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Doctors MetroDoctors THE JOURNAL OF THE TWIN CITIES MEDICAL SOCIETY

September/October Index to Advertisers TCMS OfďŹ cers

President: Peter J. Dehnel, M.D. President-elect: Edwin N. Bogonko, M.D. Secretary: Lisa R. Mattson, M.D. Treasurer: Kenneth N. Kephart, M.D. Physician Co-editor Lee H. Beecher, M.D. Physician Co-editor Peter J. Dehnel, M.D. Physician Co-editor Gregory A. Plotnikoff, M.D., MTS Physician Co-editor Marvin S. Segal, M.D. Physician Co-editor Richard R. Sturgeon, M.D. Physician Co-editor Charles G. Terzian, M.D. Managing Editor Nancy K. Bauer Assistant Editor Katie R. Snow TCMS CEO Sue A. Schettle Production Manager Sheila A. Hatcher Advertising Representative Betsy Pierre Cover Design by Outside Line Studio MetroDoctors (ISSN 1526-4262) is published bi-monthly by the Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoctors, Twin Cities Medical Society, 1300 Godward Street NE, Broadway Place West, Suite 2000, Minneapolis, MN 55413. To promote its objectives and services, the Twin Cities Medical Society prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reect the ofďŹ cial position of TCMS.

Past President: Thomas D. Siefferman, M.D. TCMS Executive Staff

Sue A. Schettle, Chief Executive OfďŹ cer (612) 362-3799 sschettle@metrodoctors.com Jennifer J. Anderson, Project Director (612) 362-3752 janderson@metrodoctors.com Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893 nbauer@metrodoctors.com Andrea Farina, Executive Assistant (612) 623-2885 afarina@metrodoctors.com Barbara Greene, MPH, Community Engagement Director, Honoring Choices Minnesota (612) 623-2899 bgreene@metrodoctors.com Katie R. Snow, Project Coordinator (612) 362-3704 ksnow@metrodoctors.com For a complete list of TCMS Board of Directors go to www.metrodoctors.com.

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The Journal of the Twin Cities Medical Society


CONTENTS VOLUME 14, NO. 5

2

Index to Advertisers

5

IN THIS ISSUE

SEPTEMBER/OCTOBER 2012

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

6

PRESIDENT’S MESSAGE

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

7

TCMS IN ACTION By Sue Schettle, CEO

Page 10

CARING FOR OUR ELDERLY

8

s

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

10

s

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

14

s

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

17

s

Page 29

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

19

s

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

23

s

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

25

s

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

Page 32

27

s

28

Patience Breeds Success

Own Your Future

By Jennifer Anderson

Senior Physicians Association News

29

Sharing the Experience Conference Expands its Reach By Barbara Greene

Career Opportunities

30

In Memoriam New Members

32 Page 7

MetroDoctors

LUMINARY OF TWIN CITIES MEDICINE

Reuben Berman, M.D. The Journal of the Twin Cities Medical Society

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

September/October 2012

3


IN THIS ISSUE...

Geriatric Care — A Prelude

THE MAGNITUDE OF CARING FOR the medical needs of our

senior population is immense. Currently, over 13 percent of the U.S. population is 65 or older. By 2030 that demographic group is expected to number 68 million. At age 65, life expectancy is about 19 years, at age 75 it’s 12 years and at 85 is 7 years. Not only are we dealing with these huge and increasing numbers, but the complexity and severity of our geriatric folks’ health-inherent conditions is increasing. This demographic group is not just representative of average adults who happen to be some years older; rather, they are unique in their health status and in the requirements necessary to care for them in a quality fashion. It is indeed a privilege to watch over and fulfill the health needs of our elderly. This issue of MetroDoctors should help us to even better accomplish just that. Regarding the first article that discusses the University Medical School’s geriatric involvement, we’re led to wonder if it’s enough for the medical community to simply service the care needs of the geriatric population — or is more to be expected? In the long run, will focused educational approaches result in accompanying improvements in both quality of care and fiscal savings? Dr. Ken Kephart addresses those questions…and more. In our Colleague Interview where meaningful questions were submitted by our Editorial Board and community physicians, Dr. James Pacala responds in covering a gamut of geriatric issues — including preventive care, polypharmacy, psychiatric care reimbursement — and provides an emphatic and forthright answer to the “death panel/rationing” question notable in today’s political rhetoric. Dr. Richard Golden explores the exploding problem of senior dementia by practically addressing many of the important aspects of this complex issue, including risk factor assessment, diagnostic symptomatology, current treatment status, vehicular operation and caregiver support. An economic view of Social Security and Medicare funding issues is clearly presented by Stephen Parente, Ph.D. along with By Marvin S. Segal, M.D. Member, MetroDoctors Editorial Board

MetroDoctors

The Journal of the Twin Cities Medical Society

future consequences and predictions of these prominent entitlement issues. Dr. John Mielke relays modern standards and expectations of long-term care facilities along with a recounting of roles, functions and practical approaches utilized by their medical directors. A concern for the future affecting all age categories is addressed by Deb Newman as she discusses the advantages of purchasing long-term care insurance by individuals and businesses along with accompanying governmental incentives for doing so. Jean Wood of the Minnesota Board on Aging provides us with a striking array of meaningful local services available to our geriatric population, and the “Own Your Future” initiative stresses the importance of planning now for the future. www.ama-assnorg/go/geriatriccare is a link to a helpful new publication by the AMA, “Geriatric Care by Design.” Check it out. What better way to cap this issue than by providing a real life example of an actual relevant and productive senior citizen? One of our own, the very special Dr. Reuben Berman is featured as our Luminary of Twin Cities Medicine. Enjoy this month’s issue of MetroDoctors…it’s a good read!

September/October 2012

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President’s Message

A 20/20 Vision for Health Care in 2020 PETER J. DEHNEL, M.D.

W

hat is your vision for ideal health care by the year 2020? What new services, treatments and medical devices will be readily available eight years from now that are not available today? What will define “optimal access” for people, both at a primary care and specialty level? Will there be transformations that redefine our roles as physicians, such as through “virtual visits” and other telemedicinebased care? What will it take to get from where we are today to your vision for great health care? As with any other high quality outcome, this will not happen by itself, but will take planning, determination and resources. Many of us firmly believe that without significant physician input and leadership, the outcome will be unsatisfactory. This topic is especially germane to this edition of MetroDoctors which focuses on health care for seniors. The opening question morphs into what will optimal care for seniors look like in 2020? What do we need to start to do today, in a collaborative fashion, to be ready for the challenges that will confront us as a profession eight years from now? The challenges are definitely daunting. By the year 2020, the first half of the “baby boomer” generation will be eligible for Medicare. We collectively have not taken care of our bodies very well. There will be increasing pressure on Medicare and the Medicare supplemental insurance programs to cover more and more innovative and highly specialized treatments for an ever-expanding portfolio of disease processes. Examples are easy to find even today: Two sequential stem cell transplantations are now the standard of care for a handful of hematopoietic-based cancers. Hepatitis C is a potentially curable infection, but may require expensive “triple therapy” to eradicate this intracytoplasmic virus. One of the newer “biologics” — rituximab — works very well on a handful of diseases through the selective reduction of B lymphocytes, but at a cost of $12,500.00 per month for just the drug, without any of the associated clinical costs. Knee replacements — while not on the list of extremely high cost procedures — will exert considerable financial pressure through the sheer volume of eligible individuals who meet the criteria for replacement surgery. There will be significant competition for financial resources nationally by 2020 as well. Social Security will have increasing “distribution pressures.” Retirees wanting monthly distributions from underfunded pension obligations, especially after retirement from public sector jobs, will add further financial stress. Subsidies for health insurance for individuals under 65 years will be substantial, given the likely costs of new and emerging technologies and pharmaceuticals. This is in addition to the very real costs of unhealthy lifestyles. Just as one example, the FDA recently approved Belviq and Qsymia for treatment of obesity. These drugs are likely to be expensive when they are finally available on the market, and with 60-plus percent of us overweight or obese, the impact can be huge by 2020. Finally, payments to service our blossoming national debt will “come home to roost” by 2020. So back to the original question: What is your vision for ideal health care by 2020? How do you propose we get there? Are you willing to jump into the planning and implementation? As I suggested above, physicians participating in and even leading these health care decisions are crucial for achieving the best outcomes by 2020 and beyond. This needs to be you and me and the majority of physicians reading this edition of MetroDoctors. Besides, we all have a personal and vested interest in this. We will all hopefully make the transition from “provider” to “recipient” as participants in the health care system as seniors ourselves. 6

September/October 2012

MetroDoctors

The Journal of the Twin Cities Medical Society


TCMS IN ACTION SUE A. SCHETTLE, CEO

TCMS News

Senator Sean Nienow and Senator Michelle Benson attended the July 2012 TCMS Board of Directors meeting. Both Senators serve on the Governors Health Care Reform Task Force and provided the TCMS Board with their perspectives on a number of legislative issues. Nate Mussell, our lobbyist, also provided the Board with a summary of the implications of the Supreme Court’s recent decision to uphold much of the Affordable Care Act.

If you’re interested in obesity prevention and want to get directly involved in advocating at the local level, send Jennifer an email at janderson@metrodoctors. com. American Cancer Society Partnership TCMS will be working with the American Cancer Society on a public awareness campaign on the dangers of tanning and tanning beds. TCMS has had a long-standing relationship with ACS in large part because of the smoke-free movement that both organizations spent considerable time and effort advocating for. Watch for more details of this partnership in our online newsletter. Foundation News

Senator Sean Nienow and Senator Michelle Benson.

Dean of the Medical School Aaron Friedman, M.D. spoke to the Senior Physicians Association at its July meeting. Dr. Friedman provided an insightful view of what’s going on at the medical school and received a lot of questions from the audience. Eagan First to Pass Healthy Eating Active Living Resolution….Away We Go! Now that the city of Eagan has approved the first Healthy Eating Active Living resolution, project coordinator Jennifer Anderson is setting her sights on other locations across the metro. It is Jennifer’s plan to have six additional cities adopt a similar resolution by the end of 2012.

