Vo l u m e X X X , N o . 4 J u l y 2 016
The Medicare Quality Payment Program What physicians need to know By Lisa Gall, DNP, FNP, and Candy Hanson, BSN, PHN
T Emergency Medical Services Regulating an evolving profession By Tony Spector, MA, JD
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or some, the term Emergency Medical Services (EMS) evokes memories of paramedics Johnny Gage and Roy DeSoto from the venerable (and industry-defining) television series “Emergency!” For others, it reminds them of early childhood in Greater Minnesota and a ride to the hospital in a hearse that doubled as the community ambulance. For me, I recall the many medical and trauma calls I responded to as a police officer and deputy sheriff. Whether viewed as part of health care, public safety, or transportation,
EMS arguably is in its infancy; it is an industry that began in the 1960s and has endeavored to evolve into a profession. To aid in its evolution, the state of Minnesota formed the executive branch regulatory agency known as the Emergency Medical Services Regulatory Board (EMSRB) in 1996. The mission of the EMSRB is to protect the public’s health and safety through regulation and support of the EMS system. We are the lead agency in Minnesota responsible for Emergency Medical Services to page 10
he past five years has heralded significant changes in health care delivery with increased provider accountability to use health information technology to document care, report quality and costs of care, and exchange health information with patients and other providers. All of these complex changes are needed to shift health care to a focus on high-quality care at a cost that’s sustainable. The Centers for Medicare & Medicaid Services (CMS) implemented several incentive programs to drive these changes: 1) the Electronic Health Records (EHR) Incentive Program requires the “meaningful use” of certified EHRs; 2) the Physician Quality Reporting System (PQRS) requires eligible providers to report additional quality measures, and 3) the Value-Based Payment Modifier (VBM) Program adjusts Medicare payments based on the cost and quality of services provided. Each program has a different mix of eligible providers and clinicians and reporting requirements have not The Medicare Quality Payment Program to page 12
Rapid Response | Critical Care Life Link III is a great Midwest model of nine hospital systems cooperatively delivering the goals of the Triple Aim. These hospital systems are member-owners of Life Link III:
Life Link III operates six helicopter bases that include Alexandria, Blaine, Cloquet, Hibbing, and Willmar, Minnesota, and Rice Lake Wisconsin. The company’s helicopter and airplane services provide on-scene emergency response and inter-facility transport for patients requiring critical care. Life Link III’s transportation services are accredited by CAMTS (Commission on Accreditation of Medical Transportation Services), ensuring the highest standards of quality and safety are met.
800-328-1377 www.lifelinkiii.com
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JULY 2016 • VOLUME XXX, NUMBER 4
FEATURES Emergency Medical Services Regulating an evolving profession
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By Tony Spector, MA, JD
The Medicare Quality Payment Program What physicians need to know By Lisa Gall, DNP, FNP, and Candy Hanson, BSN, PHN
Osmo Vänskä /// Music Director
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2016–17 SINGLE TICKETS ON SALE JULY 29
DEPARTMENTS CAPSULES 4 COMPUTER MEDICUS 7 TECHNOLOGY
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Empowering hospital
INTERVIEW
8 patients
Addressing domestic violence Hilary Stoffel, PsyD Tubman
By Todd Smith, MD
INFECTIOUS DISEASES
28
OSMO VÄNSKÄ
LEILA JOSEFOWICZ
JOSHUA BELL
STANISLAW SKROWACZEWSKI
Zika By Frank S. Rhame, MD
HEALTH CARE POLICY
The 2016 legislative wrap-up By Nate Mussell, JD
SEASON OPENING: OSMO VÄNSKÄ AND JOSHUA BELL
MINNESOTA HEALTH CARE ROUNDTABLE Medical Innovation vs. Medical Economics By MPP Staff
Sep 22–23
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Osmo Vänskä, conductor / Joshua Bell, violin Our season launches with Brahms at his most lush and Tchaikovsky at his most virtuosic, with superstar Joshua Bell adding the fireworks.
VÄNSKÄ CONDUCTS PAULUS MASS
PROFESSIONAL UPDATE: UROLOGY
Sep 29–Oct 1
Trends in prostate cancer management 30 By Peter D. Sershon, MD, FACS
Osmo Vänskä, conductor / Kathy Kienzle, harp Power and poignancy in a beautiful blend, with Ginastera’s colorful Harp Concerto and the unveiling of a hidden gem from a Minnesota master, the late Stephen Paulus.
CELEBRATING SKROWACZEWSKI: BRUCKNER SYMPHONY NO. 8 Oct 14–15
Stanislaw Skrowaczewski, conductor Get a glimpse of heaven, as Bruckner paints a picture of otherworldly serenity and beauty in his soaring Eighth.
JOSEFOWICZ PERFORMS JOHN ADAMS
www.mppub.com
Oct 20–21
Edward Gardner, conductor / Leila Josefowicz, violin
PUBLISHER Mike Starnes | mstarnes@mppub.com
Sunrises from Ravel, swashbuckling from Berlioz, and a thrilling new piece by John Adams for the blazing Leila Josefowicz.
EDITOR Lisa McGowan | lmcgowan@mppub.com
E.T. THE EXTRA-TERRESTRIAL COMPLETE FILM WITH LIVE ORCHESTRA
ASSOCIATE EDITOR Richard Ericson | rericson@mppub.com ADVERTISING DIRECTOR Stefani Pennaz | stef@mppub.com
Oct 28–29
ART DIRECTOR Sunshine Sevigny | sunny@mppub.com
Steven Reineke, conductor
OFFICE ADMINISTRATOR Amanda Marlow | amarlow@mppub.com Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is 2812 East 26th Street, Minneapolis, MN 55406; phone 612.728.8600; fax 612.728.8601; email mpp@ mppub.com. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.
“E.T. phone home.” Join us for an out-of-this-world experience as we screen one of the world’s most-beloved movies with the Minnesota Orchestra playing John Williams’ unforgettable score live!
minnesotaorchestra.org 612.371.5656 Ã Orchestra Hall PHOTOS Vänskä: Joel Larson; Bell: Lisa-Marie Mazzucco; Skrowaczewski: Mark Luinenburg; Josefowicz: Chris Lee; E.T. © Universal Studios All sales final. All artists, dates, programs, prices and times are subject to change.
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JULY 2016 MINNESOTA PHYSICIAN JUL_MN Physician Ad.indd 1
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7/7/16 9:19 AM
CAPSULES
HCMC to Study Medication for Traumatic Brain Injury Hennepin County Medical Center (HCMC) has notified the public that it is taking part in a multi-site clinical study to test whether people who experience life-threatening or life-altering traumatic brain injury have better outcomes when they receive Tranexamic Acid (TXA), a medication used to stabilize bleeding in the body. HCMC admits and treats the most traumatic brain injuries in Minnesota. The study is being conducted at 12 Level 1 trauma centers in North America. Researchers will analyze the results to determine if TXA, when given as soon as possible after an injury, improves the mental recovery for patients who have experienced traumatic brain injury. Paramedics will determine if a patient is eligible to take part in the study by using information such as blood pressure, pulse, injury type, and cognitive level. Those who enroll will randomly
receive one of two combinations of TXA or a placebo (plain salt water) by paramedics and in the hospital. One group will receive a onegram dose of TXA by paramedics and another one-gram dose in the hospital; another group will receive a two-gram dose by paramedics and the placebo in the hospital; and the third group will receive the placebo by paramedics and in the hospital. All other treatments will be the same for all patients. Those who choose not to participate will have the best course of care determined by their physicians. However, because traumatic brain injury often means a patient is unconscious, permission to participate in the study isn’t likely to be obtained before the patient is enrolled. HCMC’s Human Subjects Research Committee has granted an exception from consent for emergency research, which allows paramedics to enroll a patient without prior consent. According to HCMC, leaders of the study will conduct community consultation meetings to determine if the community is in support of the research. Patients can also opt out by contacting the
study staff and asking for the optout wristband, which indicates to paramedics that the wearer does not want to be enrolled in the study.
