent versus making health plans pay an extra fee to be on the exchange. I’d make it as transparent as possible so that the competitive nature of it can play out without having administrative costs buried within. MR. SCHUYLER: Utah pays for the exchange strictly through a per-member, per-month administrative fee. That fee includes a $6per-month admin fee to pay for operation of the exchange. Brokers that facilitate enrollment for, I believe, about 93 percent of the employers that come through the exchange, get a $37-per-month commission on each transaction. DR. DEHNEL: In our own Minnesota experience, when the provider tax first came out there were prohibitions against being able to disclose that. Minnesota doesn’t necessarily have a great track record of transparency in these mandates. I second the notion that we have a transparent disclosure of wherever fees come from. MR. MUNSON-REGALA: Massachusetts funded its exchange with an initial loan from the legislature that had to be repaid. Massachusetts’ funding source was a percentage of the premium of the policy sold in the exchange. So they kept a cut off the top or the bottom. It started at 5 percent of premium. It’s now around 3 percent, scaled down relative to its predicted revenue and projected expenses. Percentage of premium, in a way, is a fee for insurers. Another way an exchange could fund itself could be in the form of an annual license to participate in the exchange: If an exchange is a farmer’s market, you pay rent on the stall you have in the farmer’s market. There’s disagreement about whether or not the exchange is useful to anybody other than the folks buying through it. I would say it does. If you come to the exchange to shop but you go to Blue Cross to buy directly, the exchange has served some benefit to you because it has given you validation that the price you get from Blue Cross is the best one you can get. The exchange provides validation for your purchasing decision. How much that’s worth to you and where the expense for providing that service comes from, I don’t know. Also, this will be a nonprofit exchange, so generating revenues through grants and donations is another option.

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M I N N E S O T A MR. CHRISTENSON: Federal dollars are going to be available for financing the Minnesota exchange. When do federal dollars stop and when do we have to pick up the entire bill for operating the exchange? Could Congress increase or extend that allocation? MR. SCHUYLER: The last deadline to apply for a grant is December 2014. It’s possible that HHS could extend deadlines. There doesn’t seem to be a limit right now on the size of the grant award. Allocations aren’t population dependent, judging by grant awards we’ve seen. Anywhere from $18 million to over $100 million grants have been awarded to states of various population sizes. A state determines the funding it needs to build an exchange. Population is a big factor in that. Then, the state submits its budget to HHS for review and approval. HHS approves it, denies it, requests clarification, or tries to amend the amount requested. I believe you can do this relatively inexpensively, for far less than states are being awarded. It depends how comprehensive an exchange a state wants to build. To me, it doesn’t require $100 million to build an exchange, but those are some of the awards being made.

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That reflects a different organizational choice by each exchange. Minnesota’s projected operational budget is around $30 million plus. DR. SAWYER: Manny, I understand that there’s a cost in the state budget for Medicaid enrollment and eligibility certification. We won’t know for some time if this will help the consumer. MS. MCMULLEN: I want to add one piece to this. There are a number of dynamic forces in health-care insurance costs. Uncompensated care was mentioned. The cost of those individuals is shifted onto the rest of the market. We also have the market power of negotiating. Do large employers have a significant advantage in negotiating for payment of health care? We also have the government cost

MR. MUNSON-REGALA: The numbers depend on projected enrollment in the exchange. At some point you reach economies of scale, but there still will be incremental cost of providing service, particularly customer service, to more people. The other unknown that relates to ongoing operational cost is the role of agents and brokers. If the exchange is going to pay for them, that’s a cost that’s not currently in its budget. That would add to what we’d have to generate in the form of revenue to pay for that distribution channel. There are a number of unknowns as to what we expect an exchange will cost on an ongoing basis. Massachusetts’ exchange costs $30 to $40 million a year; Utah’s, less than $750,000.

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DR. SAWYER: Maybe the best configuration is a combination of agency and nonprofit. If the exchange is to be successful and respond to the needs of consumers who are patients, there needs to be a strong

A variety of options for consumers is important.

DR. DEHNEL: One opportunity with an exchange is to expand the number of people who have insurance. If you reduce the number of uninsured people, you reduce uncompensated care. Uncompensated care is something we’re all paying for through higher premiums or higher copays. An exchange would help reduce the cost of uncompensated care that you’re currently bearing in a nontransparent way. MR. CHRISTENSON: Have we set a budget for what we consider the basic necessities of operating our own exchange, Manny?

MR. MUNSON-REGALA: There are three options a state can select from in setting up the governing structure of their exchange. The first is a state agency, either an existing one or a new one. Another option: Some states have set up nonprofits to administer their exchanges. The third option is a hybrid of the two, a public-private entity. There are some of those in Minnesota already, such as the Minnesota Zoo, where public entities and private participants work together on the zoo board to administer the zoo. Such public-private entities are the preferred form in states that have passed exchange legislation. The word “hybrid” envisions a range of operational choices. One person’s hybrid could look remarkably different from somebody else’s.

Beth McMullen

shift where Medicaid pays at a lower rate. Now we add the exchange and how we pay for that, yet another complicating dynamic force. We’ve got a number of dynamic forces and we can’t pinpoint how they affect health-care insurance costs. We need to consider that as we’re looking at adding another dynamic force, which is the exchange. MR. CHRISTENSON: How should our Minnesota health insurance exchange be governed? For point of reference, the health insurance exchange of Minnesota began at the Department of Health, moved to Department of Commerce, moved to Management and Budget, and then a piece of it moved back to Department of Health. It is currently an open question as to how this exchange will be governed.