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The East Metro Medical Society Foundation and West Metro Medical Foundation have philanthropy on their minds! We have been spending time over the past year or so working to build development programs for both foundations. We have hired a consultant, Andrea Carlson Nelson, to assist us in this process and she has been working with both foundations by conducting interviews and soliciting input from TCMS members from the East Metro and West Metro. You will see a more concerted philanthropic effort from our foundations in the coming months. Honoring Choices Minnesota’s 3rd annual Sharing the Experience Conference was held on Thursday, July 19. Over 80 people attended the event. Dr. Craig Bowron provided the keynote address and focused his presentation on stories about end-of-life care experiences with patients and families. Members of the media also attended the event as well as a myriad of community members. This was by far the most inspiring

The Journal of the Twin Cities Medical Society

Sharing the Experience event. (See related article on page 29.) Kris Stevens has joined TCMS as an intern working solely on the Honoring Choices Minnesota initiative. This internship will last until the end of the year and fulfills an educational curriculum requirement for Kris. She has been an invaluable asset to the Honoring Choices Minnesota team and we are keeping her very busy. If you know of others who would be interested in volunteering their time to the Honoring Choices Minnesota initiative, please contact us at tcms@metrodoctors.com. Stefan Pomrenke, M.D., MPH, MATS has joined the Honoring Choices Minnesota initiative working as a part-time associate medical director for the faithbased outreach work unfolding with our partners from the Minnesota Council of Churches.

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

September/October 2012

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Medicalfor Caring Care ourOrganizations Elderly

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

T

he Academic Health Center (AHC) at the University of Minnesota takes great pride in its composition, bringing together the colleges of medicine, public health, nursing, pharmacy, veterinary medicine and dentistry for collaborative education and training. It is noted as one of the most comprehensive academic health centers in the nation. But, are you aware that geriatrics, as a specialty, has no clinical presence at the AHC? There is no clinical geriatrics practice at the AHC. There is no geriatrics assessment clinic. There is no geriatrics consult service or inpatient unit. There is no division of geriatrics in the medicine department at the U of M Medical School. There is no fellowship in geriatrics at the AHC. In addition, Fairview, the partner with UMP at the AHC and owner of the hospital, does not offer geriatrics assessment or primary geriatrics clinics and has no geriatrics inpatient unit or consult service at any of their hospitals. They do have a successful geriatric nurse practitioner based program for on-site care in nursing homes and assisted living. A little history. Geriatrics as a specialty in the U.S. started in the 70s but didn’t really spread through U.S. medical schools and practice until the 1980s. In contrast, the UK has recognized geriatrics as a distinct and important specialty since the 1950s and now is the most numerous of the internal medicine specialties in the UK. Locally, in the mid 70s, the AHC and the medical school at the U had some energy around geriatrics as a specialty and for a while it flourished, mainly through the department of family medicine with its research and fellowship program and through the clinical and teaching By Ken Kephart, M.D.

8

September/October 2012

programs at Ramsey and the VA in internal medicine. The department of psychiatry, in collaboration with the VA, developed a fellowship in geriatric psychiatry. The school of nursing developed their geriatric nurse practitioner program, and the school of pharmacy developed a geriatric pharmacology program. Compared to other AHCs at the time, we were competitive except for one thing — we lacked a division of geriatrics in our medicine department. Without that crucial support the geriatric activities in the medical school withered away. Now our AHC is an anomaly among other similarly sized and ranked AHCs in the U.S. with no division of geriatrics and no clinical geriatrics. What are the Effects of this Omission?

First and most immediate is the effect on clinical care when complex elderly patients go for care at the AHC. In the outpatient area there is no geriatrics assessment clinic and no primary care geriatrics clinic. This means outpatient

assessment and care is split out by a disease or organ based specialty. A typical complex geriatric patient has five or more chronic diseases and 10 or more medications. Patients go from one specialty clinic to another all trying to do their best but without a geriatrics quarterback there is some duplication of testing, frequent adverse drug interactions and frustration among patients, families and clinicians about the lack of a patient-centered prioritized care plan based on the patient’s goals of care. This splintering of care and lack of focus on the patient’s goals of care also leads to underutilizing palliative care and avoidance in discussing advance care plans. In the inpatient setting it can be even more dangerous. As geriatric patients enter the hospital for procedures and acute illness the care is again divided among several disease or procedural based specialists. They usually do have a hospitalist to help quarterback their care but few hospitalists have more than a few weeks experience in residency and only a few days education in medical school in specific geriatrics training. One commonly accepted approach in good geriatrics care in the hospital is to use this time to aggressively stop most oral medications and only very selectively restart a few old ones and add new ones if necessary for a new or worsening condition. What I see frequently is new medicine being added with each admission and then all of the original outpatient medications also restarted. It is not uncommon to see these patients in the post acute setting with 20 or more medications and the patient getting increasingly adversely affected with this potentially toxic load of medications. The second area of concern is in medical student and resident interest in geriatrics as a career choice. Without any modeling of the specialty on campus at the AHC it makes the

MetroDoctors

The Journal of the Twin Cities Medical Society


The decision to commit resources in clinical care, teaching and research in geriatrics has to come from one’s basic value that it is the right thing to do for the current and future care of patients. geriatric specialty requirements are: Completing a one year fellowship [two years if doing research] accredited through the ACGME, like all other accredited fellowships. This is after completing a three-year residency in family medicine or internal medicine. There is a dire shortage of academic geriatricians available for teaching medical students, residents and physicians out in practice. Because of this shortage many leaders in geriatrics feel the main role of geriatrics in the future will be primarily in teaching and research with the clinical care being consult based for the very complex frail elderly. There will not be enough trained geriatricians to do primary care geriatrics [like pediatrics]. The pay issue is one of the barriers to attracting students into geriatrics. Unlike most fellowship trained specialties the pay is at or usually less than the pay in the primary specialty, in this case family medicine or internal medicine. Data compiled by the American Geriatrics Society show that older adults with four or more chronic conditions account for 80 percent of all Medicare spending. Older adults account for 26 percent of all physician office visits, 35 percent of all hospital stays, 34 percent of all prescriptions and 38 percent of all MetroDoctors

emergency medical services. But there is no clinical geriatrics at the U of M AHC. There is an acute and growing shortage of geriatricians with the number of board certified geriatricians actually dropping compared to a decade ago. If you combine that with the demographics of the 75 plus being one of the fastest growing populations in the next decade you get some really scary numbers. Current projections put one geriatrician per 3,800 older Americans by 2030. Contrast this to pediatrics where there is one pediatrician per 1,300 Americans under age 18. At our AHC there are three geriatricians and 182 pediatric providers listed on their website. Continuing the comparison to pediatrics in Minnesota, there are 38 residency slots in pediatrics per year — 24 at the U of M and 14 at Mayo. In geriatrics there are four fellowship spots — two at HCMC and two at Mayo. A third consequence of no clinical geriatrics program and no academic department or division has been the loss of millions of dollars in grants that have been available over the years to help develop a geriatrics program that would include all three legs of the traditional academic stool — education, research and patient care. Several were applied for over the years but none were funded with the most common reason being “lack of institutional support.” The few academic geriatricians we have had at the University have gone on to other academic centers like John Hopkins, redirected their academic interest to other areas within the medical school or school of public health, or left for private practice or private health care companies.

of nursing, pharmacy, social work and therapy will also be necessary. The first and most immediate step is to establish a clinical presence at the AHC. Teaching and research are important, but without a visible clinical presence can’t be sustained on their own. It is certainly true that there is no procedure, diagnostic or imaging tied specifically to geriatrics that would help support it financially. The decision to commit resources in clinical care, teaching and research in geriatrics has to come from one’s basic value that it is the right thing to do for the current and future care of patients. But isn’t that the point? Isn’t it the right thing to do? Ken Kephart, M.D. is board certified in Family Medicine with CAQs in Geriatric Medicine and Hospice and Palliative Medicine. He has been practicing and teaching in the Twin Cities for 30 years and is a graduate of the University of Minnesota Medical School. He is currently medical director of Senior Services for Fairview Health System and a board member of the Twin Cities Medical Society. The views expressed are his and do not represent Fairview’s position.

Geriatric Orthopaedic Fracture Conference NOVEMBER 29-30, 2012 St. Paul Hotel, St. Paul, MN

Well, What Now?

It is easy to complain but impossible to reverse the past. In this era of scarce resources it will take a collaborative effort of all interested parties to create a viable geriatrics presence at the AHC. There are a group of committed geriatricians in the Twin Cities willing to help. There may be interested partners in the health care systems in the state. What will be needed at the AHC is commitment from the leaders to work with the larger health care community to establish a visible geriatrics presence at the AHC. Crucial to this will be establishing divisions of geriatrics in the departments of Medicine and Family Medicine. In looking at successful programs around the country they are all multidisciplinary, so engaging the schools

The Journal of the Twin Cities Medical Society

“Redux” (oil and canvas) by Donna Krin Korkes, P.O. Box 853, Morristown, NJ 07963, www.medartposters.com

already difficult task of interesting students in this specialty much worse. The medical school might argue that they have improved their geriatrics curriculum recently. Its current required experience is four afternoons of observation in nursing homes or hospice and two two-hour lectures in their first two years and NO required geriatrics in their 3rd and 4th years. This is followed by residency training that may include a few weeks of required geriatrics training in a three-year primary care residency. Current

Early Registration Discount until Nov. 1! Course Director - Dr. Julie Switzer Keynote Speakers Dr. Stephen Kates & Dr. Daniel Mendelson University of Rochester - New York

www.cme.umn.edu/geriatric

September/October 2012

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Medicalfor Caring Care ourOrganizations Elderly

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

J

ames T. Pacala, M.D., MS is the associate head, Department of Family Medicine and Community Health at the University of Minnesota, and is an associate professor with tenure. Dr. Pacala matriculated from the University of Rochester School of Medicine and Dentistry, receiving his medical doctor degree and a master’s of science from Brown University (gerontology and chronic disease epidemiology). He completed his residency at the Department of Family Medicine and Practice at the University of Wisconsin, Madison; followed by fellowships in geriatrics, Traveler’s Center on Aging, University of Connecticut School of Medicine, and Health Services Research in Gerontology/Geriatrics, Center for Gerontology and Health Care Research, Brown Institute. Dr. Pacala is board certified in family medicine with added qualifications in geriatrics. He is president-elect of the American Geriatrics Society.