Adolescent Pregnancy and Birth Rates Reach All-Time Lows Minnesota’s teen pregnancy and birth rates have reached historic lows, according to results of the University of Minnesota’s Healthy Youth Development* Prevention Research Center (HYD*PRC) 2016 Minnesota Adolescent Sexual Health Report. The report focuses on the most recent sexual health data and statistics for youth ages 15 to 19. Between 1990 and 2014, pregnancy rates declined 66 percent (from 17,272 pregnancies to 7,122 pregnancies) and birth rates declined 58 percent (from 10,672 births to 5,420 births). From 2013 to 2014, pregnancy rates decreased 8.2 percent and birth rates declined 8.1 percent. For adolescents under the age of
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15, pregnancy rates declined 7 percent and birth rates decreased nearly 26 percent from 2013 to 2014. Rates in 2014 are the lowest ever recorded in Minnesota. Gonorrhea rates showed a decline, from 218 cases in 2014 to 174 in 2015, while chlamydia rates remained about the same with 1,402 cases in 2014 and 1,403 in 2015. Sexually transmitted infections strike 7 percent of the general population in Minnesota, but adolescents ages 15 through 19 accounted for 24 percent of chlamydia cases and 16 percent of gonorrhea cases in 2015. There were 12 new cases of HIV among adolescents ages 13 through 19 in 2015, a decrease of 29 percent from 2014 when there were 17 new cases diagnosed. Geographically, the highest birth rates among adolescents ages 15 through 19 were found in Watonwan, Mahnomen, and Cass counties. All 10 counties with the highest teen birth rates were in Greater Minnesota. The highest rates of chlamydia were found in Mahnomen, Hennepin, and Ramsey counties, and the highest rates of gonorrhea were found in Olmsted, Ramsey, and Cass counties.
The report shows that racial and ethnic disparities, sexual orientation, and adverse childhood experiences were strong predictors of increased rates of negative sexual health outcomes.
Patients Report Benefits from Medical Cannabis A recent survey of patients enrolled in Minnesota’s medical cannabis program during its first three months shows that most patients experienced benefits from the medication. The Minnesota Department of Health conducted the voluntary survey, which asked patients to rate their level of benefit from one to seven. Scores of one to two indicated no or little perceived benefit, scores of three to five indicated mild or moderate perceived benefit, and scores of six or seven indicated significant benefit. The survey was sent to 435 patients who purchased their first medical cannabis medication during the first three months of the program. Of those, 241 responded. The results show that 90 percent of patients reported a score of three or greater. About 20 percent reported non life-threatening side effects such as dizziness, lightheadedness, fatigue, feeling high, sleepiness, stomach pains, burning sensations in the mouth, and paranoia. Two percent reported an increase in seizures. The largest reported drawback of the program was affordability, with 73 percent of patients saying the cost was unaffordable. The top three conditions patients used the medication for were severe muscle spasms, seizures, and cancer. Cancer had the highest reported benefit scores. “These survey data are based on a small sample of patients and should not be confused with a clinical trial,” said Ed Ehlinger, MD, Minnesota commissioner of health. “However, these results do highlight Minnesota’s data-focused approach to medical cannabis and the fact that patients are benefiting from the program.” The survey was also sent to 345 health care practitioners who certified patients as eligible for medical cannabis. Of those surveyed, 94 practitioners responded on behalf of 169 patients. About 77 percent reported seeing scores of three or higher for their patients.
Work Group Formed for Voluntary Electronic Monitoring in Care Facilities The Minnesota Department of Health has announced the formation of a new work group that will develop recommendations for future laws regarding the use of voluntary electronic monitoring such as video cameras in professional care settings. The equipment is considered potentially valuable for the purpose of detecting abuse and neglect of vulnerable people in nursing homes and other professional care facilities. The Residential Care and Services Electronic Monitoring Work Group was created in the 2016 legislative session when several measures related to electronic monitoring were being considered. The 16-member group consists of legislators, state agency staff, with a group chair appointed by the Minnesota Commissioner of Health. Ed Ehlinger, MD, has chosen Amanda Vickstrom, executive director of the Minnesota Elder Justice Center, as the work group chair and the 16 members have been finalized. The first meeting took place June 22 and the work group will submit a report with recommendations to the Legislature by Jan. 15, 2017.
MN Community Measurement’s
2016 Annual Seminar
Thursday, September 15 ~ 8:15am to 5:00pm Earle Brown Heritage Center Join us to learn how data and measurement impact health equity, cost and quality. Speakers include polar explorer Ann Bancroft; Jean Moody-Williams, Deputy Director of the Center for Clinical Standards and Quality at CMS, on MACRA; and Stephen Nelson, M.D., Director of the Sickle Cell Clinic at Children’s of Minnesota, on race, racism and health inequity. Also featuring panels on adolescent mental health and the importance of specialty care measurement.
Learn more at seminar2016.mncm.org
Sanford Clinics Add Telestroke Services Sanford Bagley Medical Center and Sanford Bemidji Medical Center now have telestroke capabilities, facilitating local and immediate neurological consultations for patients who are believed to be having a stroke. The services, provided through Sanford One Connect Emergency, allow the sites to connect instantly to a neurologist through interactive video technology. The neurologist then assists in diagnosing the patient who is having stroke-like symptoms and works with the providers to determine the best treatment options, including administering tissue plasminogen activator (tPA), a protein involved in the breakdown of blood clots. Capsules to page 6
Helping Beautiful Things Emerge From Hard Places
TWO CENTERS.
The Center for Alcohol and Drug Recovery
ONE PURPOSE.
The Vanguard Center for Gambling Recovery
www.ProjectTurnabout.org JULY 2016 MINNESOTA PHYSICIAN
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Capsules from page 5
“Utilizing telemedicine gives the physician the ability to lay eyes on the patient in a regional hospital. Being able to interview the patient firsthand and observe a neurological clinical exam directly helps solidify my decision in administering tPA,” said Jitendra Sharma, MD, interventional neurologist at Sanford Health. “A picture is worth a thousand words and in our case it’s worth a life.”
Essential Medicines at Risk of Continuing Price Hikes Researchers at the Medical School at the University of Minnesota have published a paper on a drug industry trend of pharmaceutical companies buying the rights to older, off-patent drugs in niche markets and raising prices to increase profits. They note that in some cases these drugs are considered essential by the World Health Organization (WHO) and are often only produced by one manufacturer, leaving patients
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MINNESOTA PHYSICIAN JULY 2016
with few or no alternatives. “In such a model, nothing is being put back into the health care system and patients requiring the medications are suffering,” said Jonathan Alpern, MD, chief resident at Regions Hospital, infectious disease fellow at the University of Minnesota, and coauthor of the paper that was published in the most recent issue of the New England Journal of Medicine. “We believe the new model is hurting patients and leaving providers with limited treatment options. There needs to be regulatory policies in place that help to counteract such exorbitant price hikes.” The paper notes that the increased costs can disproportionately affect vulnerable populations, making necessary treatments unobtainable for them. “This is an issue affecting everyone—patients, health care providers, policymakers,” said Alpern. “When essential medicines become disproportionately cost prohibitive to vulnerable patients, it strikes a chord with people.” Alpern and his coauthors, John Song, MD, and William Stauffer, MD, of the University of Minnesota Medical School, say
that other medications on WHO’s List of Essential Medicines may become targets for the pharmaceutical model as well. They identified a list of 17 anti-infective essential drugs that could be next. The list includes seven drugs that treat tuberculosis (rifapentine, rifabutin, pyrazinamide, capreomycin, streptomycin, aminosalicylic acid, and ethionamide) as well as drugs that are the recommended first-line treatment for leprosy (clofazimine), severe malaria (intravenous quinidine gluconate), scabies and lice (permethrin 5 percent cream), and Chagas disease (benznidazole). The rest of the drugs on the list are ivermectin, dapsone, clofazimine, sulfadiazine, inhaled and intravenous pentamidine, and paromomycin. “It is concerning that many anti-infective medications on the list share the same characteristics (produced by only a few manufacturers, limited alternative options, treat conditions leading to morbidity and mortality without treatment) as the drugs whose prices have skyrocketed,” said Alpern. “This suggests there are many essential drugs at risk of substantial price hikes.”
Hennepin County to Expand Mental and Chemical Health Services The Hennepin County Board has approved a $4 million renovation project for its chemical health services building at 1800 Chicago Ave. in Minneapolis. The project includes expanding the withdrawal management program from its current 50bed space to house 65 beds in a 5,900-square-foot space on two levels of care to include clinically managed and medically monitored withdrawal care. According to Hennepin County, the average stay for more than a third of clients is expected to decrease from two days to one. In addition, the mental health crisis program will expand to an 8,300-square-foot space with a 16-bed residential stabilization unit. The space will provide an alternative to hospital placements and redirect low-level offenders in need of mental health care services away from jail. Hennepin County expects construction to be completed by September 2017.