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advocacy element representing patient needs. MS. MCMULLEN: We support a governing structure that is nonprofit outside of state agency. We have examples of those in Minnesota that have worked really well, and you can structure it to have stakeholders around the table as a nonprofit governing board. DR. DEHNEL: You need a broad range of stakeholders at the table. You also need people who have business, insurance, clinical expertise, all coming together, and certainly the consumer. If it’s independent of a state agency, that would be best. MS. MCMULLEN: A majority of people who sit on a governing board need to have some ex-

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M I N N E S O T A pertise in what the exchange is, and that is an insurance marketplace. That should include small employers who are purchasers through the exchange, as well as individuals. It gets difficult to have that level of expertise. We need to rely on our care providers, as well as the expertise that health plans that will be selling insurance through the exchange bring to the table. DR. DEHNEL: Physicians should be on the board. The reality is that health insurance does influence the delivery of health care services. In order to see how an insurance marketplace design influences health care delivery, it’s crucial to have that voice at the table. DR. SAWYER: I agree with Peter, as long as there are folks like me representing other provider groups. We have very similar per-

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MR. MUNSON-REGALA: Should health plans have a seat at the table? Including folks who have subject matter expertise tends to be counterbalanced by arguments that those same people have an inherent conflict of interest because their livelihoods depend on the operation of the exchange. The same observation has been made about providers and facilities. If they participate in the governing structure, they may be in the position to impact their own bottom line. I’m not saying that’s a bad thing; I’m just saying that those are pros and cons of allowing folks with perceived conflicts of interest on the board. DR. DEHNEL: As long as you fully disclose a conflict of interest position, you simply recuse yourself from the discussion. Boards that operate well accommodate those different interest positions.

Up to $750 billion in our health care system is wasted every single year. Charles Sawyer, DC

spectives regarding the need to look out for the interests of patients. I agree there has to be some understanding of how the insurance industry fits into this equation. There also needs to be a voice that is independent and cares less about revenue or profit and is devoted to what patients actually need and the quest for universal access. If you really want the consummate nonpartisan advocate, it would be nurses. So I would add a third group, and that is the nursing profession. MR. MAYNARD: It’s largely about consumer shopping and selection process. That expertise is essential to making sure the exchange provides a successful way to acquire insurance or government benefits.

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DR. SAWYER: Peter, you’re right. It depends on the ethics of folks that serve on an organization like this and their ability to distance themselves from conflicts. By its very nature, the governance structure of an exchange will have to be robust. The small business community has a stake in this. Consumers have a huge stake in this. You’re going to need a mix of people around the table that have one interest in mind, and that’s getting people access to care and affordable coverage. That’s got to be the guiding principle. The plans have to be there because that’s where technical expertise is going to be if we’re going to continue with a private insurance model. MR. SCHUYLER: Stakeholder engagement

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during development of the exchange is extremely important and needs to include a cross-section of experts from all industries. That philosophy should carry over to the governing structure. MR. MUNSON-REGALA: Inherent challenges in this enterprise are barriers to data sharing and data analytics. We fully anticipate the minute we go live that someone will attempt to hack us, because we’re going to have access to personal and financial information that could be of value to someone. That’s a data security concern we have to deal with. There’s a data-sharing dynamic inherent with the requirement that we do eligibility and enrollment in real time. The only way we can do that is by connecting to the federal data hub that accesses information from the IRS, Homeland Security, and Social Security. That might pose datasharing challenges. At some point, we’re going to connect with the plans on information that they view as proprietary. DR. DEHNEL: There’s a distinction between proprietary versus protected information. That presents a huge issue in terms of what plans can work with as they collaborate with clinics and hospital systems. According to Minnesota law, there is a limited amount of information that health care providers can share with plans. Minnesota has gone above and beyond HIPAA statutes in terms of creating barriers to sharing information. As we construct this opportunity for enhancing care that’s called an exchange, looking at our data and enhancing our data analytics capabilities, we will have to revisit those barriers. Regarding data sharing, we’ll need to see what is possible, what is legal, and if there is a state statute that has to be modified in order for us to do this more effectively. MR. MUNSON-REGALA: Who should maintain, control, and disseminate that data? Should it be the exchange or some other entity? Speaking of conflicts of interest, a marketplace participant—which the exchange fundamentally is—has access to information that competitors may not. Do we prohibit the exchange from data mining their transactions to give information to their partners? Do we say that the exchange’s data should be maintained and safeguarded elsewhere? I suspect this dialogue’s going to occur during the next legislative session. MR. CHRISTENSON: What criteria should be used to determine the essential benefit set that

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M I N N E S O T A will be covered by insurance options available on the exchange? DR. SAWYER: The decision should be as evidence-informed as possible. The companion part of that decision is the value that patients place on certain therapies, care providers, certain ways of providing care, and settings of care. When it comes to essential benefits, there has to be a balance of those two factors. We waste a lot of money in this country, and all providers, regardless of the discipline, are guilty of that. Part of that waste occurs because we don’t know enough about what works and under what setting and for what reason. Plus, we’re all chasing another reimbursement dollar. If the goal is to keep costs down and improve the quality of care while responding to the desires of the consumer, we’ve got to be mindful of all of those considerations. MR. SCHUYLER: The EHB (essential health benefits) benchmark is a double-edged sword. While you’re trying to find a baseline that has a benefit level that can cover a vast majority of consumers, you also need to make sure that benchmark is affordable. Otherwise, you’ll price people out of the exchange, and then these subsidies won’t have the impact they should. That’s a struggle a lot of stakeholders are having with the EHB. MS. MCMULLEN: The discussion around EHB has been going for decades. This is not an easy question, and I was shocked when the ACA said it would identify the essential health benefit set. Really? Where did they find the answer? If you stop 100 people on the street and ask them, “What is essential for your health care coverage today?” you’ll get 100 different answers. We need to keep the consumer in mind because that is what this exchange is about: providing access to coverage, keeping the consumer in mind in terms of what options are available. If we have too broad an essential health benefit, you’re going to price people out. MR. MAYNARD: In order to meet every consumer’s need, affordability is what it comes down to. The lower cost side of the scale has to be considered, and if essential health benefits are too high, it’s going to create something that’s not affordable for one section of the economy. DR. DEHNEL: The broader and more inclusive you make that set of essential benefits, the more expensive you make it. That’s based on