Are there preventive measures that should be utilized routinely in the elderly? Preventive activities should be tailored individually according to medical and functional status: s Healthy older adults should receive the same preventive measures as younger people. Applying the USPSTF/CDC preventive guidelines are an appropriate strategy for these patients, and would include activities such as yearly measurement of height and weight, dyslipidemia screening every five years (more often in patients with diabetes or vascular disease), bone mineral density screening at least once in women over 65, mammography every two years for women aged 50-74, and yearly screening for depression. s &OROLDERADULTSWITHestablished chronic illnesses such as coronary disease or diabetes, many of the USPSTF/CDC recommendations also still apply, but the clinical priority should be on preventing further adverse manifestations of the patients’ chronic diseases by treating them as optimally as possible. s Frail older adults with multiple advanced chronic conditions should work with their doctors to prevent or address what are referred to as geriatric syndromes — conditions such as functional decline, immobility, delirium, falls, incontinence, and adverse drug events. Recommended preventive activities would include inquiring frail adults and their caregivers about falls in the previous year, vitamin D supplementation for those who are at increased risk of falls, inquiring about loss of urine > 5 times in the previous year, screening for gait disorders by having the patient perform a semi-tandem 10

September/October 2012

stand and the Get-Up-And-Go test (see Arch Phys Med Rehabil. 1986;67:387-389), having a low threshold of suspicion for mental status testing to detect cognitive impairment, and regular measurement of functional status. Immunizations and some form of exercise are preventive measures that are appropriate for virtually all older adults. Other types of preventive activities are not indicated in older adults. For example, according to the USPSTF, pap smears are not indicated in women over 65 who have had previously adequate screening, and prostate cancer screening with PSA measurement is not recommended in men regardless of age, with data being particularly supportive against screening in men over 75.

Is there a point when a physician should stop providing preventive care services to the geriatric population? One has to consider two factors: the life expectancy of the patient and the time delay between the preventive activity and when it results in a payoff of improved function or longer life. Certain types of preventive activities (e.g. aspirin after an MI) have an immediate preventive effect, while others, most notably cancer screening, have a significant time lag until the preventive benefit is realized. In the case of most cancer screenings, it takes at least five years for a patient to benefit from early detection and treatment. Older adults with a life expectancy of five years or less should not be screened for most cancers. MetroDoctors

The Journal of the Twin Cities Medical Society


Polypharmacy in the geriatric population is a major issue in caring for the elderly as we assess the balancing act between risk and effectiveness in medication use. What is the responsibility of practicing physicians (in counseling toward appropriate and efficacious utilization) when patients enter their office with a brown paper bag chock-full of pills? As patients age and acquire chronic conditions, the risk of polypharmacy and adverse drug events increases dramatically. Doctors should regularly review ALL medications that their geriatric patients are taking and attempt to discontinue unnecessary medications (or medications that have minimal impact on overall functioning). For more complicated patients who see a number of physicians, it is advisable to have the primary care doctor prescribe all the medications. Consulting pharmacists in geriatric team care have been demonstrated to significantly reduce adverse drug events. The American Geriatrics Society has just published the updated 2012 Beers Criteria For Potentially Inappropriate Medication Use in Older Adults, an outstanding evidence-based reference for minimizing adverse drug events. This reference provides recommendations for avoiding use of selected medications in specified clinical situations due to a high incidence of adverse effects in older adults. Some of the recommendations call for avoiding whole classes of drugs such as benzodiazepenes for insomnia, delirium, or agitation, while other recommendations focus on single medications such as metoclopramide, which is to be avoided except in cases of gastroparesis. The 2012 guidelines contain many new

2012-13 CME Activities

recommendations, such as avoiding the use of sliding scale insulin, which evidence shows can lead to hypoglycemia without improvement in hyperglycemia regardless of clinical setting. The Beers Criteria are available for free at http://www.americangeriatrics.org/health_care_professionals/ clinical_practice/clinical_guidelines_recommendations/2012.

Increasingly we are graduating residents skilled in either inpatient or outpatient care. For those who will become hospitalists, what part of the geriatrics curriculum would you most want them to learn? Have such objectives or competencies been incorporated yet into any hospitalist preparation residency program? If not, what complications might follow? The American Geriatrics Society (AGS), with support from the John A. Hartford Foundation, sponsors the AGS Geriatrics for Specialists Initiative, the goals of which include improving the amount and quality of geriatric education received by medical and surgical residents. Through the initiative, the AGS works with 10 specialty boards and societies to infuse geriatric principles into training and care, similar to what the AGS is doing in additional discussions with the Society for Hospitalist Medicine. The AGS is also working to incorporate geriatric competencies into the new ACGME Next Accreditation System (NAS) for accrediting residency programs. (Continued on page 12)

www.cmecourses.umn.edu

(All courses in the Twin Cities unless noted)

FALL 2012 Pediatric Clinical Hypnosis (NPHTI) September 20-22, 2012 Psychiatry Review & Update October 1-2, 2012 North Central College Health Association Conference - Duluth, MN October 2-4, 2012 Twin Cities Sports Medicine October 5-6, 2012 Maintenance of Certification in Anesthesiology (MOCA) Training October 20, 2012 Internal Medicine Review & Update October 24-26, 2012

Practical Dermatology for Primary Care - Duluth, MN October 26-27, 2012 Emerging Infections in Clinical Practice & Public Health November 16, 2012 Geriatric Orthopaedic Fracture November 29-30, 2012

Cardiac Arrhythmias April 26, 2013 Controversies in Cardiovascular Disease May 4-5, 2013 Global Health Training (weekly modules) May 6-31, 2013

SPRING 2013

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WORLD Symposium Orlando, FL February 13-15, 2013 Lillehei Symposium April 4-5, 2013 Integrated Care Conference April 12, 2013 Chronic Pain April 19, 2013

ONLINE COURSES (CME credit available) www.cme.umn.edu/online

Office of Continuing Medical Education 612-626-7600 or 1-800-776-8636 email: cme@umn.edu

Promoting a lifetime of outstanding professional practice

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September/October 2012

11


Caring for our Elderly Colleague Interview (Continued from page 11)

What is your reaction to recent political rhetoric on the topics of “death panels” and rationing of care? My reaction is disgust. Engaging an older adult in a sensitive discussion of care preferences, including end-of-life treatment, is an important professional duty that respects the patient’s autonomy, individual rights, and humanity.

Proceeds from MPS help to support the operations of TCMS. Please consider our business partners listed below as you look to reduce your operational costs.

Means testing (third party assessments of ability to pay) is now in use in Medicare and likely to be expanded as a method to reduce and apportion its costs. What do you see as the positive and negative consequences for the elderly from Medicare means testing on care access and quality? The positive consequence is that it helps in a small way to improve the financial solvency of the Medicare program. Although it has the potential to motivate seniors not to enroll in Parts B and D (which are subject to means testing), I am not aware that this has been the case. In the case of Part B, only about 5 percent of Medicare enrollees (i.e. those with the highest incomes) have to pay higher monthly premiums than the standard premium, which is currently about $100/month.

Medicaid eligibility is by definition means tested and often also related to demonstrated disability. Do elderly Medicaid enrollees “graduate” to Medicare when they reach the age of eligibility? Are there dual enrollees in Medicaid and Medicare among the elderly population? Yes, these individuals have both Medicare and Medicaid status and are known as “dually eligibles.” Out of about 48 million Medicare enrollees in the U.S., about 9 million are dually eligibles.

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Currently Medicare is funded as a Social Security entitlement with both fee-for-service and managed care options. Do we know how health care outcomes compare between (managed care) capitation and pay-for-service enrollees? Is there evidence that competition among insurance providers will/can reduce Medicare costs or improve quality? Beneficial effects when doctors or clinics compete for patient loyalty? What is the evidence from Medicare Part D regarding controlling drug costs and ensuring access to medications? I am less familiar with more recent studies, but on the whole I believe the research shows that health outcomes between capitated and fee-forservice models are comparable (e.g. see comparison studies Health Serv Res 2003 Aug;38(4):1065-79, JAMA 1997 Jul 9;278(2):119-24, and Eff Clin Pract 2000 Sep-Oct;3(5):229-39 measuring outcomes of acute MI, stroke, and hip fracture respectively). There is some evidence that competition can improve quality. For example, public reporting of quality measures as is done with the Minnesota Community Measurement MetroDoctors

The Journal of the Twin Cities Medical Society


program has motivated clinics and systems to improve care. Competition among providers of capitated models, such as was the case in the HMO heyday of the late 1980s and early 1990s, was successful at controlling overall health care costs. But a backlash against HMOs has resulted in a resumption of spiraling costs since then. For older adults, the Medicare Advantage program (which creates competition between private insurance plans with prepaid Medicare contracts) has not yet realized its potential to control costs. Overall, Part D has significantly increased access to medications and lowered out-of-pocket drug expenditures, helping millions of Medicare enrollees. But the prices of drugs for the Medicare Part D program are much higher than for Medicaid, due to the fact that the former are negotiated with private health plans while the latter are negotiated with the government.

Allowable Medicare payments for outpatient psychiatric services, for example, are now so low that psychiatrists in independent medical practices cannot afford to remain in the Medicare program as providers. Your recommendations to address this situation? Opinions on the wisdom or likely success of the AMA campaign to eliminate the Medicare Sustainable Growth Rate (SGR) physician payment formula? Alternatives? The situation with psychiatric services is an extreme example of a larger problem: lowering reimbursement pressures physicians to opt out of Medicare, threatening access for patients to desperately needed services. I see no difference between mental health services and other types of medical care, and they should be compensated similarly. Eventually, we — doctors and the rest of society — are going to have to come to grips with the detrimental aspects of fee-for-service care and its propensity to create overservice waste and spiraling costs. Most lawmakers I know recognize that the SGR formula is broken and needs to be fixed. Having the political will, however, to fundamentally change the system, including addressing the limitations of fee-for-service care, is another thing.

Presently physicians cannot, by law, bill Medicare patients more than the government will allow. Nor can a patient receive direct government payment if s/he receives services from a Medicare “non-provider.” Should U.S. law be changed to allow physicians to bill Medicare patients the difference between their fees and what the government will allow, i.e. enact a private contracting option as recommended by the AMA? Or, should the government require doctors to treat Medicaid or Medicare patients as a necessary condition of state licensure as has been proposed in Massachusetts? Personally I disagree with the idea of a private contracting option. While the Medicare program has its share of warts, it is difficult to dispute that it has been astoundingly successful in providing older adults with affordable access to care. I would be in favor of policy reforms that would provide further access to Medicaid and Medicare services, as long as those reforms addressed adequate compensation for appropriately administered medical services. MetroDoctors

The Journal of the Twin Cities Medical Society

Tell us about funding physician services in long-term care facilities. Problems? Pilot programs? Recommended solutions? The problems are similar to other types of Medicare services: discounted fee-for-service reimbursement that devalues evaluation and management (E&M) codes. Mental health services in nursing homes are poorly compensated and in short supply. Possible solutions would involve altering the care and reimbursement structures of long-term care. Care models using teams of advance practice nurses and other non-physicians working in conjunction with a physician have improved quality and reduced hospitalizations and emergency room visits. Comprehensive, prepaid financing models such as PACE (Program of All-Inclusive Care of the Elderly) have demonstrated similar outcomes. For a review of the evidence regarding these and other care models, see: Boult C et al: Successful models of comprehensive care for older adults with chronic conditions: Evidence for the Institute of Medicine’s “Retooling for an Aging America” Report. J Am Geriatr Soc 2009;57:2328-37.