MEDICUS Alan Spiro, MD, MBA, has been named chief medical officer at Medica. He will step into the position on July 5, where he will have overall responsibility for the work of Medica’s health management segment. Previously, Spiro founded, and served as executive vice president and medical officer of, Accolade, Inc., a company dedicated to helping large health plan orgaAlan Spiro, nizations and employers improve the member MD, MBA experience and control costs. Prior to that, he served as vice president and chief medical officer at Anthem National Accounts and principal and national clinical practice at Towers Perrin, where he helped Fortune 100 companies develop corporate health strategies and implemented some of the first health advocate and care management programs in the industry. Spiro earned his medical degree at Columbia University College of Physicians and Surgeons and his masters of business administration degree from Northwestern University Kellogg School of Management. Marilyn Peitso, MD, FAAP, pediatrician at CentraCare Clinic, has received the 2016 Distinguished Service Award from the Minnesota Chapter of the American Academy of PediatMarilyn Peitso, rics (MNAAP) for her dedication to improving MD, FAAP care for children in Minnesota. Peitso has been a pediatrician for more than 30 years. Before joining CentraCare Clinic in 1991, Peitso served as president of the MN-AAP. Currently, she serves on the Minnesota Medical Association’s board of trustees and foundation board. She is involved in quality improvement efforts in primary care and pioneered the development of Medical Homes for children with special health care needs at local, state, and national levels through the Minnesota and National Pediatric Medical Learning Collaboratives. She is certified by the Institute for Healthcare Improvement (IHI) as an Improvement Advisor. She has also recently been appointed by the governor to the Minnesota Task Force on Health Care Financing. Peitso earned her medical degree at the University of Minnesota Medical School and completed a residency in pediatrics at the University of Iowa Hospitals and Clinics. Arthur J. Sit, MD, researcher and assistant professor of ophthalmology at the Mayo Clinic College of Medicine in Rochester, has been elected president of the Minnesota Academy of OphthalArthur J. Sit, MD mology. Sit specializes in glaucoma and has a particular interest in novel surgical devices and techniques. He earned his medical degree at the University of Toronto, where he also completed an ophthalmology residency, and completed a fellowship at the Hamilton Glaucoma Center, University of California, San Diego. In addition, Robert C. Ramsay, MD, has received the 2016 Budd Appleton Award for Service to Ophthalmology from the Minnesota Academy of Ophthalmology in recognition of his many years of commitment to patient care, public education, and political advocacy. Ramsay is a clinical professor of ophthalmology at the University of Minnesota, where he has taught and conducted medical clinical research since 1988, and practices Robert C. with VitreoRetinal Surgery, which he founded in Ramsay, MD 1988 and has grown to include five locations in the metro area. He earned his medical degree at the University of Manitoba in Winnipeg and completed a residency at the University of Minnesota Hospital.
MINNESOTA HEALTH CARE ROUNDTABLE
FORTY-SIXTH SESSION
Value - Based Reimbursement:
A new way to pay for health care
Thursday, November 3, 2016 • 1:00-4:00 PM
The Gallery (lobby level), Downtown Minneapolis Hilton and Towers
Background and Focus: As initiatives driven by federal health care reform move forward, the term “Value-Based Reimbursement” (VBR) is being applied to a wide spectrum of issues. But what does this mean? CMS is developing measurements, well over 150 to date, to define what “value” means in health care. It is proposed that these metrics will be used to create incentives that pay more for better care in every element of health care delivery. Hospitals, physician practices, home care, and long-term care will all be reimbursed by an emerging new math. Objectives: We will explore the motivations behind this changing approach to reimbursing health care. We will examine what is being measured and what value really means. We will discuss the arguments that claim VBR is a bad idea and those that believe it is the best solution. We will discuss how a collaborative, transparent system, that integrates care teams, health information technology and improved reimbursement methods will help achieve increased access to high-quality, cost-effective care for patients. Panelists include: • Curtis Hanson, MD, Chief Medical Officer, Mayo Medical Laboratories • Allison LaValley, Executive Director, athenahealth Sponsors include: • athenahealth • Mayo Medical Laboratories Please send me tickets at $95.00 per ticket. Tickets may be ordered by phone at (612) 728-8600, by fax at (612) 728-8601, on our website (mppub. com), or by mail. Make checks payable to Minnesota Physician Publishing. Mail orders to MPP, 2812 East 26th Street, Mpls, MN 55406. Please note: tickets are non-refundable. Name Company Address City, State, ZIP Telephone/FAX Card # Check enclosed Bill me
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JULY 2016 MINNESOTA PHYSICIAN
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INTERVIEW
Addressing domestic violence
Hilary Stoffel, PsyD Tubman Dr. Stoffel joined Tubman in 2012. As the associate director of clinical services, she is responsible for the daily operation of the division, for supervising clinical and contract staff, and for program development. Prior to joining Tubman, Dr. Stoffel was a psychiatric rehabilitation practitioner, and she provided services to adults with co-occurring disorders, and worked with adults, youth, and children as a mental health therapist for over 10 years. She has supervised clinical staff and graduate students for over four years and has developed programs including therapeutic experiential art activities and integrated dual diagnosis treatment programming. She holds a PsyD in counseling psychology from the University of St. Thomas and an MA in counseling psychology from Alfred Adler Graduate School.
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P lease give us an idea of the scope of domestic violence in America today. The true scope of domestic violence in America is difficult to measure. It is among the most underreported crimes for a variety of reasons, including fear and shame, difficulty identifying abuse, and hoping that the abusive partner will change. We know that nationally, one in three women and one in four men have been victims of some form of physical violence by an intimate partner, and one in five women and one in seven men have been victims of severe physical violence by an intimate partner. On a typical day, nationally, there are more than 20,000 phone calls to domestic violence hotlines.
developing anxiety (including PTSD), depression, digestive issues, headaches, heart disease (including high blood pressure), sleep problems, weight gain, unwanted pregnancy and other reproductive issues, or memory and concentration issues. Substance abuse is another concern, as it can act as a CNS depressant, temporarily suppressing the body’s fight-or-flight response.
Patients who experience domestic violence are at risk of experiencing a higher level of stress, which can be damaging. Patients are at higher risk of
Please discuss issues pertaining to cultural diversity and domestic violence. Different cultures can have very different traditions around the household and family structure, gender
How should physicians broach the topic when they believe a patient is a victim of domestic violence, but the patient is unwilling to discuss the issue? Many patients may deny abuse for fear of retaliation, which could be in the form of denying access What are some of the ways Tubman to care, continued abuse, fear of custody issues, addresses domestic violence? socioeconomic barriers to accessing care, low Tubman believes that violence is a learned behavior self-esteem, and shame. Research shows that most patients say they would discuss domestic violence that can be unlearned. We offer the widest range of choices to the men and women we serve and use if asked in a caring and confidential manner. Start creative strategies to help people build violence-free by expressing concern about your patient’s safety, and mention that you routinely screen all of your lives. Domestic violence is a complex issue, and patients for risk of violence in their lives. For there is no single approach that works for every relationship and every situation. Domestic violence most patients, seeking medical care is “safer” than seeking mental health care. Patients often develop often occurs simultaneously with sexual assault, addiction, mental health issues, and homelessness. long-term trusting relationships with their primary care physicians. Oftentimes, discomfort on the proTubman offers 24-hour crisis support and safety vider’s behalf can be a barrier to asking pertinent planning; emergency shelter; legal advocacy; mental health services that include counseling, therapy, questions, but several researchers have identified that patients want and need to be asked directly. and support groups; career, housing, and financial Validate their experience and how strong they are. workshops; youth education; and violence preTell patients that no one deserves to be hurt or vention programs. Additional information can be harmed. By broaching the topic, it is no longer a found at tubman.org. taboo subject. Patients are more likely to address Many survivors don’t want to end their relathe issue of violence in their lives if they feel safe tionships; rather, they want their partner to get and trust the professional asking the questions. help to stop the abuse. For people who have been Be patient. There is often a lot of shame associated abusive, Tubman offers group programming with with being a victim of violence. licensed mental health professionals who use an evidence-based holistic approach. Abusers work Why is it important for physicians to be through personal trauma or abuse they have careful and specific about documenting endured, and learn to better manage emotional domestic abuse? reactions and respond more effectually to their Documentation can be used as evidence in court partners. It also helps participants learn to be when a patient makes the decision to prosecute accountable for their own behaviors and responses, their abuser. Patients may need medical records including accountability within the criminal justice to demonstrate evidence of physical harm by the system when applicable. After people complete the perpetrator. As a result, it is imperative that phyprogram, Tubman conducts recidivism checks with sicians document the history of abuse by taking probation officers and voluntary check-ins with the careful and complete notes, including any screenparticipants and their partners. In 2015, 95 percent ing details, and if possible, drawings or digital of program participants did not reoffend within six photographs regarding physical injuries that may months of completion, with additional checks done be treated in the emergency room or doctor’s office. at 12 months and 18 months. If victims are afraid of testifying in court, medical Please discuss the downstream health issues records can be important evidence for prosecutors and law enforcement. that are a byproduct of domestic violence.