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the cost of delivering that care. MR. MUNSON-REGALA: EHB applies inside and outside the exchange; it applies to our entire marketplace. Beth is right, this one’s going to be an ongoing conversation. Criteria for EHB say you must meet roughly 60 percent of actual value in every product. You can’t sell a product that pays for 20 percent of potential losses now. Going forward, 60 percent of projected claims have to be covered by this product. In addition, for you to be sold in an exchange, you have to meet network adequacy provisions, marketing standards, and quality standards. Those three elements are going to be subject to dialogue at the legislature. There are federal parameters in which those decisions are going to be made. We’re going to have a dia-

other modern economies, there’s a big cliff between the U.S. and the next highest country. Nobody’s projecting this cost curve will flatten anytime soon. Another statistic that’s staggering: A few months ago, the Institute of Medicine published a report that estimated that up to $750 billion in our health care system is wasted every single year. They also estimated that about $190 billion of that $750 is pure administrative excess. Fraud, unnecessary procedures, practice variation, and a host of factors add up to that $750 billion. We’re spending boatloads of money and not getting value, and we will have to wrestle with this question about what benefits are in, what kinds of providers are in, and what will patients have access to. It’s going to be a huge challenge. DR. DEHNEL: When a consumer has a portfolio of plans from which to choose, how are they going to decide which of the various options to go with? They will likely look at their health care needs and

An exchange will increase transparency around cost and quality. Daniel Schuyler

logue around what it means to have an adequate network, what it means to have a quality plan or an acceptable level quality, and what marketing standards should apply. One of the big policy questions I think we’re going to have is: should standards of network, quality, and marketing apply to nonexchange products? MR. CHRISTENSON: A current component of health insurance is preauthorization for a number of services and procedures. Would that be included in the exchange, or is there the opportunity to reject it? DR. SAWYER: I think that would be left up to the plans to determine, or for that decision to be made through another mechanism. To give you some context, we spend about 18.5 percent of our GDP on health care. When you look at where the U.S. ranks among

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ask, do you cover this? They may say, my child has autism; do you cover autism services? That’s going to be at a plan-specific level. It’s likely that you will have some variation on what plans cover. That may be the value of having choices. For example, I’m healthy. My BMI is 25. I don’t smoke. How can I get a more limited array of services because I choose to live healthy, versus someone with a BMI of 45 who says, “I like to sit around and watch Sunday afternoon football and Thursday night football and eat my Doritos and drink my beer and smoke my cigarettes at the same time”? You may have a different set of health care needs at that point, and you may choose a different plan based on what your needs are as a consumer.

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M I N N E S O T A MR. MUNSON-REGALA: Remember that an exchange’s fundamental role is to connect people with an insurance product. Our ability to utilize the exchange as a lever to do other health reform initiatives, modify environmental determinants of care, modify lifestyle choices, do this, do that, will have to be filtered through the connection between pocketbook—what you pay for a premium or copay—and insurance product. I propose that it’s a fairly limited type of tool. It’s not the only tool in the toolbox. When we consider what we can use the exchange to do, in a lot of these areas it will complement other initiatives. Where it is going to be the primary lever is in connecting people to access and potentially driving information around quality. MR. SCHUYLER: The exchange is not a silver bullet, it is a silver BB.

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than average populations. Risk adjustment smooths out that winner and loser perspective. We would take money from one plan and give it to another plan to reflect the fact that the plan that is receiving money is insuring a sicker than average population. It seems straightforward, but you can imagine the challenges of taking money out of my pocket and giving it to Dan, for example. I’m going to say, wait a minute, we’re not that different, or, you’re taking too much because his population isn’t that sick. That becomes the dynamic whenever you start swapping money around carriers. That’s the fundamental concept of risk adjustment: to eliminate risk selection as a reason for plans to participate in the marketplace and, hopefully, get them to compete around things like outcomes, quality, or other metrics. We’re relying on federal risk adjustment method-

An exchange’s fundamental role is to connect people with an insurance product. Manny Munson-Regala, JD

MR. CHRISTENSON: What risk adjustment methodology should be incorporated into an exchange to provide fair and transparent pricing once enough data has been collected to impact policy rates? MR. MUNSON-REGALA: First, what is risk adjustment; what does it accomplish? It stems from the tendency of people to act in their economic self-interest. If you know you can buy an insurance product whenever you want, the tendency would be to wait until the last moment to buy. That would mean insurance would be purchased by people who need it and prices would increase. In order to eliminate that, we require everyone to pool in order to purchase. Within that pool, there will be some winners and some losers with the plans because some plans will have sicker than average or healthier

MINNESOTA

ology for the time being. We have no statutory authority to use the state source of data that would allow us to do a state-based risk adjustment mechanism. Our hope is to move toward a state-based risk methodology system that is prospective. Getting there involves technologic and political barriers. DR. SAWYER: The other piece of this that is probably under-recognized is accuracy and granularity of the data. For example, there’s a difference between a little back pain and a lot of back pain. If I’m not accurate as a clinician or if a physician isn’t accurate in diagnosing and coding a procedure, it can skew the math and characterize an individual or a collection of individuals as more severely ill when they’re not. There is a lot of gaming going on now in the form of upcoding. I don’t know how to resolve that. Using accu-