Home-based and patient-centered care is on the rise. Please describe innovative care models and results. How can access to home-based care be improved? There are numerous examples of patient-centered and home-based care models that improve outcomes, prevent complications, save money, and increase patient satisfaction. Examples include the GRACE (Geriatric Resources for Assessment and Care of Elders) model developed at Indiana University, the Independence at Home model that grew out of work at Virginia Commonwealth, and the Hospital at Home model pioneered at Johns Hopkins. All of these models share several common features: team care featuring a geriatrician as the primary care physician working with advance practice nurses and other health care professionals, comprehensive care coordination, and a functionally based or whole-person orientation to care. You might notice that these features are virtually identical to those of another care model — the Patient-Centered Medical Home. SAVE THE DATE “Engaging Patients/Improving Outcomes”

Tuesday, October 2, 2012 Ramada Plaza Minneapolis 6:00 p.m.—Registration/hors d’oeuvres 6:30–7:45 p.m..—Jan Schuerman will lead a discussion on ICSI’s Collaborative Conversation model 7:45–8:30 p.m..—Larry Morrissey M.D., Stillwater Medical Group, Engaging patients from theory to practice to results Cost: Free for MMA/TCMS members; $35 non-members and guests

Register at: http://www.mnmed.org/collaborative Co-sponsored by Minnesota Medical Association and Twin Cities Medical Society

September/October 2012

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Medicalfor Caring Care ourOrganizations Elderly

Boiling Down the Basics of Cognitive Impairment and Alzheimer’s Disease for Family Practitioners As a neurologist in private practice with the Noran Clinic, I see many patients at various stages of dementia. Here are some of the most common questions I hear from my patients, their caregivers, and their family practitioners. What are the Major Risk Factors for Cognitive Impairment?

There are many important risk factors to consider when diagnosing and treating patients with cognitive impairment. Having a full and clear picture of a patient’s medical history will help define the nature of the impairment and may point to possible courses of treatment. It’s important to remember that cognitive impairment does not necessarily mean a diagnosis of Alzheimer’s Disease (AD), as there exist several other causes of dementia which merit additional discussion. Of the many risk factors for cognitive impairment, the most important is age. Dementia specialists often say it is normal for cognitive attributes to slow as part of the aging process, but the important difference is that with “normal” memory issues, desired information may still be recalled, though it may be several hours, or perhaps even the next day, before the desired name or word comes to mind. For a patient with dementia, the process of recollection remains incomplete. Additionally, the discovery of genetic biomarkers Apo lipoprotein E in the allelic form E4 has been linked to earlier and more aggressive AD. Patients who have one E4 gene have two to three times the risk of those without the E4 allele, and those with two E4 genes (homozygous) have a 13-20 fold risk. Having an E4

pattern does not, however, mandate a course of memory decline, but rather, it seems as though E4, in a manner similar to high cholesterol in heart disease, serves as a warning for increased risk. There are still other factors associated with increased risk of cognitive impairment. Lower levels of educational attainment as well as a previous history of head injury (with or without loss of consciousness) are markers for increased risk. Therefore taking note of recent or remote head trauma should be a part of the pertinent history taken by medical professionals. Vascular risk factors including hypertension, hypercholesterolemia, smoking, lack of exercise, as well as hyperglycemic states also increase the risk of dementia.

s

s

s

What Symptoms Should Make Us Suspicious of Dementia?

1.

2.

3.

4.

Does the patient’s cognitive impairment interfere with their ability to function at work or during his/her usual activities? Does the patient’s cognitive impairment represent a clear decline from previous levels of functioning? Can the patient’s cognitive impairment be explained by another factor (i.e. delirium or major psychiatric disorder)? Are at least two of the following domains impaired? s The ability to acquire and remember new information. (Does the patient engage in repetitive questions or conversations, misplace personal belongings, forget events or appointments, or get lost on familiar roads?)

s

The ability to reason. (Does the patient demonstrate impaired reasoning or poor judgment, inability to handle complex tasks, exhibit poor understanding of safety risks, seem unable to manage finances or to plan complex sequential activities?) The ability to discern/make use of visual stimuli. (Does the patient have impaired visual spatial abilities, inability to recognize faces or common objects, inability to sight objects despite good visual acuity, or inability to use simple implements or have problems getting dressed?) The ability to use language. (Does the patient have trouble speaking, reading or writing, suffer from the inability to find the right word, hesitate while speaking, or have problems spelling or errors in writing?) The ability to be socially active. (Does the patient exhibit personality and/or behavior changes, demonstrate decreased interest in previously pursued hobbies, show a loss of inner drive and motivation, appear apathetic or exhibit a loss of empathy?)

By Richard Golden, M.D.

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If more than two of the above bring a yes, then suspicions of Dementia is heightened. How Useful are the Cholinesterase Inhibitors and Glutamate Modulating Medications in Treatment of Dementia?

Many physicians mistakenly believe cholinesterase inhibitors and glutamate modulating medications only work for very short durations and should be discontinued after a few months to a few years time. However, studies have shown that cholinesterase inhibitors increase the amount of acetylcholine in the brain and are effective throughout the entire course of illness. The clear changes in behavior, cognition and the ability to function which these drugs afford are clinically significant throughout the course of the illness. Unfortunately, as the disease worsens, an observer may find it harder to quantify the benefit. But the question that needs to be asked by the practitioner, patient and family members is, “How much worse would the patient be if they weren’t taking these drugs?” That said, there are still no hard and fast rules on how long someone should use cholinesterase inhibitors. While it might seem like a simple idea to stop and “test” the benefit, there are some risks involved. Discontinuation has been associated with worsening of symptoms, and restarting the medications may not bring the patient back to the previous level of function. For this reason any decision to discontinue cholinesterase inhibitors should be carefully considered. Glutamate modifying medication should be considered when there is rapid deterioration. It is also helpful in patients who have developed behavioral symptoms related to agitation or aggression. For these reasons, this type of drug is generally used in the mid-to-later stages of the disease. Cholinesterase inhibitors and glutamate modifiers can be used in combination with one another and both classes of drugs are relatively well tolerated in patients. Having said that, interactions with other medications are

(Continued on page 16) MetroDoctors

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Medicalfor Caring Care ourOrganizations Elderly Boiling Down the Basics (Continued from page 15)

possible, and side effects exist, so it is important to clarify all medications for possible interactions. Finally, with the changes in medical coverage some insurance plans will, unfortunately, make the decision financially. Time will tell how guidelines for coverage will develop, and it is important to note that neither class of drugs produce a slowing in the progression of disease, they are simply the most effective at helping patients live with its symptoms. Is There Anything Promising on the Horizon For a Cure?

Nothing appears to be the cure yet. Slowing progression of the disease process — i.e. Amyloid protein and other depositions which may play a role — using intravenous immunoglobulin, seems to come the closest so far. The Driving Question

As many of you know, most clinicians would rather have a colonoscopy prep than discuss patients’ driving privileges. Unfortunately, though, there comes a time when a patient’s driving abilities must be discussed. This becomes more urgent when a patient’s cognitive abilities are impaired. The Academy of Neurology has put forward a set of guidelines, which, although far from perfect, are at least an attempt to bring some sanity and reason to this topic. There are some signs that prove particularly important when assessing a patient’s ability or declining ability to drive safely. The obvious indications for considering a revocation of privileges include accidents and tickets (for speeding or reckless driving). The presence of either aforementioned indication signals it might be a good idea to further assess a patient’s driving skill. Aggressive or impulsive behaviors are another issue — especially in someone who has not had those tendencies prior to changes in their cognitive ability. Sometimes individuals “restrict” their own driving even before their loved ones or physicians do — by refusing to drive in certain circumstances (during rain or after nightfall). This indicates the patient senses the loss of some abilities and fears their driving would endanger themselves or others. 16

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There is strong evidence that people with dementia who report they “can drive just fine” pose a greater risk than those who are aware of their shortcomings. In the case of the former, their dementia simply doesn’t allow them to realistically judge their abilities, so caregivers and family must help identify the issues. Keeping track of stories where the patient got lost or “lost the car” in the parking lot will help families make their case in a more formidable but less emotional manner. Sometimes it is actually harder for families to let go of the idea of their loved one’s independence and self sufficiency — that is until they step back and take an objective look at the situation, or once they are forced to answer pressing questions like, “Would you let your children ride with the patient?” Suddenly the gravity of the situation is presented in a different light and their true feelings come forward. As a Practitioner, What is My Role With Regard to the Caregiver? Do I Need To Counsel or Consider Their Needs?

I simply cannot say this more plainly. Without a doubt, no medical intervention is as important to the successful treatment of the patient as helping caregivers coexist with this disease. When caregivers are not part of the treatment planning, the grind of providing care makes them five times more likely to experience significant depression, and their risk of suffering major medical problems of their own goes up nearly six-fold. If as a result of a caregiver’s decline in health, or for any other reason, he or she is no longer able to provide care, this absence causes the degree of difficulty in managing the patient to rise dramatically. Five to ten minutes spent one-on-one with the primary caregiver on whatever is topmost on their list, telling them something you read in a recent journal article that might help them, or giving them tips on behavior modification may seem simple to us as physicians, but those minutes can mean the world to the person taking care of our patient. There is no end to the topics you can research to help aid your patient’s caregivers (the use of light and quiet music, touch or massage therapy, how to communicate with people suffering cognitive impairment, how to relieve their own stress

and anxiety so they don’t lose their patience, the list goes on). What is most important is that the caregiver sees you as their partner in the care of their loved one. Spending just a few minutes to make sure they realize you truly are seems like a small price to pay. At a certain stage in the disease there will be hard questions to discuss. Things like, “Is it still safe for my loved one to be home alone?” It is at these moments when true assessment of the capabilities of both patient and caregiver will need to be evaluated, and you will be glad for the time spent building a trusting and cooperative relationship with your patient’s caregivers. Our practice also uses allied health professionals to direct people toward resource outlets, both non-profit and for profit. Making the arduous journey with a patient and their caregivers through the course of cognitive impairment can be a challenging responsibility. Insightful identification of risk factors and symptoms, partnered with medication that may help symptomatically, as well as the development of an understanding and supportive relationship with the patient and caregiver will enable the patient and his or her family to maximally enjoy their time together and will help the patient live graciously and meaningfully. Conclusion

This disease is so disabling on several levels that its complexity may cripple our ability to respond adequately if the current trends continue. Medications and care organizations can and will be of great help, but certainly will not be the total answer. Society’s response to the HIV epidemic, which was multidimensional, e.g. pharmaceutical, governmental, spiritual and — in my humble opinion — well-funded, provides a framework to use. The question is — can we be just as successful in this type of dementia affecting our senior population? Richard Golden, M.D. has been a practicing neurologist at Noran Clinic since 1985, with a special interest in neurodegenerative disorders. He currently serves as the director of the Memory Disorder Clinic at Abbott Northwestern Hospital and is a former board member of the Alzheimer’s Association.