MINNESOTA PHYSICIAN JULY 2016
roles, and expectations between spouses. Seeking help outside the family may be taboo or seen as a denial of one’s cultural norms. They can be hesitant to seek help within the cultural community, especially if it is close-knit, or outside the community for fear of not being understood or that it will reflect badly on their culture. Often, it is more important to provide resources that will not disrupt the family unit rather than insist a patient leave her abuser. What advice can physicians give to patients they identify as victims of domestic violence? The most important things you can say to a victim of domestic violence is simply, “This is not your fault. You aren’t alone. There are places that can help.” Ask questions. Listen. Give patients time to talk if they need it, or if you know you can’t, kindly provide them with a quiet place, a telephone, and the number to the statewide domestic violence hotline: (866) 223-1111. Have a list of local community resources available to give to patients, and document that it was provided. Let your patients know that you care about them and you would like to provide them with additional resources and support when they are ready.
W hat are the biggest issues around the underreporting of domestic violence? Even though no one is to blame for violence committed against them, many people still struggle to tell others about the violence in their homes. They often feel a wide range of emotions, including shame, confusion, guilt, and hope that the violence stops without outside intervention. In addition, violence often occurs cyclically, with periods of happiness and peace at home, leading the victim to believe their abuser has changed or that it won’t happen again. If the violence continues, it can lead to continued trauma, including mental health issues for children who witness it.
It is imperative that physicians document the history of abuse.
H ow can victims move beyond the physical and mental trauma of domestic violence? Trauma doesn’t just go away—it becomes a part of one’s life story. There are immediate needs a person has in the midst of a violent
situation, such as learning to manage the after-effects on a daily basis as he or she continues to heal. That being said, patients can learn effective techniques to mitigate the effects of trauma. Time and patience are important to the healing process. Taking care of physical and mental health is also important, having a strong support network, and creating a general sense of safety through a safety plan can be essential for most if not all survivors of domestic violence. For some patients, talking about the trauma is helpful in processing and overcoming the abuse. W hat can we do as a society to reduce domestic violence? One thing every person can do is to listen to their inner voice when it tells them that something isn’t right with a situation. Know the signs of domestic violence and don’t ignore red flags, for example, if a patient’s partner refuses to leave their side and answers questions for the patient. Violence is a complex issue and no one single approach works for all people, but we can all agree that violence is not acceptable. It can be difficult when you know someone is hurting, but you can provide support and information by learning more about domestic violence, available resources, and safety planning.
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JULY 2016 MINNESOTA PHYSICIAN
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Emergency Medical Services from cover
credentialing all EMS personnel: emergency medical responders, emergency medical technicians, paramedics, and community paramedics. We approve and audit all EMS education programs, thus ensuring the delivery of nationally-recognized education and testing standards. We license and inspect all ambulance vehicles and ambulance services, and we investigate all allegations of misconduct involving those individuals and entities subject to our jurisdiction. We insist that ambulance services are safe, reliable, and available around-the-clock both in metropolitan areas and in Greater Minnesota. Areas of our state with small populations often rely on volunteer EMS personnel to provide continuous ambulance service. Indeed, 62 percent of licensed ambulance services in Minnesota are comprised of volunteer or a combination of paid and volunteer EMS professionals. Recruitment and retention of these volunteers continues to be stretched by the general societal decrease in volunteerism and an overall population decrease in 74 Minnesota counties. Within those counties, there continues to be an increase within the geriatric population, i.e., a population segment generally requiring more frequent and complex medical care. The EMSRB continues to work with stakeholders, partners, and subject-matter experts to address this very serious issue. Like all state agencies, the EMSRB derives its operational authority from state law. The relevant state statutes pertaining to the EMSRB are found in Chapter 144E; the relevant state rules pertaining to the EMSRB are found in Chapter 4690. Board composition The EMSRB has 19 board members, appointed by the governor, who are passionate about EMS and protecting the public’s health and safety. This is a large
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board, but it was designed as such, because our “creators” sought to craft a regulatory body with membership inclusive of all facets of EMS. Of course, EMS is a physician-driven
Because there is an element of public health and community health in EMS, the Board has representatives from the Minnesota Department of Health and from a community
The backbone of EMS in Minnesota is the ambulance service.
industry. Therefore, an emergency physician certified by the American Board of Emergency Medicine, a pediatrician certified by the American Board of Pediatrics, and a family practice physician involved in emergency medical services are members of the Board. The delivery of EMS care involves other professionals. Police officers, sheriff’s deputies, state troopers, firefighters, and rescue squad members are an indispensable part of the EMS system. In many parts of the state, these public safety professionals are the true first responders and provide critical care until the arrival of the ambulance. In Greater Minnesota, ambulance arrival can take time; 20 minutes is not unusual. The emergency care provided by law enforcement officers and firefighters can be critical to patient survival and illustrates why they are such an important EMS provider and partner. Accordingly, the Board is comprised of a full-time firefighter, a volunteer firefighter, a fire chief, a sheriff, and a representative from the Department of Public Safety.
MINNESOTA PHYSICIAN JULY 2016
health agency. Board membership also includes a paramedic from an ambulance service, an ambulance service director, a registered nurse practicing in an emergency department, and a public member. Our Board meets bi-monthly in an open forum. The Board also has several committees and work groups. One exceedingly important committee is the Medical Direction Standing Advisory Committee (MDSAC), a group of physicians from throughout Minnesota dedicated to improving the public’s health and safety. MDSAC provides a forum for physicians to discuss prehospital care and work toward improving medical direction statewide. MDSAC also provides guidance to new ambulance medical directors through mentorships and informal networks, and by offering free classes such as Strategies for Successful Rural EMS Medical Direction that will be presented at the EMS Medical Director’s Conference in Alexandria, Minnesota on Sep. 9, 2016.
Ambulance services The backbone of EMS in Minnesota is the ambulance service. There are three-types of services entities: municipally-based, fire-based, and hospital-based (in addition to a handful of privately-owned services). There are four levels of ambulance service licenses issued by the EMSRB: basic life support, advanced life support, part-time advanced life support, and specialized life support (e.g., an air ambulance service). Notwithstanding the type of entity or the level of care, all ambulance services must have a medical director, i.e., a physician who, inter alia, (1) establishes standing orders for prehospital care and the administration of drugs, (2) participates in quality improvement programs that includes run reviews with the EMS professionals, and (3) assesses the practical skills of each person on the ambulance service roster. The EMSRB believes that a successful ambulance service is in no small part the direct result of an informed and engaged medical director. Sadly, the converse is true for the struggling ambulance service. We work with ambulance services and medical directors to ensure their success. One of this agency’s very valuable programs has been the rural ambulance assessment, a multiday process where the EMSRB brings subject matter experts to the ambulance service for a comprehensive evaluation of operations, finances, organizational culture, training and education, and a host of other performance dimensions and measures. Teams interview a variety of stakeholders, and the interviews often conclude with a town hall forum where the assessment process is explained and comments are sought from those in attendance. Our rural ambulance assessments have proven to be successful, providing services with the tools and guidance to succeed, and the EMSRB has measured the successes both short- and long-term.
Regulation and support The EMSRB—Board and staff—think that regulation and support need not be mutually exclusive. By providing the necessary support to those individuals and entities that we regulate, we believe strongly that our contributions ensure continuous, consistent, and safe emergency medical services throughout Minnesota. To that end, on the support-side we act as resources for EMS entities as well as our partner agencies and organizations: the Minnesota Department of Health, the Minnesota Department of Public Safety, the eight regional EMS organizations, the 157 approved education programs, the 285 ambulance services, and the nearly 30,000 credentialed EMS professionals. The EMSRB administers grant dollars and provides funding to the state’s eight regional EMS organizations. These dollars are used for EMS education on the local level, for equipment and technology, and for other resources not funded by an EMS entity’s home agency. We also provide funding for the two medical resources control centers—one in Hennepin County and one in Ramsey County. These centers serve as the online radio liaison between EMS ambulance crews and destination hospitals. Through a federal grant initiative, the EMSRB is very pleased to fund the Emergency Medical Services for Children program, a terrific partner that helps improve pediatric emergency care infrastructure throughout Minnesota. The EMSRB believes very strongly in protecting our most precious asset: our children. The EMSRB also collects pre-hospital care records of all patients seen by an ambulance service. The Minnesota State Ambulance Reporting System (MNSTAR) of the EMSRB enables ambulance services and their medical directors to monitor pre-hospital emergency care by reviewing its own data as well as other non-identifiable
patient care information to improve the quality of prehospital emergency care. The EMSRB also submits non-identifiable patient information from MNSTAR to the National
All ambulance services must have a medical director.