H E A LT H

CARE

rate data for risk adjustment is critical if this is going to work. The federal system is woefully imperfect, but that’s the one we’re going with for now. Would it be better to have a Minnesota-based formula? Clearly, but that’s going to mean a lot of diligence and resolve in terms of accurate information. MR. MAYNARD: There are big issues involved in sharing data so that you can monitor it from health plan to health plan. In order to tell whether people are complying or not, you have to look at the data. There are significant issues from a data aggregation standpoint as well as from a data sharing perspective that will make it difficult and complex to do that. MS. MCMULLEN: Risk adjustment should be invisible to the consumer purchaser, which means it needs to be fair. DR. DEHNEL: On the clinician side, there have been attempts at risk adjusting patient populations of clinics and hospital systems for the last 30 years because, as a physician, I’ll say my patients are always sicker and that’s why the cost of delivering care is higher. Right now, we have risk adjustment methods that may account for 25 percent to 30 percent of the true variation in disease cost. I’m not sure how we’re going to do that at an exchange level. Risk adjustment hasn’t been solved in the last 30 years or more; I’m not sure how we’re going to do it in a short time frame for this operation. MR. SCHUYLER: We don’t know who the pool of insureds will be. So although we can forecast the type of risk that will come from all of the new enrollees in an exchange, we won’t know until we have at least a year’s worth of data. I predict you’ll see different risk adjustment models state by state, a federal model, and models being distributed by other entities. MR. MAYNARD: Insurers have to deal with risk adjustment whether it’s coming from the exchange or not. MR. CHRISTENSON: At this point in time, who is eligible to use the Minnesota exchange? MR. MUNSON-REGALA: Legal immigrants and small businesses of 50 or fewer. People who are eligible for subsidies through the exchange includes individuals from Medicaid who are between 138 percent and about 400 percent of the federal poverty level. That translates to roughly $44,000 a year for an individual or $90,000 for a family of four. Eligibility for the small-employer

ROUNDTABLE

sponsored by Minnesota Physician Publishing, Inc.

FEBRUARY 2013 MINNESOTA HEALTH CARE NEWS

M I N N E S O T A two-year tax credit is for employers of 25 or fewer. It’s a combination of the average salary your employees make and the size of you as an employer. So it’s not all small employers, it’s a subset of them. MR. CHRISTENSON: In order for the exchange to be successful, we need a lot of participants. What must be done to ensure that the eligible population uses the exchange? MR. MAYNARD: Education and choice. Participation is going to come from consumers and small businesses benefiting from the exchange. If there isn’t choice, if it isn’t affordable, you’re not going to get participation. If you don’t have participation, insurers aren’t going to want to be on it At the end of the day, you need affordable products on the exchange.

H E A L T H

C A R E

R O U N D T A B L E

MR. CHRISTENSON: Should a time period be set for accomplishing the process of setting up administrative processes and continuity of care? DR. DEHNEL: If a participant in the exchange says, I’m going to use this plan this year, but this other plan looks less costly for next year, that’s going to cause tremendous problems. If the insurance exchange says that you have to provide continuity of care with existing providers for X length of time, that may diminish your ability as an insurer to create a product that meets the needs of all of your stakeholders. I would get very concerned about this notion that people can

MS. MCMULLEN: Make sure that the exchange is easy to navigate and communicate to employers how an exchange might increase the purchasing power of a small business. MR. MUNSON-REGALA: Sixtyfive percent of small employers trusted their agents and brokers more than their spouses when it came to insurance decision-making. If we don’t involve agents and brokers, our ability to get small employers to participate will be nil. MR. MAYNARD: Small employers use brokers because they don’t have HR departments or benefits specialists. Somebody’s going to have to provide that service to small employers in order to draw them to the exchange. DR. DEHNEL: Physician and chiropractic communities can help people navigate insurance choices. DR. SAWYER: I work with the Harbor Light Center, the Salvation Army facility in downtown Minneapolis. There are homeless people who not only lack access to computers, but will need someone sitting with them to help them navigate a user-friendly navigation structure.

move in and out of plans quickly. That will be a problem for their continuity of care. If they have significant chronic ongoing disease, it’s going to cause problems. MR. MUNSON-REGALA: I’ll argue the opposite. Think about a dynamic where consumers get to choose which product they want to purchase irrespective of who their employer is. If they find the product compelling enough, it doesn’t matter when they change jobs. If you are a carrier, you now have that consumer as a participant, potentially for the duration of their life. MR. CHRISTENSON: How should a health insurance exchange’s success be measured? MR. MUNSON-REGALA: Did it meet the minimum requirements required by law around enrollment, eligibility, and connectivity with Medicaid? Did it increase access to care? If we don’t reduce the number of uninsured, we haven’t done our job. Did individuals find their experience helped them understand how their decisions impact their health?

MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

MR. MAYNARD: Getting the uninsured insured. That’s what this is all about. DR. DEHNEL: The term “Triple Aim” refers to improving the experience of care for the individual; improving the health of the population as a whole, in this case in Minnesota; and mitigating increasing health care costs. If the exchange helps to accomplish the Triple Aim, then it will have succeeded. MS. MCMULLEN: Does it increase access to coverage? Minnesota has a relatively low uninsured rate, but a significant number of uninsured are currently eligible. If we can reach them and get them enrolled, it helps the system as a whole. Does the exchange increase my purchasing power? “Am I able to get better value for my dollar that I’m bringing to the table?” is an important measurement for the exchange. MR. SCHUYLER: One metric I hope everybody takes away from this is that in the Utah exchange, 30 percent of employers using the exchange didn’t offer coverage to their employees prior to enrolling in the exchange. If we can provide greater access, reduce the number of uninsured, and make the process of choosing a health plan less painful, that would be a great benefit. DR. SAWYER: The Exchange Advisory Task Force set out six guiding principles. Three resonate very strongly with me: universal coverage, high quality affordable health care, and elimination of health disparities. It’s a necessary, high aspiration. The exchange will help, to some extent, accomplish those aspirations. Let’s reduce the immense complexity we have that creates barriers for patients to receive the care they need in a timely fashion.