MetroDoctors

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Baby Boomers Reckoning on Medicare

H

ealth economists and demographers have been concerned about the wave of baby boomers hitting the “Shore of Medicare” and Social Security for decades. What is the primary concern? Impending program bankruptcy that imperils the U.S. economy is the issue. To understand why that is possible, it’s important to understand what Medicare is. The program was created by law in 1966 to be financed by the taxing powers of Congress. The federal government would then administer this program that functions as a multi-generational insurance contract. It was designed so that people younger than age 65 pay a share of their federal taxes into the program and expect a health insurance program when they reach the age of 65. The baby boom population is a unique demographic bubble where the fertility rates in the United States, immediately after World War II from 1946 until 1964, were significantly higher than normal. The first baby boomer to become a Medicare recipient was in 2011. The last baby boomer will enter Medicare in 2029. Before 2020, Medicare’s program payments will be greater than the amount collected by Medicare taxes, at which point the program will be financed by taking on more U.S. debt. This is the driving concern of fiscally conservative economists who believe that additional debt on a massive scale is acceptable for infrastructure or national defense but not long-term social assistance programs. It is important to clarify Medicare’s fiscal revenues and obligations. Currently, Medicare operates as two separate trust fund accounts held by the U.S. Treasury. These funds can only be used for Medicare. The first is the

By Stephen T. Parente, Ph.D.

MetroDoctors

Hospital Insurance (HI) Trust Fund that pays for Part A services such as inpatient hospital care, skilled nursing facility care, home health care (some), and hospice care. The second is the Supplementary Medical Insurance (SMI) Trust Fund which pays for Part B benefits, such as doctor services, outpatient hospital care, home health care not covered under Part A, durable medical equipment, and Medicare Part D prescription drug benefits. Medicare Advantage health plans are financed by a joint allocation of HI and SMI funds. The HI Trust Fund is financed by payroll taxes and the SMI Trust Fund is financed by funds authorized by Congress and premiums from people enrolled in Part B and Part D as well as interest earned on the trust fund investments. If over time payroll taxes for HI and general taxes for SMI are insufficient, Congress can deficit finance the program. As of April 2012, the HI and SMI Trustees Report1 projects that HI tax income and other dedicated revenues will fall short of HI expenditures in all future years under current law. Furthermore, they find “The HI Trust

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Fund does not meet either the Trustees’ test of short-range financial adequacy or their test of long-range close actuarial balance.” However, they find the Part B and Part D accounts in the SMI trust fund are adequately financed under current law, since premium and general revenue income are reset each year to match expected costs. This will remain the case as long as the additional tax revenue required does not adversely affect the long-term growth rate of the U.S. economy. The Medicare program today is unlike the one in 1990 and will also be unlike the one offered in 2022. In 1990, less than 5 percent of the Medicare population was in a Medicare Managed Care plan or HMO and there was no prescription drug coverage. Today, the Medicare program has prescription drug coverage and over 20 percent of the beneficiaries are in Medicare Managed Care. By 2022, many expect Medicare Managed Care to have well over half the program participants and perhaps have as many as 80 percent of the population in managed care. From the viewpoint of a health economist, the demand of the population will likely be determined by expected benefits. Culturally the baby boom population is quite different from the World War II generation and the millennial population born in 1990s. For example, World War II generation patients generally took direction from physicians without question. Baby boom generation patients looked to have physicians be co-equal members of their treatment team. Millennial patients would want to use social networking and the internet to customize their solution and then direct their care team if possible. The baby boom population may actually be best seen as two cohorts: the early and the (Continued on page 18)

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Medicalfor Caring Care ourOrganizations Elderly Baby Boomer’s Reckoning on Medicare (Continued from page 17)

late boomers with break point being the late 1950s. The early boomers grew up in a postwar America where the economy soared and trust in technology and government were high because both were seen as critical to winning World War II as well as enabling a giant export boom. This early boomer population grew up in a world where their parents had full benefits and growing salaries. This is likely to affect the expectation of what the Medicare program should provide to them as they enter it. The most prominent representative of this cohort coming of age is President Bill Clinton. The late boomers into the Generation-X population, born between 1965 and 1980, entered into a more cynical world with the Vietnam War in full swing, the assassinations of the Kennedy’s and Martin Luther King Jr. as well as the Watergate scandal. Technology was less valued since it brought the world to the brink of a nuclear exchange with the Cuban Missile crisis. The expectations of this population are likely to be more measured and even cynical because they grew up with parents who were

more likely to be ravaged by recessions in the 1970s as well as a federal government that was clearly seen to betray the trust of the public. It is likely that this cohort will look to the Medicare program as something less likely to be available to them. This group would more likely prefer a voucher to supplement their own contribution to make sure they have adequate medical care in 2023 to 2026 when they start entering the program. This may be why Rep. Paul Ryan’s (WI-R) proposal to have Medicare become a voucher program in 2024 with outlays matched to projected HI and SMI long-term revenues and expenses may be more politically tractable than many people think. The most prominent representative of this cohort is President Barack Obama. The central factor driving cost increases is the increasing longevity of the U.S. population. When the Social Security program was created in 1936, approximately 10 percent of the population was likely to live to 65. Today, the expectation is that well over 60 percent of the population will live past the age of 80. Furthermore, the costs associated with end of life, when palliative care is still in its infancy for

cultural acceptance, will likely lead the nation to still prefer care to generate a cure into age 80 than accepting one’s age and physiological limitations. Another concern is the expectation that the use of technology to enhance mobility through orthopedics may be a large cost driver for baby boomers who are fine tuning limbs and mobility under the Medicare program. From a standard of care perspective, this is fine. From an actuarial perspective, it is a set of unexpected benefits to be paid by the program that either needs more tax receipts to pay in ahead of time or more cost sharing from current beneficiaries to make sure the Medicare program does not reach a point of bankruptcy. If bankruptcy did occur, it would most simply be an exhaustion of benefits paid by the trust funds and reduction in program staff from sudden or gradual shutdown of Medicare. While it is impossible to predict the future with any clarity, it’s almost certain that the baby boom population will experience a Medicare transformation. The question is not if, but when. If changes take place for the early cohort of boomers, they will be very apprehensive because of their expectation of generous benefits accorded to them throughout their lives. Certainly this has been the case for higher education prices as well as home prices from 1970 to 1985 when the early boomer cohorts came of age to economically thrive as adults and professionals. If it changes for the late cohort of the boomers, their expectations have already been tempered, throughout life, to lower their expectations. Thus, the Medicare program may pivot to a Ryan-like voucher program to achieve better long-term sustainability that emphasizes greater personal beneficiary responsibility to achieve long-term health. Stephen T. Parente, Ph.D. is Professor of Finance, Minnesota Insurance Industry Chair of Health Finance, and Director of the Medical Industry Leadership Institute in Carlson School of Management at the University of Minnesota. He was a senior health adviser to Senator John McCain (R-AZ) in the 2008 Presidential election and a legislative fellow for Senator John D. Rockefeller (D-WV). Notes: 1. To examine the Medicare Trustees report for 2012, see: http://www.cms.gov/Research-Statistics-Dataand-Systems/Statistics-Trends-and-Reports/Reports TrustFunds/Downloads/TR2012.pdf.

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The Role of the Long-Term Care Medical Director A Little History

The history of medical direction dates back to 1970 when a Salmonella outbreak caused the deaths of 36 nursing home residents in a Baltimore nursing home.1 This led to increased federal scrutiny of substandard nursing homes. The AMA became involved and lobbied for the requirement for medical direction at all long-term care (LTC) facilities. In 1974 the federal regulations included medical direction as a condition of participation. A 1984 revision of the nursing home regulations threatened to leave out the medical direction requirement, but this time many other organizations (AMA, American Geriatrics Society, the new American Medical Directors Association (AMDA) and others) weighed in and the position was subsequently retained. Dr. James Pattee and Dr. Thomas Altemeier, here in Minnesota, researched the role of the medical director (the results of which were used in a book authored by Drs. Pattee and O. J. Otteson2) and began teaching a nine day course for medical directors that became the impetus for the Certified Medical Director program through AMDA. I was privileged to take this life-changing course here in Minneapolis in the early 1990s. The IOM 2001 report, Improving the Quality of Long Term Care, recommended, “One approach to improving the quality of nursing home care would be for facilities to vest greater authority and responsibility in medical directors for medical care services and require attending physicians and nurse practitioners to follow facility medical policies and procedures.”3 In By John W. Mielke, M.D., CMD

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November 2005 CMS updated the expectations of medical directors in the F501 portion of the “interpretative guidelines.” This document can be accessed by searching the AMDA website for f501 or at the CMS website.4 It should be clear from the historical perspective that the medical director role is to assure quality of medical care in nursing homes. It should also be clear that the historical quality of care has been inadequate at times, even abusive and negligent. The medical director is therefore viewed as an essential component in preventing abuse, neglect, and substandard quality of care. How is this best accomplished? The Definitive Document

“The Nursing Home Medical Director: Leader And Manager” I encourage you to access this document at the following website: http:// wwwlivepage.apple.com.amda.com/governance/whitepapers/A11.cfm. Four Main Roles, Nine Essential Functions

The AMDA white paper identifies four main roles for the medical director: s 2OLE — Physician Leadership The medical director serves as the physician responsible for the overall care and clinical practice carried out at the facility. s 2OLE  — Patient Care-Clinical Leadership The medical director applies clinical and administrative skills to guide the facility in providing care. s 2OLE — Quality of Care The medical director helps the facility develop and manage both quality

The Journal of the Twin Cities Medical Society

s

and safety initiatives, including risk management. 2OLEˆ%DUCATION )NFORMATION and Communication The medical director provides information that helps others (including facility staff, practitioners, and those in the community) understand and provide care.