EMS Information System, a repository of data used to develop nationwide EMS training curricula, evaluate patient and EMS system outcomes, and to address resources for disaster and domestic preparedness. On the regulation side, the EMSRB investigates all allegations of misconduct involving those individuals and entities subject to our jurisdiction. We receive a broad spectrum of complaints including theft committed by the EMS professional in the course and scope of patient care, diversion of controlled substances, and practicing on an ambulance service with expired EMS credentials. The agency’s EMS Specialists are trained investigators who work these cases with the level of detail, thoroughness, and professionalism typically found in a law enforcement agency. To be clear, however, the EMS Specialists are not licensed peace officers. But the subjects of our investigations and the public who we protect are entitled to a skillful, impartial, and comprehensive inquiry. Due process demands it. There is no greater act taken by a regulatory agency than limiting or stopping an individual’s ability to practice one’s profession. Parents tell their children, “. . . you can be anything or do anything as long as you work hard.” There should be an endnote to that aphorism:
“. . . but if your ‘anything’ requires a state-issued credential, be sure that you pass scrutiny by the regulatory agency charged with issuing that credential.” The EMSRB therefore is committed to doing the right thing and doing it right. Chapter 144E of Minnesota Statutes defines those criminal matters and behavioral issues that could compromise one’s EMS credentials. Sometimes the agency explores conduct that may impact the initial issuance or renewal of a credential. For example, if an applicant discloses (or if the agency subsequently learns of) three prior DWIs and current court probation for a controlled substance crime, such a scenario could impact that person’s ability to obtain and maintain an EMS credential. Agency staff members prepare very detailed case files that are reviewed by the agency’s Complaint Review Panel (CRP), which is a subset of the full Board. The CRP also
is aided by an assistant attorney general. Matters before the CRP are confidential and remain confidential unless and until a final and adverse action is decided by the full Board. Procedural due process allows for a contested case hearing before an administrative law judge, and final decisions can be appealed before the Minnesota Court of Appeals. Whether under the rubric of support or regulation, the ten staff members and 19 board members are deeply committed to the success of EMS in Minnesota and ensuring that the public’s health and safety continue to be protected.
Tony Spector, MA, JD, is executive director of the EMSRB. He has worked as a licensed peace officer since 1989, an attorney since 2002, and currently serves as a part-time sheriff’s deputy in Greater Minnesota. Prior to joining the EMSRB, he served as the Meeker county attorney.
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The Medicare Quality Payment Program from cover
aligned well, creating confusion among health care providers and organizations. The programs aim to push our health care system to one that rewards value of care rather than volume. The complexity of these CMS programs reflects the challenge of evolving the system. Overview of MACRA and QPP In April 2016, CMS released the proposed rule for the new Quality Payment Program (QPP), which is based on MACRA (Medicare Access and CHIP Reauthorization Act). MACRA repealed the Sustainable Growth Rate for Medicare Part B Physician Fee Schedule in 2015 and set in place a new payment structure that rewards clinicians for providing value (high quality, low cost services) rather than volume-based payments and for coordinating care with other providers.
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The proposed QPP aims to simplify reporting options for clinicians and health care organizations by combining three Medicare payment programs into a single reimbursement
system under the Advanced Alternative Payment Model evolves. According to CMS, clinicians will report under MIPS the first year of the program
In 2016, eligible providers and clinicians should aim to successfully report to the EHR Incentive and PQRS programs to avoid significant payment adjustments in 2018. platform with two paths to Medicare Part B payments beginning in performance year 2017 affecting Medicare Physician Fee Schedule (MPFS) payments in 2019: 1. Merit-Based Incentive Payment System (MIPS) or dvanced Alternative 2. A Payment Model (APM) Most eligible clinicians are expected to be under the MIPS path in the first few years of the program, while the payment
MINNESOTA PHYSICIAN JULY 2016
to determine whether clinicians met the requirements for the Advanced APM track. The proposed rule has aligned standards to try to make it easy for clinicians to move between the MIPS and APM paths. Who is impacted by MACRA payment adjustments? In the first years of the program, MIPS only applied to office-based clinicians. CMS has coined the term “eligible
clinicians” for those who are reimbursed by Part B MPFS and who qualify for payment adjustments under MIPS or APMs. This includes those clinicians who bill Method II. Under the QPP proposed rule, eligible clinicians subject to MIPS payment adjustments are those who see at least 100 Medicare patients and bill at least $10,000 under Part B. Beginning with performance year 2017, eligible clinicians include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists. Under the proposed rule, other clinicians currently subject to payment adjustments under PQRS and VBM will have the option — and are encouraged — to continue reporting their quality performance measures under MIPS or APM (beginning in 2017), but will not be eligible for upward or downward MPFS payment adjustments until they are added into
the program sometime after 2020. QPP does not apply to hospitals or facilities and does not replace the Medicaid EHR incentive program (which ends in 2021) for eligible hospitals and providers. Medicare EHR incentive payments for providers end after performance year 2016 and are replaced by those in the proposed QPP, but the Medicaid EHR incentives remain in place for Minnesota eligible providers until performance year 2021. Providers potentially could receive incentive payments under the Medicaid EHR Incentive Program, and also be eligible for Medicare payment adjustments under MACRA (MIPS or APM). If providers meet qualifying criteria for the two programs, they must report into both. MACRA Path 1: Merit-Based Incentive Program CMS anticipates that most, if not all, Medicare eligible
clinicians will initially participate in Path 1 of the proposed Quality Payment Program: the Merit-Based Incentive Program. MIPS streamlines three programs and adds a fourth category of Clinical Practice Improvement to produce a single composite score that factors performance in four weighted categories on a 0–100 point scale. 1. Quality: Replaces PQRS and the quality component of the VBM Program. Clinicians report six quality measures versus the nine measures currently required under PQRS. This category proposes to expand the number of quality measures available to specialty practices. 2. C ost/Resource Use: Replaces the cost component of the VBM Program. No reporting requirements for clinicians, as information is based on Medicare claims data. 3. Advancing Care Information: Replaces the Medicare EHR Incentive Program.
Simple. efficient. ingeniouS.
Clinicians would choose to report customizable measures to reflect their use of EHR technology in day-to-day practice, with a particular emphasis on interoperability and information exchange. Unlike the existing Meaningful Use program, this category allows clinicians to receive a partial score for successfully attesting to only some of the measures. 4. Clinical Practice Improvement Activities: A new category with over 90 options focused on care coordination, beneficiary engagement, and patient safety. Clinicians may select activities to report on that match their practices’ goals for improvement. Clinicians would receive full credit in this category for participating in Alternative Payment Models and in Patient-Centered Medical Homes (PCMH), without having
to select specific activities. CMS will analyze all PCMHlike models, such as Minnesota’s Health Care Homes, to determine whether they can receive the credit. MIPS scoring and reporting Eligible clinicians can choose measures and activities appropriate to the type of care they provide, for two of the four categories. They can choose to be assessed as a group or as individuals across the four MIPS performance categories. The Composite Performance Score from the four categories will be compared to the MIPS performance threshold to determine the adjustment percentage the eligible clinician will receive. The MACRA law requires MIPS to be budget neutral, which means MIPS can impose either neutral, negative, or positive payment adjustments to Medicare Part B payments. The Medicare Quality Payment Program to page 14
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The Medicare Quality Payment Program from page 13
Negative payment adjustments from low performers will be used to pay positive payment adjustments from high performers. Those who meet baseline threshold performance will not have payment adjustments. The payment adjustments in the proposed QPP are: • Up to 4 percent in 2019 based on 2017 performance • Up to 5 percent in 2020 based on 2018 performance • Up to 7 percent in 2021 based on 2019 performance • Up to 9 percent in 2022 based on 2020 performance An additional $500 million (exempt from budget neutrality) is available during the first five years of the program for clinicians who meet the eligibility criteria for “exceptional performance” on their MIPS score. The total upward adjustment cannot exceed 10 percent.
MACRA Path 2: Advanced Alternative Payment Models Alternative Payment Models are new approaches to paying for medical care through Medicare that incentivize quality and value. Qualified Advanced
Two-Sided Risk Arrangement (available in 2018) To qualify as an Advanced APM under the proposed QPP, a payment model must:
Payment adjustments for not reporting can result in -2 percent.