Preventing cancer from page 15

Food for thought

One is the need to establish that any compound being tested is not only effective but is as harmless as a vitamin tablet, completely nontoxic for long-term use by humans, and free of unwanted side effects that would severely limit its use. Another challenge encountered in conducting Common human research intended to replicate results in laborasense is tory animals is figuring out whether a certain chemothe best preventive treatment is actually working in humans. It’s relatively straightforward to assess this in lab lifestyle animals: Expose the animals to known carcinogens guide. in addition to a dietary compound and see if the compound prevents the appearance of cancer. It’s more difficult to assess the effect of a potential chemopreventive compound in humans because we can’t deliberately expose humans to carcinogens. Instead, we need surrogate biomarkers that indicate whether a chemopreventive treatment has an effect. The surrogate biomarker substitutes for the appearance of detectable cancer symptoms, but few biomarkers are currently available. Another challenge is deciding whether clinical trials should test purified dietary compounds or instead test a vegetable or fruit itself. Testing purified compounds would likely require a large-scale trial that would last for at least several years.

It’s unrealistic for someone to consume sufficient quantities of cruciferous vegetables and other foods containing chemoprotective compounds to approximate the doses of purified compounds studied in laboratory animals. So far, there are no convincing examples in humans of successful dietary chemoprevention. However, clinical trials currently examining the effects of PEITC, green tea, and other compounds may move us closer to answering the question: Can dietary substances prevent cancer? Until we know the answer, common sense is the best lifestyle guide. The Academy of Nutrition and Dietetics recommends filling at least two-thirds of your plate with vegetables, fruits, whole grains, and beans, which are linked with a lower risk of lung, oral, esophageal, stomach, and colon cancer. Stephen S. Hecht, PhD, is Wallin Land Grant Professor of Cancer Prevention at the University of Minnesota’s Masonic Cancer Center and American Cancer Society Professor in the university’s Department of Laboratory Medicine and Pathology. His research group studies mechanisms and prevention of tobacco-induced cancer.

WHO’S GOT BETTER MOVES ON THE DANCE FLOOR, YOU OR ME? Every day is a reason for a person with Down syndrome to smile. And find joy in things the rest of us often overlook. To learn more about the richness of knowing or raising someone with such an enthusiasm for life, call your local Down syndrome organization. Or visit ndsccenter.org today. It is the mission of the Down Syndrome Association of Minnesota to provide information, resources and support to individuals with Down syndrome, their families and their communities. We offer a wide range of services, programs and materials at no charge. If you are interested in receiving one of our information packets for new or expectant parents, please email Kathleen@dsamn.org or For more information please call:

(651) 603-0720 • (800) 511-3696

FEBRUARY 2013 MINNESOTA HEALTH CARE NEWS

L E G I S L AT I O N

2013 legislative preview

rguably the single most important topic for Minnesota’s 2013 legislative session is the federal Affordable Care Act (ACA). Specifically, the new state legislature, with Democrats in control of both chambers and with the backing of Gov. Dayton, a staunch supporter of the ACA, needs to determine how to implement the ACA’s cornerstones: a state health insurance exchange and expanded Medicaid. The 2013 legislative session is shaping up to be a critical one for the future of health care in Minnesota. DFL in control Key health care committees formerly headed by Republicans have Democratic (DFL) leadership this session. In the House, Rep. Tom Huntley

Shaping health care in Minnesota By Jeremy L. Johnson, JD

(DFL–Duluth) leads the Health and Human Services Finance Committee, Rep. Tina Liebling (DFL–Rochester) leads the Health and Human Services Policy Committee, and Rep. Paul Thissen (DFL–Minneapolis) is speaker of the House. In the Senate, Tony Lourey (DFL–Kerrick) heads the Health and Human Services Committee and Tom Bakk (DFL–Cook) is the newly elected majority leader. The DFL is on record as “support[ing] the Affordable Care Act and urg[ing] Minnesota to create a health insurance exchange,” so the shift in control at the Legislature was welcome news for the governor, who fought for the ACA’s implementation against steadfast Republican opposition during the past two years. Most newly elected DFLers, though, are middle-of-the-road Democrats, so the governor may have difficulty finding overwhelming support. Health insurance exchange A key component of the ACA is its requirement that by 2014, all states have a health insurance marketplace called an exchange. The

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MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

Pressing issues exchange is intended to simplify the process of researching and buying health insurance for The most pressing issue before lawmakers this consumers and small businesses by creating a session is determining, before Jan. 1, 2014, how single marketplace that will match consumers to fund the exchange. Recommendations include with plans. The ACA allows states to design using Medicaid funding, withholding a percenttheir own exchanges, but for those states that age of premiums paid for exchange coverage, decide not to, the federal government will and increasing assessments on insurers. In establish and run an exchange for them. December 2012, the U.S. Department of Health Minnesota has made significant progress and Human Services proposed establishing a user The most pressing in building a state-run exchange and met the fee for health insurers that want to offer policies issue before lawmakers January 2013 federal deadline for demonstrating in federal exchanges. The insurance industry is determining how to exchange readiness. claims that this fee would increase costs to conHowever, because the Republican Party sumers. Proponents of the fee claim it would be fund the exchange. gained control of both legislative chambers in offset by concurrent savings resulting from a the 2010 general election, the Legislature still streamlined insurance-purchasing process that has not approved legislation authorizing the state to create and imple- would eliminate, among other things, the need for insurance brokers. ment an exchange. Instead, building the exchange has been funded by It remains to be seen whether Minnesota will adopt the federal govfederal exchange grants (as of the date this issue went to press). Thus, ernmentâ&#x20AC;&#x2122;s proposed fee concept. a critical question is: What happens to the exchange if the Legislature Another issue that the Legislature may discuss this session is the does not pass authorizing legislation this session? Without it, the state development of private health insurance exchanges. Some view such has authority to create and operate an exchange only for as long as exchanges as a positive development that could force the state federal grants support it, and federal monies run out Dec. 31, 2013. exchange to serve consumers and small businesses less expensively Officials are optimistic that legislation authorizing the state to than they would be served without this competition. Others fear that create and implement an exchange will be passed this session. But such private competition could result in adverse selection. Adverse even if this legislation passes, questions remain about how the stateselection refers to a situation in which healthy individuals drop out of run exchange will operate, although itâ&#x20AC;&#x2122;s expected that all Minnesota the state-funded exchange pool in favor of private exchanges, thereby insurers will participate in it. raising premiums charged to those in the state exchange. 2013 Legislative preview to page 32