The nine essential functions inherent in these roles are: s &UNCTION — Administrative s &UNCTION — Professional Services s &UNCTION — Quality Assurance and Performance Improvement s &UNCTION — Education s &UNCTION — Employee Health (Continued on page 20)

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Caring for our Elderly

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Long-Term Care Medical Director (Continued from page 19)

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&UNCTION — Community &UNCTION — Rights of Individuals &UNCTION — Social, Regulatory, Political, and Economic Factors s &UNCTION — Person-Directed Care The article further lists tasks under each function, dividing them into essential and optional categories. This list can be overwhelming and discouraging. I can tell you at a practical level it is impossible to accomplish all these tasks. So the following is an attempt to make these high level goals possible at a practical level. At a Practical Level

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It is important to consider each of the functions with every visit to the facility. How am I functioning as a physician leader, overseeing physician services, providing quality review and education to the staff? Many of these functions can be combined into your routine visits, if we are mindful of these roles. Become part of the leadership team: Visit with the administrator and Director of Nursing (DON) at least monthly. Find out about strategic planning. Ask to be included in decision-making, especially clinical decisions such as radiology providers, dental services, new service lines. Discovering decisions after the fact means you are not considered part of the leadership team, and this severely limits your effectiveness. Round on each nursing unit regularly: There is nothing more important than hearing from the front-line staff. Peters and Waterman5 described this as “Management by Walking Around� in their 1982 bestseller, In Search of Excellence. This MBWA activity can accomplish all four roles. You gain informal leadership by showing interest and solving problems for front-line staff. You hear about provider-nurse interactions, patterns of care, and concerns about medical care issues. Use your senses: smell, hearing, sight to discover quality care problems. Are there urine odors, too many pages/alarms/loud talking, poor quality interactions between staff and residents? And, look for excellence and MetroDoctors

The Journal of the Twin Cities Medical Society


reward it with an immediate, “you’re doing a great job here!” When issues come up, use the time to educate staff. Quality Committee engagement: The traditional role of eating donuts, drinking coffee and signing our name countless times to unread documents is gone. If QA meetings are boring, change them. They must be relevant to our goals as medical directors. I need an overview of how we compare to state and federal benchmarks. Then we need to identify quality deficiencies to process improvements. The new terminology “Quality Assurance/Process Improvement” (QAPI) emphasizes this pattern. Dr. Sontagg advises us to bring the latest articles and research to these meetings to stimulate quality improvement initiatives. I review late physician visits, INR values, infection control and antibiotic utilization, use of antipsychotics for “dementia behaviors” and other issues at various nursing homes. It is the time for my primary interaction with the consulting pharmacist. The QA meeting is vital to accomplishing all four roles of the medical director. Always, always be available for emergency back-up: Long-term care nursing can be lonely and isolating. It shouldn’t be without a life-line. I tell the nurses at orientation that they should never leave their shift with a bad feeling in the pit of their stomach. They should always call for assistance. Emergency availability is a crucial role for the medical director in assisting with critical patient care decisions. It also stabilizes the work force. They must feel supported and protected. Of course these after hours phone calls can accomplish many of our other goals: quality monitoring, education, and physician services oversight. We are always doing more than one thing as a medical director. (If we can’t be available — establish a credible back-up plan.) Policy and Procedure: The previous suggestions have involved developing informal leadership. Policy and procedures allow for formal authority to be exercised by the medical director. This includes many important medical care policies to be reviewed and revised. In addition, MetroDoctors

admission policies are increasingly critical. Will your facility admit chest tubes, nasogastric tubes, BIPAP for ventilatory insufficiency, or certain behavior challenges? This is a critical area for medical directors to assess the management and nursing skills of the facility and match them with the referrals for admission. It is part of our role to limit admissions that we are not medically capable of managing. Medical provider credentialing falls under this authoritative leadership and should be considered as a means to establish leadership within the medical staff. At one home we have a one page attending physician agreement that establishes a basic code of conduct for practicing physicians in the facility. The medical care committee reviews deviations from this code of conduct and supports my role in overseeing provider care and conduct. Survey and compliance issues need the presence of the medical director. I make every effort to stop and introduce myself to the survey team early during the

The Journal of the Twin Cities Medical Society

annual survey. I specifically ask them to call me for any questions regarding medical care issues. I always review the findings, help investigate questionable tags and attend any “informal dispute resolution” hearings. I frequently add a medical director note to charts when an adverse incident requires investigation and comment. These notes have been invaluable in explaining the steps taken by staff in providing good care, even when the outcome was negative. Unique Needs

Each home has its own unique style and needs. Smaller homes deal with quality at the front desk. It seems that everyone knows all the patients, families and their medical care needs. The administrator likely answers the phone. The small home doesn’t need a data gathering tool, but they do need a wide variety of expertise because they can’t afford a full-time infection control nurse, or wound specialist. So, in a small home the medical director (Continued on page 22)

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Caring for our Elderly

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Long-Term Care Medical Director (Continued from page 21)

needs to supplement the staff limitations. Larger homes have a broader range of staff, but it is harder to see where quality may be breaking down. A more robust quality data approach is needed. There may be more need for provider staff monitoring and intervention/education.

Worried about making rash decisions?

Conclusion

Flexibility is a key attribute of medical direction. While the roles and functions remain stable, the tasks will change based on the need of the organization. It is a rapidly changing landscape. Our facilities and the residents are dependent on our engagement with the medical director role. If we strive to assure the best quality of care for this frail population we will fulfill the roles of the medical director with excellence. John Mielke is an internist/geriatrician who specializes in care of the elderly in nursing and assisted living facilities. He is a certified medical director and past president of the Minnesota Medical Director’s Association. He is the Chief Medical Officer of Presbyterian Homes. In that role he is working with a team of care givers called Optage House Calls, a primary care clinic of Presbyterian Homes. They are a certified Health Care Home intent on delivering patient-centered care in the elder’s home environment.

Since 1949, we’ve been helping physicians and their patients

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

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September/October 2012

Endnotes: 1. Elon, Rebecca D., Medical Direction in Nursing Facilities: New Federal Guidelines accessed on April 30, 2011 at http://www.annalsoflongtermcare.com/ article/4782. 2. Pattee, JJ, Otteson OJ. Medical Direction in the Nursing Home—Principles and Concepts for Physician Administrators. Minneapolis, MN: Northridge Press, 1991. 3. IOM report accessed on April 30, 2011 at http://www. nap.edu/openbook.php?record_id=9611&page=201 4. https://www.cms.gov/transmittals/downloads/ R15SOMA.pdf. 5. Peters, Tom and Waterman, Robert, In Search of Excellence: Lessons from Americas Best Run Companies Harper and Row, New York 1983.

MetroDoctors

The Journal of the Twin Cities Medical Society


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

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ortality is down, morbidity is up. As medical professionals, you are acutely aware that although people are living longer, they often live with chronic, debilitating illness that in the past would have been fatal. The good news is that those illnesses are now manageable; the bad news is, of course, that they often necessitate years of care. Most of us know someone who is receiving long-term care. However, few of us stop to think of the ramifications that a need for extended long-term care would have for either our own family member or a member of our medical office. In this regard, consider the statistics provided in the state of Minnesota’s “Own Your Future” public awareness campaign, which urges state residents to prepare for long-term care: it estimates that at least 30 percent of Minnesota boomers will not have sufficient resources to pay for health and long-term care when they retire. In order to lessen or even eliminate the burden of caregiving imposed on family members caring for their loved ones, many people prefer to hire caregivers. Paid longterm care, whether provided in-home or in a facility, is what long-term care insurance (LTCI) is designed to cover. Without LTCI, the bill for paid caregiving is covered either by the individual, or (needs-based) means-tested government programs such as Medicaid. One of the deficiencies of most government programs is that they do not cover the most desirable care in the setting of your choice. As fiscal pressure rises

on these programs, qualifying has become tougher in many cases. Governments have responded to this new reality with both state and local incentives to purchase LTCI (see shaded box on the next page). This year, the median cost of a private one-bedroom unit at an assisted-living facility in the Minneapolis area is almost $47,000. In 30 years, that cost is projected to be over $200,000, according to Genworth Financial’s 2012 Cost of Care Survey. The cost of home care services can also be daunting; the median annual rate for a home health aide in Minneapolis is

currently $63,492 [44 hrs/week]. Because the possibility of needing long-term care is so very real, it makes sense that, in the same way that we traditionally insure our bodies with life, health and disability insurance, we must plan ahead for the possibility of needing extended care. While long-term care insurance used to be considered a policy purchased at retirement age, that is no longer the case. Partly due to the awareness that illness or injury necessitating long-term care services (Continued on page 24)

By Deb Newman, CLU, ChFC, LTCP

MetroDoctors

The Journal of the Twin Cities Medical Society

September/October 2012

23


Caring for our Elderly

You will be surprised how little it costs to: • Promote Your Professional Image • Build Patient Confidence • Reduce Employee Turnover • Increase Office Efficiency

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Long-Term Care Insurance (Continued from page 23)

can befall anyone at any age, the average issue age has dropped over the years, and is now 57. While most LTCI claims occur in post-retirement years, it makes good sense to include this coverage as part of pre-retirement planning. No one can predict if or when a need for long-term care will arise. If it does, people without coverage are often forced to make the difficult decision of choosing which of their assets to liquidate in order to pay for care. Long-term care insurance is a viable way to avoid being forced into making those tough decisions. You could say it is preventive medicine for your retirement. Long-term care coverage also gives consumers the freedom of choice and control over the care they receive. Whether individuals wish to stay in their own homes, in an assisted living community or other facility, this type of insurance lets the policyholder stay in control, which means more flexibility and better care. Long-term care insurance can be offered in medical groups as an employer-paid benefit, a voluntary employee-paid benefit or a combination of both. Medical groups seek

benefits that offer flexible coverage, discounted rates and reduced underwriting. A properly-designed multi-life long-term care insurance program can offer all these elements to even small offices with as few as three individuals. Additionally, spouses and other qualified family members are eligible for coverage with considerable premium savings under these multi-life programs. There are no requirements that every employee be covered. The tax advantages to a business are tremendous. The premiums of employees and their spouses are 100 percent deductible to the business, cannot be included in an employee’s income and are tax-free when the benefits are received. Additionally, there are no requirements that everyone be covered. This is a great benefit to enhance a retirement plan where the physicians, for example, have already maxed out their contributions. Deb Newman, CLU, ChFC, LTCP, is the founder and president of Richfield-based Newman Long Term Care, focusing solely on long term care planning solutions. For more info, please visit www.newmanlongtermcare.com

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Government Incentives for Long-Term Care Insurance

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The Minnesota Long Term Care Insurance Partnership Program allows people to protect assets that otherwise would need to be spent before qualifying for Medicaid in the event of a prolonged care need that exceeds the limits of their policy. A partnershipqualified policy enables people to protect one dollar of personal assets for every dollar their policy pays out in benefits. Minnesota State Tax Credit Policyholders receive a tax credit for the lesser of 25 percent of premiums paid, or $100, per person/year.