APMs in the proposed QPP currently include: • Comprehensive ESRD Care Model (Large Dialysis Organization arrangement) • Comprehensive Primary Care Plus (CPC+) • Medicare Shared Savings Program — Track 2 • Medicare Shared Savings Program — Track 3 • Next Generation ACO Model • Oncology Care Model
1. Require clinicians to use certified EHR technology 2. Meet quality measurement criteria comparable to those used in the MIPS quality performance category 3. Require participants to either a. Bear more than nominal financial risk for monetary losses, or b. Participate in a medical home model expanded under the Innovation Center authority For clinicians participating in an Advanced APM, the APM reports on behalf of eligible clinicians, which covers the requirements for MACRA Path 2. The QPP proposed rule recommends that beginning in performance year 2017–2018 (payment years 2019–2020), eligible clinicians “significantly participating in Advanced APMs” under Medicare will be exempt from payment adjustment under the MIPS path, and will qualify for a 5 percent Medicare Part B incentive payment. Significant participation means that through the Advanced APM, clinicians receive 20 percent of their Medicare payments or see 10 percent of their Medicare patients. Providers participating in an APM who fall short of the requirements would be able to choose whether they would like to receive a payment adjustment through MIPS. Starting in performance year 2019 (payment year 2021), the participation requirements for Advanced APMs may include non-Medicare payers and patients.
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MINNESOTA PHYSICIAN JULY 2016
Reporting to Quality and EHR Incentive Programs 2016 performance period In 2016, eligible providers and clinicians should aim to successfully report to the EHR Incentive and PQRS programs to avoid significant payment adjustments in 2018. Eligible professionals must successfully report to PQRS this year to avoid negative payment adjustments for PQRS and VBM Programs in 2018. Payment adjustments for not reporting can result in -2 percent for not reporting into PQRS and an additional -2 percent to -4 percent for the Value-Based Modifier program, as PQRS is a required component. Professionals eligible for the Medicare EHR Incentive Program must also successfully attest to Meaningful Use in 2016 to avoid an additional 2 percent MPFS payment adjustment in 2018. 2017 performance period All eligible clinicians should expect to report through MIPS during the first performance year, which begins January 2017 unless they are informed by their organization that they qualify for an advanced payment model. Payment adjustments will occur in 2019 based on Composite Performance Scores. Physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists are subject to MIPS payment adjustments in 2017 performance year. However, because they are not eligible for the Medicare EHR Incentive program, they have the option of including or excluding their score for the Advancing Care Information category as part of their MIPS composite score in 2017. How to prepare for proposed QPP changes? Everyone involved in patient care needs to have at least a basic understanding about how they impact value. Organizations that will flourish in this new environment take the time to learn the details and align their workflows with them.
Program from page 19
Anticipating that the proposed Quality Payment Program will be finalized in some form, it would begin Jan. 1, 2017. Clinicians should prepare for QPP by first understanding their organization’s experience in attesting to Meaningful Use and reporting PQRS data. If it hasn’t been successful to date at one or the other, Minnesota’s Medicare Quality Innovation Network–Quality Improvement Organization (QIN-QIO) — Lake Superior Quality Innovation Network — offers education to clinicians. The CMS PQRS and EHR Incentive program websites explain the details of each program with links to tools and resources.
Also, clinicians should understand how their organizations rate related to cost and quality. In the fall of each year, CMS provides organizations with a Quality and Resource Use Report
heart is the push to invest taxpayer dollars wisely to improve the care of our senior population. A goal we should all be able to get behind.
announces when the QRUR is available. Clinicians who are part of an Accountable Care Organization or Medicare Shared Savings Program should be thinking about whether their organizations
Medicare EHR incentive payments for providers end after performance year 2016.
(QRUR) that presents patient/ provider/organization specific data related to cost and quality of Medicare services as well as their payment adjustment. CMS
would qualify for the Advanced Alternative Payment Model and what it would take to qualify. While the devil of payment reform is in the details, at its
Lisa Gall, DNP, FNP, clinical program manager, and Candy Hanson, BSN, PHN, program manager, at Stratis Health, help physicians and clinics understand and succeed in the EHR Incentive Program, PQRS, VBM Program, and MIPS, to make lives better for Medicare beneficiaries. They work with the health care community to achieve Medicare’s quality improvement goals in Minnesota through Lake Superior Quality Innovation Network.
Resources CMS website Quality Payment Program: Delivery System Reform, Medicare Payment Reform, & MACRA, https://www.cms.gov/ Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html CMS 14-page overview of proposed Quality Payment Program, 4/27/16, https://www.cms.gov/Medicare/Quality-Initiatives-PatientAssessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/NPRM-QPP-Fact-Sheet.pdf
JULY 2016 MINNESOTA PHYSICIAN
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HEALTH CARE POLICY
T
The 2016 legislative wrap-up
he short 12-week, 2016 Minnesota legislative session came and went and each week seemed to be filled with drama and intrigue. Looking back before the session began in early March, the big question on the table was whether legislative leaders could come together to agree on a tax and transportation package that had been left hanging at the end of the 2015 session. Pair that immense task with the politics of an election year, a supplemental budget, and a bonding bill and you had the makings for the drama that played out in the final hours of the session in May. Tensions were high over the final weekend of the session as the Legislature put together a $270 million tax bill. An additional $130 million supplemental budget bill, which was largely decided behind closed doors, left onlookers waiting to see what would be rolled out in each bill. Emotion was at its highest concerning
An election year session By Nate Mussell, JD the bonding bill which — after two unsuccessful votes in the Senate and House respectively — finally passed the House with enough DFL votes in the wee hours of that last Sunday night. The Senate then acted on the bill adding an amendment related to Southwest Light Rail Transit — a key sticking point with House Republican members — sending it back over to the House but not before time had run out on the session. After last minute legislative volleying to end the session, the blame game started in earnest as legislators left the Capitol to head into a contentious fall election season.
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Fall election preview All 210 legislators are up for re-election this November and control of the House and Senate hangs in the balance. One of the key factors that won’t play
she chaired the HHS Reform committee for the last four years. She was a key public health advocate who championed the Freedom to Breathe Act of 2007 in her first legislative session and helped advance e-cigarette and tobacco tax regulation in recent years. She was also a key leader on nursing issues having most recently carried the advanced practice registered nurse (APRN) bill in the 2013 legislative session. On the House side, Rep. Mack announced midway through the session that she would not seek
This year is particularly important for health care and the future of the provider tax.
out until late October is the effect of the national presidential ticket on the House and Senate races, particularly in the suburbs and outstate areas. Looking back over the last six years, the House majority in particular has shifted back and forth between Republican control in off year elections and Democratic control in presidential year elections. The other significant factor in the elections is the large number of legislative retirements — including many veteran legislators and key caucus leaders — in both the House and Senate. In total 23 legislators will not seek re-election and an additional five House members will vacate their seat to run for Senate this fall. On the health care side there were two notable retirements: Sen. Kathy Sheran (D–Mankato) and Rep. Tara Mack (R–Apple Valley). Prior to the opening of the Legislature in March, Sen. Sheran announced that this would be her last session at the Capitol. She has been a long-time member of the Health and Human Services (HHS) Reform and HHS Finance committees, and
re-election. Mack chaired the House Health Policy committee the last two years and was a leader on health care issues among the Republican House caucus members. The looming provider tax While the balance of power coming out of any election is critical, this year is particularly important for health care and the future of the provider tax. Currently the provider tax is scheduled to be repealed at the end of the 2019 calendar year. The Senate Democrats gave an early preview this session of the upcoming battle likely to take place in 2017 with a proposal to reduce the overall tax rate and to continue the tax past 2020. The proposal also included changes to Minnesota Care eligibility increasing the current income threshold and proposing a potential public option. House Republicans on the other hand have long been supportive of keeping the repeal in place — a key victory they got in the lengthy government shutdown back in 2011. If the majorities stay where they are, you can expect a battle over the
future of MinnesotaCare and the provider tax; but should the Democrats regain the majority in the House, anything is possible. Within the medical community there might be an increasing divide over the provider tax and the existing funds in the health care access fund. Earlier this year the Minnesota Hospital Association (MHA) came out in favor of keeping the provider tax in place while the Minnesota Medical Association (MMA) has remained staunchly opposed to removing the repeal. Much of the concern from the MMA has stemmed from the Legislature’s continued use of the provider tax dollars that are put into the Health Care Access Fund or non-health care General Fund spending. The pattern continued again this year in the supplemental budget where the Health Care Access Fund was the primary source of funds for new Health and Human Services spending. The supplemental budget bill In the second year of a legislative biennium the supplemental budget bill generally takes a backseat to the Legislature passing a bonding bill. Recent years have bucked this trend — particularly over the past two years when the Legislature operated with a budget surplus. In Health and Human Services, the pattern from last year largely continued with further investments in the state’s fractured mental health system. The House and Senate agreed in the last days of the session to take $75 million from the Health Care Access Fund to pay for the new spending in the HHS budget. The most significant spending was directed toward state-operated facilities including the Anoka Regional Treatment Center and bringing the state’s Community Behavioral Health Hospitals up to full bed capacity to try to deal with the ongoing bed crisis felt around the state. The additional $60 million in mental health
funding comes on top of the significant investment the Legislature made in community-based
prosthetists. The licensure of athletic trainers, which physical therapists continue to oppose,
All 210 legislators are up for re-election this November and control of the House and Senate hangs in the balance.
mental health solutions in the 2015 legislative session.
did not move forward this session.