FEBRUARY 2013 MINNESOTA HEALTH CARE NEWS

2013 Legislative preview from page 31

Medicaid expansion Gov. Dayton has never made any secret of his desire to expand the state’s Medical Assistance (Medicaid) program. Minnesota opted into the ACA’s Medicaid expansion program, thus positioning the state to receive significant federal funding. It’s estimated that Minnesota’s implementation of this option will save $1.7 billion through 2015, in part by ending the state-funded General Assistance Medical Care program and moving beneficiaries into a federally matched Medicaid program. Such savings are partially responsible for the state reaching a balanced budget agreement for fiscal year 2012–2013. The Legislature has not completed implementing this option, however, and must decide several aspects of Medicaid expansion. One of the more pressing is the future of MinnesotaCare recipients with incomes greater than 138 percent of the federal poverty line (FPL). Under the ACA, Medicaid coverage for adults can be eliminated beginning in 2014 for those with incomes greater than 138 percent of the FPL and states may not use federal funds provided under the ACA to support this demographic. This could be a particularly serious problem for Minnesota because of the breadth of coverage it has offered under its MinnesotaCare plan. In 2011, the state obtained a waiver through which federal Medicaid funds now help finance MinnesotaCare coverage for childless adults with incomes between 75 percent and 205 percent of the FPL, but that is a temporary fix. One option is to adopt a Basic Health Program (BHP). The ACA contains a little-known provision that allows states to create a more affordable alternative to health insurance exchanges: a BHP. Under a BHP, Minnesota would contract with health plans or providers to cre-

ate a managed care plan that meets essential health benefit requirements. Individuals with incomes between 133 percent and 200 percent of the FPL (i.e., $15,000 to $21,800) would be eligible to participate in this BHP. The 2013 Legislature may consider this a reasonable solution to the 138 percent FPL Medicaid qualification minimum. Policymakers have not yet decided whether or how to implement a BHP. Another question facing the 2013 Legislature is whether to increase Medicaid provider payments beyond federally approved increases for 2013 and 2014. The state also faces issues relating to Medicaid benefit changes that start in 2014, when newly eligible adults can receive “benchmark benefits” rather than standard Medicaid coverage. There is some concern over how essential health benefits would be defined and how they would compare to current Medical Assistance and MinnesotaCare benefits. No decisions have been made. Finally, the Legislature will need to figure out how to implement ACA-mandated expansion of Medicaid coverage without worsening provider shortages. Primary care providers already are in particularly short supply in rural areas, especially in the area of behavioral health care. Gov. Dayton has created a workgroup to address this problem, and some suggest expanding opportunities for midlevel practitioners such as advanced practice nurses and physician assistants. Although proponents of the ACA control the capitol, much of this law’s implementation in Minnesota remains to be determined. The 2013 Legislature’s decisions will shape health care in Minnesota for the foreseeable future. Jeremy L. Johnson, JD, is a principal with Gray Plant Mooty in Minneapolis, practicing law in the areas of health care and nonprofit/taxexempt organizations.

Minnesota

Health Care Consumer January survey results ... Association

1. I have acted as an extended care provider for a member of my family.

Each month, members of the Minnesota Health Care Consumer Association are invited to participate in a survey that measures opinions around topics that affect our health-care delivery system. There is no charge to join the association, and everyone is invited. For more information, please visit www.mnhcca.org. We are pleased to present the results of the January survey.

46.2%

40 30 20 10

60 50 40 30 20 10 0

12.8%

7.7%

2.6% Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

17.9%

20 7.7%

0.0% Strongly agree

Agree

Does not apply

Disagree

5. This work had a significant impact on my relationships with other family members. 60 53.8%

50 40 30 20

69.2%

Percentage of total responses

70 Percentage of total responses

Percentage of total responses

64.1%

Yes

4. This work had a significant impact on my personal finances.

56.4%

53.8% Percentage of total responses

Percentage of total responses

3. I found adequate support from state and community programs in providing this care.

2. I felt I had sufficient training to provide this care.

15.4% 10.3% 5.1% Strongly agree

0.0% Agree

Does not apply

Disagree

Strongly disagree

50 40 28.2%

30 20 12.8% 10 0

5.1% 0.0% Strongly agree

Agree

Does not apply

Disagree

Strongly disagree

Minnesota

Health Care Consumer Association

Welcome to your opportunity to be heard in debates and discussions that shape the future of health care policy. There is no cost to join and all you need to become a member is access to the Internet.

Members receive a free monthly electronic newsletter and the opportunity to participate in consumer opinion surveys.

www.mnhcca.org

Join now.