To schedule a consultation, please contact Eric Garten, HealthStyle Services Consultant, at 612-362-0353 or email at eric.garten@ameripride.com 700 Industrial Blvd Minneapolis, MN 55413

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September/October 2012

Health Savings Accounts, or HSAs, can pay for qualified medical expenses tax-free, including tax-qualified long-term care insurance premiums. Federal Tax Deductions* Like traditional major medical insurance, LTCI is tax deductible by businesses. While C-Corporations may take a 100 percent deduction (policies paid for employees, their dependents, spouses and retirees), the deduction available to other entities (and their shareholders) may be limited to an age-based maximum. Employees receive benefits from the policy tax-free. *Refers to the typical tax-qualified, reimbursement policy, as well as almost all other policies.

MetroDoctors

The Journal of the Twin Cities Medical Society


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

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innesota’s aging network is the first place to start when your frail older patients need to connect to local services. The Minnesota Board on Aging — a state agency — oversees a statewide network of Area Agencies on Aging (AAAs) that can be reached easily through the phone, the internet and live chat. The AAAs provide easy access to an array of core social services for older adults and their family caregivers. These services help older adults recover from acute illness, manage chronic conditions and prevent injurious falls and at the same time, help them and their caregivers identify ways to make their homes appropriate for aging well and safely. The aging network’s Senior LinkAge Line® is toll-free and available statewide at (800) 333-2433. Senior LinkAge Line® (SLL) staff have for over a decade helped patients bridge the gap between getting a prescription and paying for it by providing training and support to help connect doctors and patients to the patient assistance programs. The linkage line also provides help with the annual open enrollment period by supporting thousands of callers to select the most appropriate Medicare Part D plan. This assistance is available free of charge to all callers — older adults, family members and providers — including hospitals and clinics. The SLL welcomes calls from hospitals before a patient is discharged in order to begin planning for a successful transition home. The home and community-based services delivered by the aging network are critical to health status following an acute illness and for successful chronic care management. These services are available through networks of publicly subsidized, private and voluntary service providers. Engaging these networks in

a coordinated strategy through a partnership with the Minnesota Board on Aging and Area Agencies on Aging offers great potential to help older adults live well at home. This is particularly true after a hospital stay when assistance at home can make the difference between being readmitted to the hospital or successfully managing at home. These home and community-based services are available to individuals of any income level and most offer a sliding fee scale. The sliding fee scales are based on self-reported income. Services include: s #HRONICDISEASESELF MANAGEMENTTHAT teaches older adults to take action to better manage their chronic conditions. s %VIDENCE BASEDFALLSPREVENTIONINTERVENtions that help older adults address their fall risks and be safe at home.

s

s

s

s

!SSISTANCEWITH-EDICARE0ART$OROTHER prescription drug payment issues, as well as medication management assistance, to help older adults maintain medication compliance at home. (OME DELIVEREDMEALS INCLUDINGSPECIAL diet and ethnic meals, to support adequate nutrition. 4RANSPORTATION SERVICES TO ENSURE THAT older adults are able to follow through on referrals and access community services. (ELPWITHCHORES HOMEMAKERSERVICESAND home modifications to create an accessible and safe environment. (Continued on page 26)

The Senior LinkAge Line® provides easy access to connect to these in-home and community services. The Senior LinkAge Line® is available toll-free across the U.S. on weekdays at 1-800-333-2433. Senior LinkAge Line® is on the internet through live chat with access to 30,000 services statewide at www.MinnesotaHelp.info. When connecting to the Senior LinkAge Line®, clinic staff will link to an expert who: s 5NDERSTANDSWHATPROVIDERSOFFERINTHEPATIENTSCITY s #ANLOCATESERVICESINAPATIENTSNEIGHBORHOOD s 5SESAPERSON CENTEREDAPPROACHTOCREATEAPLANFORUSINGIN HOME supports s ,INKSOVERWHELMEDFAMILYCAREGIVERSWITHRESPITE SUPPORTGROUPSAND caregiver consultants

By Jean K. Wood

MetroDoctors

The Journal of the Twin Cities Medical Society

September/October 2012

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Caring for our Elderly Minnesota Board on Aging (Continued from page 25) Minnesota Epilepsy Group is the largest and most comprehensive epilepsy program in the Midwest. As a regional referral facility, we are the recognized leader in treating epilepsy and other seizure-related conditions in patients of all ages, from infants to the elderly. We also offer comprehensive neuropsychological assessment for a broad range of acquired or developmental neurological conditions in both adult and pediatric patients. Adult Epileptologists Deanna L. Dickens, MD Julie Hanna, MD Patricia E. Penovich, MD Pediatric Epileptologists Jason S. Doescher, MD Michael D. Frost, MD Frank J. Ritter, MD Functional Neuro-Imaging Wenbo Zhang, MD, PhD Neuropsychologists Elizabeth Adams, PhD Robert Doss, PsyD Ann Hempel, PhD Donna Minter, PhD Gail Risse, PhD

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September/October 2012

These home and community-based services are just as important over the long haul as they are immediately following an acute episode to reduce the overall risk of hospitalization and complications when age and chronic disease combine to increase frailty. Family caregivers play a critical role in supporting their loved one at home. Many caregivers offer intense levels of support and, as a result, need help in maintaining their own health. Respite services provide a caregiver with a much needed break. Evidence-based training and education programs, such as Powerful Tools for Caregivers, equip caregivers with the skills that they need to help their loved one manage chronic illnesses. One-on-one caregiver consultation, through the use of an evidence-based assessment process, focuses on the needs of the caregiver and helps the caregiver take action to maintain their own health while fulfilling their caregiving role. These services are especially helpful for caregivers who are supporting a loved one with Alzheimer’s Disease or other dementias. Area Agencies on Aging can assist in convening community providers and participate in planning efforts to develop comprehensive community approaches to care transitions and other efforts that improve outcomes for older adults. The Area Agencies on Aging have a long track record of convening a broad range of public and private partners to address critical issues affecting older adults. The AAAs have facilitated the development of numerous falls coalitions to address the multiple risk factors that lead to a high rate of falls in older adults. Health and community professionals, older adults and family caregivers can learn how they can take action to prevent falls at www.mnfalls prevention.org. To learn more about the Minnesota Board on Aging, go to www.mnaging.org. Jean K. Wood is the executive director of the Minnesota Board on Aging and director of the Aging and Adult Services Division, Minnesota Department of Human Services. In these roles, Ms. Wood oversees the management of state and federallyfunded home and community-based services for older Minnesotans, of which the Senior LinkAge Line® is the most utilized. MetroDoctors

The Journal of the Twin Cities Medical Society


Own Your Future “Do you have a plan for your long-term care?” This is the question that the State of Minnesota will be asking its residents over the next few months as part of the Own Your Future initiative. The purpose of Own Your Future is to urge Minnesotans to have a plan for their longterm care, including how to pay for it. The campaign addresses the dramatic increase in the number of Minnesotans who will need longterm care by 2030 and the need to increase the numbers of individuals using private financing options to pay for their long-term care. Without additional private financing, the state could see significant — and unsustainable — increases in Minnesota’s public long-term care budgets in the future. Physicians know the risks for long-term care: Over 70 percent of persons 65+ will need long-term care at some point in their remaining lives and increasing numbers of young persons need long-term care. Many individuals also mistakenly believe that Medicare covers long-term care costs. It does not. It only covers this type of care under very limited circumstances. Minnesota’s Own Your Future initiative was created to educate and encourage individuals to get the facts and plan for their long-term care. It includes three components: s )MPLEMENTAPUBLICAWARENESSCAMPAIGN throughout the state. s $EVELOPMOREAFFORDABLELONG TERMCARE products for use by individuals who are not poor enough to quality for public programs but are not wealthy enough to self-fund their long-term care. s #HANGE-EDICAIDSLONG TERMCAREPROVIsions to better align with and encourage private payment for long-term care. The objectives of Minnesota’s Own Your MetroDoctors

Future campaign over the next year are: s 2AISEAWARENESSAMONG-INNESOTANSOF the importance of planning now so they have personal and financial options to meet future long-term care needs. s )NCREASETHENUMBEROF-INNESOTANSWHO have taken action to address and provide for their future long-term care. In June Lt. Governor Yvonne Prettner Solon and Minnesota Department of Human Services Commissioner Lucinda Jesson convened a 28-member advisory panel that

includes Barbara Greene, director of community engagement for the Twin Cities Medical Society’s Honoring Choices Minnesota initiative, and other key stakeholders. “We need to engage all Minnesotans in thinking about how they will plan for and pay for the care they are likely to need as we, as a society, are living longer and growing older,” said Prettner Solon. “We are grateful for the assistance in this campaign of Minnesotans representing key sectors of labor, business, health care, the faith community and nonprofit organizations.” “Employers have a stake in this issue because long-term care planning can help ease demands on family caregivers and give employees a greater sense of security about their futures,” said Jesson.

The Journal of the Twin Cities Medical Society

Because the effort will focus on helping individuals create a plan for long-term care, there is a clear message to physicians. “As authority figures in the areas of health and long-term care, physicians can assist in promoting Own Your Future educational messages to their patients,” said Greene. “We know that advance care planning has a significant role in one’s health and wellbeing. Other important conversations are needed such as where patients want to receive long-term care, who they prefer as their caregivers (family members, assisted/ skilled living nurses and aides, others), and whether they wish to remain in their home or prefer another kind of housing and care. A variety of long-term care conversations are needed so our wishes are known to our loved ones and our physician. Once these conversations take place, most people feel a sense of relief in knowing that their preferences are clear and understood by their family and care provider.” Physicians can also provide information, including the website for Own Your Future and brochures that describe more about the risks for long-term care and what actions can be taken to address those risks. The campaign will launch in early fall and will include a website and other written materials, community meetings around Minnesota and other grassroots efforts suggested by panel members. Through a partnership with the federal government, Governor Mark Dayton and Lt. Governor Prettner Solon will send a letter to all Minnesotans this fall urging them to plan. More information will be available this fall at the Own Your Future website,www.mn.gov/ ownyourfuture, as the campaign is launched and gets underway. September/October 2012

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Patience Breeds Success

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s with any new idea, it takes time to get to the end goal. Along the way, twists and turns are part of the hard work that’s invested to make a goal attainable and successful. Since the Twin Cities Obesity Prevention Coalition was created in November 2010, we have worked diligently to craft a strategy that would allow us to be effective and successful in providing leadership to improve public health through the creation of healthy eating/active living strategies. Patience has been an important factor in rolling out the work and building the partnerships with cities across the metro. In a perfect world, our work would be seamless, void of By Jennifer Anderson

any snags and there would be 10 to 12 communities boasting about their newly crafted healthy eating/active living resolutions by now. As we have learned, we don’t live in a perfect world and although the goals of the project are being met, it’s been a slower process than we anticipated. It isn’t necessarily a bad thing however. We have had the good fortune to be able to partner and strategize with multiple city staff including mayors, council members, city planners and park and recreation staff who have taken a genuine interest in looking at all the strategies that can move their community toward a healthier future. In March 2012, Eagan was the first Minnesota city to pass a healthy eating/active living resolution. Another metro community will unveil their new resolution in late August.