The Legislature also continued to invest in graduate medical education with an additional $1 million in 2016 for the Medical Education and Research Costs (MERC) program and new funding for a targeted rural family practice residency program that will go towards family residency programs in St. Cloud, Duluth, and Mankato. The MERC program in Minnesota provides just over $57 million in state and federal dollars on top of the dollars that come in from Medicare spending for graduate medical education in Minnesota. Going forward, as highlighted a bit earlier, the Health and Human Services budget will be a major discussion point in 2017 not only for the provider tax and MinnesotaCare debates, but also based on significant funding increases that have been hinted at by key legislators for home- and community-based providers and for Minnesota Family Investment Program (MFIP) the state’s cash assistance program.
It is worth pointing out that prior authorization, once again, gained little traction in the House this session. The MMA, along with many other provider and patient organizations, have pushed for major changes to current prior authorization policies going back to the 2015 legislative session. Despite some changes to the bill, the issue continues to run up against strong opposition from the pharmacy benefit management
companies. Prior authorization will continue to be an issue in 2017 and potential success will largely depend on the outcome of the fall elections. Back to normal in 2017 After two years of construction-related distractions, life will return to normal for returning legislators, newly elected legislators, and the public for the 2017 legislative session. The newly renovated Capitol will reopen to much fanfare in January 2017 and for at least a couple of days, politics will be put aside. But with a full plate and a newly elected Legislature, 2017 will likely be a return to “normal” as the bricks are laid for another session.
Nate Mussell, JD, is with the Minnesota law firm of Lockridge Grindal Nauen, PLLP. The firm provides legal and government relations services to a variety of health care providers.
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What else passed? What didn’t? Scope of practice issues always start interesting discussions in the Legislature, but the trend in recent years has been for the Legislature to only hear scope of practice issues that have been worked out between the parties. There were a couple of scope of practice bills that passed this year — none of which had any opposition — including licensure of genetic counselors, orthoptists, pedorthists, and JULY 2016 MINNESOTA PHYSICIAN
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COMPUTER TECHNOLOGY
H
ospital patients often lack tools with consistent, trusted, and useful information that enables them to be actively involved in decision-making related to their care. The only method of communication is talking directly with their care team. They don’t have a lot of control or pre-knowledge of their daily activity schedules for therapy, medications, and tests. Educational resources, when available, are in the form of paper handouts. To assess the situation further, a steering committee was formed at HealthEast, including physicians, nursing leaders and staff, therapy leaders, and information services. Led by Clinical Manager Derek Ryan, RN, they started with a Lean root cause analysis. It showed excessive care team time spent responding to call lights for simple non-urgent needs, and heavy foot traffic due to wasted travel time walking the hallways. While care team interaction
Empowering hospital patients How technology improved health care literacy By Todd Smith, MD
is a critical part of patient care, the opportunity to improve was evident. The committee set out to best utilize the care team’s time and medical expertise, and enhance the patient experience through improved access to health information, educational resources, and schedules. Identifying the solution The solution was a case of ideal timing and partnership. After identifying objectives, the committee approached partners at Epic, a health care software development company who had launched HealthEast’s
electronic health record (EHR) system. Epic offered an innovative MyChart Bedside application as a tool to improve the inpatient experience. The committee determined that the app had strong potential to meet their overall goals. The tablet-based MyChart Bedside app enables patients and their families to access educational materials and aspects of their medical chart, daily schedules, and test results. They can also learn about their care team and communicate non-urgent requests through the app. Increased patient understanding of diagnoses and daily plans can lead to more robust questions, and enhanced relationships between patients and their care teams, which broadens a patient’s health care literacy. The request feature can also reduce call light usage and give time back to the frontline staff.
Unique uses of technology are becoming a big part of health care.
Learning through a pilot The steering committee used a collaborative team approach with Epic to customize the app for the needs of HealthEast and our patients. They adjusted and reviewed the content that patients would see, developed new training and education for nursing staff, and created key workflows to make the pilot successful. In January 2015, one nursing unit at Bethesda Hospital, a
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MINNESOTA PHYSICIAN JULY 2016
member of HealthEast, began piloting MyChart Bedside. Care teams assisted patients on how to use the app on their own tablet or one owned by the hospital. With the patient’s permission, a family member or caregiver could access MyChart Bedside from a remote tablet, making it easy to check on the patient’s progress. Hospital-owned tablets also provided well-known medical and social media apps, Internet access, and more. Bethesda Hospital is one of Minnesota’s only two long-term acute care hospitals. With a longer length of stay and complex patient cases, it was an ideal location for the pilot. Patients and their families undergo traumatic, life-changing events and are inundated with complex medical information from the time of diagnosis. While at Bethesda Hospital, they transition from short-term, critical care to a longer-term planning state and want a deeper understanding of their care plan. Initial pilot patient surveys indicated that the patient schedule, showing rehab therapies, scheduled medications, and diagnostic tests, was the most popular feature, and caregivers especially appreciated accessing this information from home. They also highly valued seeing lab results and being able to access information about their medications. Patients were enthusiastic about having access to educational information because they could better understand their care and learn more about their care team. Their longer hospital stay allowed more time to become familiar with the tool, and to develop relationships with the nursing staff. Based on positive patient feedback, nursing leadership and multiple governing boards at HealthEast decided on May 20, 2015, to go live hospital-wide at Bethesda Hospital and became the first long-term, acute-care hospital to do so. Critical launch preparation work Before the target December 2015 launch, the committee worked to conquer some key
barriers. One issue was overcoming the challenge of cleaning hospital-owned tablets in isolated rooms, where enteric precautions are used to prevent the spread of VRE (vancomycin-resistant enterococcus) and C. diff. Both are highly contagious and can be very dangerous to compromised patients. The only chemical cleaning methods approved to effectively sterilize the devices used in these isolation rooms are bleach and alcohol-based cleaners. Both of these cleaners degrade and cloud the plastic cover on the device’s camera. The cameras are used to provision the tablet and enroll each patient in MyChart Bedside by scanning a barcode in Epic Hyperspace. If the camera cover becomes permanently cloudy, it can no longer scan the barcode and the device is rendered useless. The problem was solved when HealthEast obtained a UV cleaning device approved by infection control in September 2015. The device kills germs from Enteric Precaution Isolation rooms without the use of harsh chemicals. It was also challenging to decide whether to provide some tablets, or whether to focus on a “bring your own device” (BYOD) strategy. We started by providing a small number of tablets, but are now looking at expanding the BYOD strategy. Having a solid policy in place for the use of personal devices is imperative. This includes security around the guest network and the ability of anyone to access that network. MyChart Bedside users connect to the guest network and potentially put additional demands on limited resources, so there is a need to ensure that only current patients, guests, and staff are using it. It is also necessary to track the type of device in use by each patient, ensure that sessions end with patient discharge, and that all hospital-owned devices are collected. Approximately 400 hospital staff received hands-on training and targeted communications to prepare for an enhanced way of working with patients
using the tablets. This included mandatory training, open lab sessions to view MyChart Bedside and ask questions, the use of Nurse Champions to help
linens, clean room, assist with various activities, etc.). As with all new technology rollouts, the committee continues to work to improve the workflow and
Patients were enthusiastic about having access to educational information.
peers embrace the change, and a launch command center to assist with technical questions.
overall process to increase daily usage, both through patient use and proxy access.