â&#x20AC;&#x153;A way for you to make a differenceâ&#x20AC;? FEBRUARY 2013 MINNESOTA HEALTH CARE NEWS

Health-care credit cards from page 13

Be aware that any time you take out credit, it can affect your credit score. A credit card is a serious obligation and, if you do not pay it back according to the terms of the credit card, your credit history can be tarnished. This can affect other aspects of your daily life, from the price you pay for homeowners and automobile insurance, to the price you pay for credit, to your ability to get a job or rent an apartment.

an extremely expensive way of financing treatment. It can be very hard to pay off a credit card balance once interest starts accruing at rates of up to 29.99 percent. Shop around

Carefully evaluate whether a health-care credit card is the best deal for you. You may be able to obtain a lower-cost loan through your bank or credit union. Also ask whether your clinic has a payment plan that would allow you to spread out your payments over a longer period of time without taking out a credit card. If you have Read the fine print trouble paying for your bills, consult a legitimate nonprofit creditLenders often rely on clinics to promote health-care credit cards counseling agency. for them, with the patient having little or no contact with the credit For more information, or to file a complaint, contact: card company. Some patients report that the terms of the healthOffice of Minnesota Attorney General care credit card were not fully explained to them by their clinic. Lori Swanson For example, patients have reported 1400 Bremer Tower that they were not informed that the 445 Minnesota Street zero-interest promotion applied to St. Paul, MN 55101 some but not all serviInterest rates can quickly (651) 296-3353 or ces or that they would be responsi(800) 657-3787 ble for retroactive interest if they jump to as much as www.ag.state.mn.us missed a monthly payment. 29.99 percent retroactively. If you do decide to take out a health-care credit card, read the fine print. Just like any other credit card, healthcare credit cards can be

Now accepting new patients

A unique perspective on cardiac care Preventive Cardiology Consultants is founded on the fundamental belief that much of heart disease can be avoided in the vast majority of patients, and significantly delayed in the rest, by prudent modification of risk factors and attainable lifestyle measures. Elizabeth Klodas, M.D., F.A.S.C.C is a preventive cardiologist. She is the founding Editor in Chief of CardioSmart for the American College of Cardiology www.cardiosmart.org, a published author and medical editor for webMD. She is a member of several national committees on improving cardiac health and a frequent lecturer on the topic.

We are dedicated to creating a true partnership between doctor and patient working together to maximize heart health. We spend time getting to know each patient individually, learning about their lives and lifestyles before customizing treatment programs to maximize their health. Whether you have experienced any type of cardiac event, are at risk for one, or

are interested in learning how to prevent one, we can design a set of just-for-you solutions. Among the services we provide • One-on-one consultations with cardiologists • In-depth evaluation of nutrition and lifestyle factors • Advanced and routine blood analysis • Cardiac imaging including (as required) stress testing, stress echocardiography, stress nuclear imaging, coronary calcium screening, CT coronary angiography • Vascular screening • Dietary counseling/Exercise prescriptions

To schedule an appointment or to learn more about becoming a patient, please contact: Preventive Cardiology Consultants 6545 France Avenue, Suite 125, Edina, MN 55435 phone. 952.929.5600 fax. 952.929.5610 www.pccmn.com

MINNESOTA HEALTH CARE NEWS FEBRUARY 2013

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Important Patient Information This is a BRIEF SUMMARY of important information about VictozaÂŽ. This information does not take the place of talking with your doctor about your medical condition or your treatment. If you have any questions about VictozaÂŽ, ask your doctor. Only your doctor can determine if VictozaÂŽ is right for you. WARNING During the drug testing process, the medicine in VictozaÂŽ caused rats and mice to develop tumors of the thyroid gland. Some of these tumors were cancers. It is not known if VictozaÂŽ will cause thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people. If MTC occurs, it may lead to death if not detected and treated early. Do not take VictozaÂŽ if you or any of your family members have MTC, or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). This is a disease where people have tumors in more than one gland in the body. What is VictozaÂŽ used for? @ "-'73=%ÂŽ -6 % +08'%+32 0-/) 4)47-() 5)')4735 %+32-67 86)( 73 -14539) &033( 68+%5 +08'36) '327530 -2 %(8076 :-7, 7<4) 2 (-%&)7)6 1)00-786 :,)2 86)( :-7, % (-)7 %2( );)5'-6) 453+5%1 @ "-'73=%ÂŽ 6,380( 237 &) 86)( %6 7,) >567 ',3-') 3* 1)(-'-2) *35 75)%7-2+ (-%&)7)6 @ "-'73=%ÂŽ ,%6 237 &))2 678(-)( -2 )238+, 4)340) :-7, % ,-6735< 3* 4%2'5)%7-7-6 -2?%11%7-32 3* 7,) 4%2'5)%6 !,)5)*35) -7 6,380( &) 86)( :-7, '%5) -2 7,)6) 4%7-)276 ÂŽ