Over the coming months, be on the lookout for more cities to craft and pass their own healthy eating/ active living resolutions — each meeting the unique needs of its community. As a coalition, we’re confident we’ll have a successful 2012 and even better 2013 while we continue to create healthier communities for all. Jennifer Anderson, project coordinator, Twin Cities Obesity Prevention Coalition.

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September/October 2012

The Senior Physicians Association held their summer luncheon on Tuesday, July 10, 2012. Aaron Friedman, M.D., dean of the University of Minnesota Medical School, and vice president for Health Sciences spoke on the Vision of the Medical School. His presentation was very insightful and was followed with an engaging question and answer session.

Additional information is online at www.MetroDoctors.com. Click on Senior Physicians Association in the menu on the left hand side.

Mark your calendars and join us at our upcoming events! September 4, 2012 Senior Physicians Association Annual Event Weisman Art Museum Tour & Lunch

October 9, 2012 Fall Luncheon Great Lakes and Threats to Minnesota Waters Doug Jensen, U of MN Sea Grant Program

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

MetroDoctors

The Journal of the Twin Cities Medical Society


Sharing the Experience Conference Expands its Reach

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hat happens when you share advance care planning perspectives with health care system providers, community leaders, faith organizers, and multicultural representatives? The July 19, 2012 Sharing the Experience Conference, sponsored by Honoring Choices Minnesota and the Twin Cities Medical Society, demonstrated that important conversations, learning and new strategies happen quickly when stakeholders are gathered together. With an audience of 80 participants including attendees from Wisconsin and Michigan, this year’s event focused on collectively sharing growth, stories and vision. Highlights included Craig Bowron, M.D., Abbott Northwestern hospitalist and Hillery Smith Shay, featured in the HCM documentaries, who shared keynote ad- Craig Bowron, M.D., conference keynote, dresses on their Abbott Northwestern personal and pro- Hospital. fessional end-of-life care experiences. Barry Cohen, Ph.D., Rainbow Research, provided a compelling overview on the power of evaluation and establishing realistic outcome measures. Faith panel Hillery Smith Shay, conference keynote, participants Helen HCM documentary Jackson Lockett-El, participant. Minnesota Council of Churches Community Organizer, Scott McRae, director of Spiritual Care & Clinical Pastoral Educator, Park Nicollet Health Services, and Ann Ellison, director of Community Health, Fairview Health Services shared

spiritual perspectives in beginning ACP conversations founded on core values and beliefs. Multicultural panelists JosĂŠ GonzĂĄlez,

Multicultural presenters JosĂŠ GonzĂĄlez, MN Dept. of Health and Aida Strom, HCMC.

CAREER OPPORTUNITIES

OfďŹ ce of Minority and Multicultural Health, MN Dept. of Health, and Aida Strom, patient advocate, HCMC, described how age, gender and acculturation impact conversations around advance care planning. Health care system leaders and representatives shared successes and progress in reaching patients and their families on end-of-life care decision-making. This year’s conference was successful in bringing together community members and health system staff in an interdisciplinary, intergenerational and culturally rich way. Barbara Greene, MPH, Honoring Choices Minnesota director of Community Engagement.

See Additional Career Opportunities on page 30.

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By Barbara Greene, MPH

MetroDoctors

The Journal of the Twin Cities Medical Society

September/October 2012

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In Memoriam ROBERT HEETER, M.D., age 70, passed away recently. Dr. Heeter attended the University of Minnesota Medical School. He was an orthopaedic surgeon at Ridgeview Medical Center for 35 years. Dr. Heeter became a member in 1976. DUDLEY HILKER M.D., passed away on June 7, 2012. Dr. Hilker graduated from the University of Minnesota in 1942. He was a World War II Veteran who rose to rank of captain, and then served as a field surgeon receiving a bronze star before discharge in 1945. Dr. Hilker practiced OB and family medicine in Minnesota for over 60 years. He became a member in 1948. ALEXANDER E. RATELLE, M.D., passed away at age 87 on Sunday, June 10, 2012. Dr. Ratelle graduated from the University of Minnesota Medical School in 1951. He founded the Anesthesiology Department at Methodist Hospital and practiced there for 38 years. Dr. Ratelle became a member in 1955. STANLEY STONE, M.D., age 96, passed away on July 5, 2012. Dr. Stone graduated from the University of Minnesota Medical School in 1941 and practiced family medicine at North Memorial Hospital and Golden Valley Clinic. Dr. Stone became a member in 1994.

New Members Marc C. Osborne, M.D. Colon & Rectal Surgery Associates General Surgery/Colon and Rectal Surgery Youssef A. Sawers, M.D. Anesthesiology, P.A. Anesthesiology Angela D. Siwek, M.D. Southdale Pediatrics Associates, Ltd. Pediatrics

SAVE THE DATE: EMMS Foundation Fall Event Wednesday evening, November 7, 2012 Twin Cities Public Television Studios, Saint Paul

CAREER OPPORTUNITIES

See Additional Career Opportunities on page 31.

Internal Medicine? Family Medicine?

Yup.

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

Internal and Family Medicine Physician Opportunities: Stillwater Medical Group has exciting new Internal and Family Medicine Physician opportunities at our NEW Mahtomedi, MN clinic opening Fall 2012! Additional opportunities also available in Stillwater, MN. Mahtomedi, MN? (Ma-toe-me-dye) So what if you can’t pronounce it? We can help with that. Mahtomedi is located in Washington County, on the east shore of White Bear Lake. Residents appreciate the community’s small town charm, lakeside flavor, and close proximity to the Twin Cities Metropolitan Area. In addition, the Mahtomedi School District and other area colleges offer excellence in education.

For further information please contact: Patti Lewis, Director Human Resources 1500 Curve Crest Blvd, Stillwater MN (651) 275-3304, plewis@lakeview.org stillwatermedicalgroup.com

Christa L. Waymire, M.D. Glencoe Regional Health Services Family Medicine 30

September/October 2012

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MetroDoctors

The Journal of the Twin Cities Medical Society


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MetroDoctors

The Journal of the Twin Cities Medical Society

September/October 2012

31


LUMINARY of Twin Cities Medicine By Marvin S. Segal, M.D.

REUBEN BERMAN, M.D. A cardiologist approached the frail patient’s hospital bed and introduced himself. “Your doctor asked me to see you in consultation. I’m Dr. Reuben Berman.” The startled patient sat bolt upright and exclaimed, “Oh no … am I that sick?” The clinical reputation of our popular Luminary was obviously far reaching — beyond the medical community and well into the general population — both in his chosen field and in a myriad of other pursuits by this ultimate Renaissance man. Reuben was born of Eastern European immigrant parents and reared in Minneapolis. An outstanding student at North High, he obtained his bachelors degree and in 1932 a medical degree at the U of M. After a Minneapolis General Hospital residency, he joined Dr. Moses Barron, a leading Twin Cities internist, in private practice at the Medical Arts Building. He served in the Civilian Conservation Corps during the depression and was called out of private practice to spend 4+ years as an Army Flight Surgeon at the height of WWII. His heroic battlefield European service was rewarded by the presentation of a Bronze Star and the French Croix de Guerre. At Dachau, he witnessed first hand the chaotic aftermath of the holocaust and described the inhumanity he observed in a written narrative currently housed at the Minnesota Historical Society. His beloved Isabel and their six extraordinary children shared with him a life chock-full of accomplishments: a founder of and chief of staff at Mount Sinai Hospital; editor of Minnesota Medicine; acknowledged leader in the American Heart Association and the American College of Cardiology; president of the Minnesota Medical Foundation; recipient of the Charles Bolles Bolles-Rogers Award; founder of the Minneapolis Society of Internal Medicine; and professor of medicine at the U of M. Prior to becoming the driving force of Mount Sinai’s Clinical Research Center — which continues today at Hennepin County Medical Center as the Berman Center — he closely collaborated with noted research physicians, Drs. Paul Dudley White and Ancel Keys. Reuben reluctantly agreed to the naming by others of the Berman Center and generously saw to it that a huge amount of money intended for him by 32

September/October 2012

grateful patients went entirely to support that research program. He was an Eagle Scout at age 15 — somehow passing the rigorous array of badge requirements despite the fact that his time for running a 100-yard dash — as he stated — was “only slightly faster than that of a quick turtle.” In between Reuben’s professional exploits, he somehow found time to bake delicious bread, take expert photos, sound the Shofar (ram’s horn) at his synagogue, hunt and delectably prepare wild mushrooms, regularly pilot an airplane, play superb music — first on his clarinet and later a bassoon — and exercise by riding a bicycle on the streets of Minneapolis into his 80s. He was generous and directive in nature. To the admiring young physician just leaving the Army in the 60s, who expressed interest in following his lead in teaching, research and patient care, he quietly though forcefully stated, “You’ll be starting with us in July, we’ll exceed any offers you receive from others, and caring for our patients will be the focal point of all we do!” Reuben Berman was a gentle man whose every pore exuded wisdom. A favorite quotation of his after complex experiences — both good and bad — was, “There’s a lesson to be learned from all of this.” And of his most beloved pursuit he said, “Medicine is a combination of art and science — don’t belittle the art… without which the science fails.” During his nearly 96 years of a full and energetic life, Reuben found and followed the perfect combination of both. This last page series is intended to honor esteemed colleagues who have contributed significantly to Twin Cities medicine. Please forward names of physicians you would like considered for this recognition to Nancy Bauer, managing editor, nbauer@metrodoctors.com.

MetroDoctors

The Journal of the Twin Cities Medical Society


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