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@ "-'73=%ÂŽ 1%< '%86) 2%86)% 931-7-2+ 35 (-%55,)% 0)%(-2+ 73 7,) 0366 3* ?8-(6 (),<(5%7-32 ),<(5%7-32 1%< '%86) /-(2)< *%-085) !,-6 '%2 ,%44)2 -2 4)340) :,3 1%< ,%9) 2)9)5 ,%( /-(2)< 453&0)16 &)*35) 5-2/-2+ 40)27< 3* ?8-(6 1%< 5)(8') <385 ',%2') 3* (),<(5%7-32 @ -/) %00 37,)5 (-%&)7)6 1)(-'%7-326 "-'73=%ÂŽ ,%6 237 &))2 6,3:2 73 ()'5)%6) 7,) 5-6/ 3* 0%5+) &033( 9)66)0 (-6)%6) - ) ,)%57 %77%'/6 %2( 6753/)6 What are the side effects of VictozaÂŽ? @ !)00 <385 ,)%07,'%5) 4539-()5 -* <38 +)7 % 0814 35 6:)00-2+ -2 <385 2)'/ ,3%56)2)66 7538&0) 6:%003:-2+ 35 6,3572)66 3* &5)%7, :,-0) 7%/-2+ "-'73=%ÂŽ !,)6) 1%< &) 6<147316 3* 7,<53-( '%2')5 @ !,) 1367 '31132 6-() )**)'76 5)4357)( -2 %7 0)%67 5% 3* 4)340) 75)%7)( :-7, "-'73=%ÂŽ %2( 3''855-2+ 135) '311320< 7,%2 4)340) 75)%7)( :-7, % 40%')&3 % 232 %'7-9) -2.)'7-32 86)( 73 678(< (58+6 -2 '0-2-'%0 75-%06 %5) ,)%(%',) 2%86)% %2( (-%55,)% @ 1182) 6<67)1 5)0%7)( 5)%'7-326 -2'08(-2+ ,-9)6 :)5) 135) '31132 -2 4)340) 75)%7)( :-7, "-'73=%ÂŽ '314%5)( 73 4)340) 75)%7)( :-7, 37,)5 (-%&)7)6 (58+6 -2 '0-2-'%0 75-%06 @ !,-6 0-67-2+ 3* 6-() )**)'76 -6 237 '3140)7) #385 ,)%07, '%5) 453*)66-32%0 '%2 (-6'866 :-7, <38 % 135) '3140)7) 0-67 3* 6-() )**)'76 7,%7 1%< 3''85 :,)2 86-2+ "-'73=%ÂŽ What should I know about taking VictozaÂŽ with other medications? @ "-'73=%ÂŽ 603:6 )147<-2+ 3* <385 6731%', !,-6 1%< -14%'7 ,3: <385 &3(< %&635&6 37,)5 (58+6 7,%7 %5) 7%/)2 &< 1387, %7 7,) 6%1) 7-1) Can VictozaÂŽ be used in children? @ "-'73=%ÂŽ ,%6 237 &))2 678(-)( -2 4)340) &)03: <)%56 3* %+) Can VictozaÂŽ be used in people with kidney or liver problems? @ "-'73=%ÂŽ 6,380( &) 86)( :-7, '%87-32 -2 7,)6) 7<4)6 3* 4)340) Still have questions?

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FOR TYPE 2 DIABETES

Victoza® helped me take my blood sugar down…

and changed how I manage my type 2 diabetes. Victoza® helps lower blood sugar when it is high by targeting important cells in your pancreas—called beta cells. While not a weight-loss product, Victoza® may help you lose some weight. And Victoza® is used once a day anytime, with or without food, along with eating right and staying active.

Model is used for illustrative purposes only.

Indications and Usage: Victoza® is an injectable prescription medicine that may improve blood sugar (glucose) in adults with type 2 diabetes when used along with diet and exercise. Victoza® is not recommended as the ﬁrst medication to treat diabetes. Victoza® is not insulin and has not been studied in combination with insulin. Victoza® is not for people with type 1 diabetes or people with diabetic ketoacidosis. It is not known if Victoza® is safe and effective in children. Victoza® is not recommended for use in children. Important Safety Information: In animal studies, Victoza® caused thyroid tumors—including thyroid cancer—in some rats and mice. It is not known whether Victoza® causes thyroid tumors or a type of thyroid cancer called medullary thyroid cancer (MTC) in people which may be fatal if not detected and treated early. Do not use Victoza® if you or any of your family members have a history of MTC or if you have Multiple Endocrine Neoplasia syndrome type 2 (MEN 2). While taking Victoza®, tell your doctor if you get a lump or swelling in your neck, hoarseness, trouble swallowing, or shortness of breath. These may be symptoms of thyroid cancer. Inﬂammation of the pancreas (pancreatitis) may be severe and lead to death. Before taking Victoza®, tell your doctor if you have had pancreatitis, gallstones, a history of alcoholism,

If you’re ready for a change, talk to your doctor about Victoza® today.

or high blood triglyceride levels since these medical conditions make you more likely to get pancreatitis. Stop taking Victoza® and call your doctor right away if you have pain in your stomach area that is severe and will not go away, occurs with or without vomiting, or is felt going from your stomach area through to your back. These may be symptoms of pancreatitis. Before using Victoza ®, tell your doctor about all the medicines you take, especially sulfonylurea medicines or insulin, as taking them with Victoza® may affect how each medicine works. Also tell your doctor if you are allergic to any of the ingredients in Victoza®; have severe stomach problems such as slowed emptying of your stomach (gastroparesis) or problems with digesting food; have or have had kidney or liver problems; have any other medical conditions; are pregnant or plan to become pregnant. Tell your doctor if you are breastfeeding or plan to breastfeed. It is unknown if Victoza® will harm your unborn baby or if Victoza® passes into your breast milk. Your risk for getting hypoglycemia, or low blood sugar, is higher if you take Victoza® with another medicine that can cause low blood sugar, such as a sulfonylurea. The dose of your sulfonylurea medicine may need to be lowered while taking Victoza®.

Victoza® may cause nausea, vomiting, or diarrhea leading to dehydration, which may cause kidney failure. This can happen in people who have never had kidney problems before. Drinking plenty of ﬂuids may reduce your chance of dehydration. The most common side effects with Victoza® include headache, nausea, and diarrhea. Nausea is most common when ﬁrst starting Victoza®, but decreases over time in most people. Immune system-related reactions, including hives, were more common in people treated with Victoza® compared to people treated with other diabetes drugs in medical studies. Please see Brief Summary of Important Patient Information on next page. If you need assistance with prescription drug costs, help may be available. Visit pparx.org or call 1-888-4PPA-NOW. You are encouraged to report negative side effects of prescription drugs to the FDA. Visit fda.gov/medwatch or call 1-800-FDA-1088. Victoza® is a registered trademark of Novo Nordisk A/S. © 2011 Novo Nordisk 0611-00003312-1 August 2011

To learn more, visit victoza.com or call 1-877-4-VICTOZA (1-877-484-2869).

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