Current patient protocols and usage Now upon admission to inpatient units, the primary nursing team determines if the patient is a candidate for using MyChart Bedside. The app is not offered to patients in behavioral health who are committed, in restraints, or in an altered mental status. Staff explain what MyChart Bedside is to appropriate patients and ask if they’d like to use it. Patients can use MyChart Bedside themselves, and grant proxy access to family members or caregivers, especially when unable to use it themselves. After discharge, the hospital-owned tablets are wiped of all personal information and cleaned with the UV cleaning device. Patient user surveys can be submitted through the app. Results continue to prove the value we realized during the pilot, scoring high in improving communication with care teams, understanding medications better, and improving patients’ confidence in their stay. The features most highly rated are the daily schedule, lab results, and information pages about medications. Statistics since the December 2015 launch show a daily average of 15 to 18 patients using the app. A total of 108 patients and caregivers have enrolled and logged in a total of 1,173 times. There have been 50 messages sent from patients to their care team or vice versa. Patients have made 30 care requests (change bed/bath
Future plans HealthEast will continue to enhance the app for patients over the next six to eight months. Future functionality will include ordering diet-specific meals, scheduling therapy sessions, and integrating with Vocera, a hands-free communication device used by hospital staff for real-time message notifications. Bethesda Hospital was a great place to pilot this
app, but we do recognize some challenges with the patient population where behavioral health and other conditions prevent optimal use. In these cases, we strongly encourage proxy use. We also hope to grow usage as we roll out the app to HealthEast’s short-term acute hospitals. Unique uses of technology are becoming a big part of health care, and this is a powerful example that enhances our patient experience. We can now physically put transparent medical information into our patients’ own hands, empowering them to more actively participate in their care.
Todd Smith, MD, is vice president and chief medical information officer at HealthEast. He is instrumental in implementing a new era of patient care, utilizing technology as a bridge between providers and patients, while maintaining the deep personal connection critical to patient care.
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Mr. Starnes: Today we will discuss an important element in the evolution of health care delivery — innovation — how it is paid for and how it becomes assimilated into day-today medical practice. All too often, despite the best training, brightest minds, and highest intentions, short-sighted economic policies can delay adopting innovation and limit quality of life, in a way that other industries do not face. While these problems are hardly new, they demand our attention now because of the escalating pace of innovation. Significant advances in patient care are occurring almost too fast to track, and the health care delivery system must find better ways of utilizing them. Let’s start with a baseline question: what do we mean by medical innovation? Dr. Abbasi: I see medical innovation as being able or willing to look at a problem differently and to come up with solutions that go beyond what we are used to. An example is Dr. [Barry] Marshall, who went through a significant personal hardship to prove that a stomach ulcer is truly a bacterial infection that can be treated with a very short course of antibiotics. Up until then, it was treated with horrendous surgery, with high complication rates. He ingested [Helicobacter pylori] bacteria himself to prove that. Another example of looking outside the box may be the approach that [Takeru] Kobayashi takes in hot dog eating contests. I’m not advocating for that, but until then, everybody saw the problem as, “How can I eat so many hot dogs in a certain period of time?” He looked at it as, “How can I eat one hot dog as fast as I can?” By looking at it that way, he suddenly cut the times and records by one-third. All of a sudden this was a solvable problem, and now everybody could do it that way. Dr. Lumi: Innovation in medicine could best be defined as finding a way to treat a problem in a manner that is different from the standard of care. That might be a new discovery, a new technique, a new medication, or it may be a return to previous ways of doing things that just aren’t standard now. Innovation covers a broad spectrum, from technology to implementation. Dr. Beecher: One innovation would be covering people for risk, conditions, and circumstances that they can’t afford to
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Medical Innovation vs. Medical Economics When payment policies limit quality of life
ABOUT THE ROUNDTABLE Minnesota Physician Publishing’s forty- fifth Minnesota Health Care Roundtable examined the topic of “Medical innovation vs. medical economics: When payment policies limit quality of life.” Six panelists and our moderator met on April 21, 2016, to discuss this topic. The next roundtable, on November 3, 2016, will address Value-Based Reimbursement: A new way to pay for health care.
treat. Under the ACA [Affordable Care Act], we have seen a policy push towards government third-party payment and expansions of insurance. But innovation can also come at a cost, and we may see unintended consequences. So I’m looking for a patient-centered approach. A clinical example of that, for me, would be comparing addiction treatment over the last 50 years, when we didn’t have any form of organized treatments, to the current industry of addiction treatments. The Hazelden Betty Ford approach can be very effective, but it now has been grafted onto a managed care structure. What I’m curious about and following closely is individualized addiction treatment, which is an innovation in both the payment and the treatment arenas.
Mr. Starnes: That brings up an interesting point: can medical innovation include business models? Ms. McClernon: As a health care administrator, I’ve seen technology adopted by different disciplines. I’ve seen where it works and I’ve seen the need for a more organized approach to technology assessment. One example would be our quality committees. At one time, medical staff ran the medical committee, and I ran the hospital quality committee, which was looking at infection control, pharmacy, and other areas. We created one single quality committee. Initially that was not seen as the right thing to do, but that changed. For example, we once had an issue in cardiac where we had a high bleed rate. Our pharmacy people went back and worked together. Six months later, we realized that there was an issue between the protocols. Those two clinicians, working together, got everything corrected. I see that as innovation at a system level and an operations level. Dr. English: I think all of us view innovation as a new drug or a new surgical procedure or a new surgical machine, but my essential mantra is that cost is the issue that drives all the others. The area that I’m really interested in now is called direct pay to primary care physicians. It’s a membership model whereby for $75 a month, about what you pay for your cell phone bill, you have access to a network of primary care physicians, and you can see the doctor as often as you want. In theory, there are no bills to an insurance company. There is no coding. Whatever medical record you want to keep, you may keep. There are no mandates for electronic medical records. It is a contract strictly between the physician and the patient. If at any time the patient wants to leave, they leave. They don’t pay the bill the next month. Granted, you still need catastrophic insurance, but that is now a federal mandate under the ACA. So if you need specialty care, or if you need major medical illness care, your insurance will kick in. The philosophy is that primary care is or at least should be something that everybody uses at least once a year. It is an expected cost, just like your dentist. Medicine used to be like this. This is basically taking you back to a time when the
MINNESOTA HEALTH CARE ROUNDTABLE contract was between the doctor and the patient. This is actually innovation in the financing of medicine, but that is critically important, in my opinion. Ms. Larson: As others point out, innovation is just a new way of thinking about an existing problem. We know that the current health care system is not sustainable in the way that we have financed it and funded it to date. So I see innovation as looking at different models to pay for health care — for example, the Accountable Care Organizations [ACOs] through Medicare and the integrated health partnerships, which are essentially a Medicaid ACO. Under some types of payment models, you are starting to have a more collaborative relationship with the health plans, something that hasn’t happened in the past. Mr. Starnes: How do payment policies either slow the adoption of innovation or limit the quality of life? Dr. Lumi: For people with severe life-threatening obesity, bariatric surgery can improve quality of life and increase longevity; reduce risks of cancer, degenerative disease, and the number of medications used; and cut overall health care costs by three years after surgery. However, the average person only spends 2.5 years with any particular insurance company. The companies recognize this, and have pooled together to create barriers against bariatric surgery. In my mind, this is really quite unethical. If you had coronary artery disease and needed a four-vessel bypass and your insurance company said, “I’m sorry, you have to prove to us you can keep your LDL cholesterol under 150 for six months,” or, “You have to prove that you can remain nonsmoking for six months before we’ll authorize an operation that will improve your quality of life and longevity,” you would not stand for it. You would be up in arms, screaming, but that is what morbidly obese people face. Their insurance mandates that they must do this for six months, must do that for one year, and now there is a mandate amongst all insurance companies that they have to lose 10 percent of their body weight and keep it off for 12 full months before they will authorize bariatric surgery. Dr. Beecher: When I was a medical director in a large PPO [Preferred Provider Organization], I was on the pharmacy and therapeutics committee. Like most of the major payers
in Minnesota, we hired a pharmacy benefit management company [PBM] to try to balance the costs and benefits of specific medications. Many times there was some reference to peer-reviewed research, but in most cases it was a matter of holding onto something old that seemed to work just as effectively as something new unless it could be proven otherwise, because the new medications were usually patented and more expensive. There was a real pressure to ration care for the more expensive patented medications. That still happens. You might have an innovation for hepatitis C, perhaps, a new drug that is incredibly effective but costs an extraordinary amount. How would a committee balance those things? In our organization we relied a lot on the PBM, relied on the Express Scripts, or on other contractors to give us advice. They in turn would talk about what other companies were doing, so there is a consensual process that goes on within that rationing process in the insurance companies. Dr. English: Your plan undoubtedly has a formulary, and usually the company will say, “Well, this is based on best practices or expert opinion,” but the point is that formularies are different from one company to another, which doesn’t make any sense. Either there is one formulary, there is one best way to do things, or there isn’t one best way to do things. That’s not termed “kick-backs,” but “rebates.” Health insurance companies get tremendous amounts of money back that they don’t tell you about. They just say that the pharmacy cost was X. They don’t say that the pharmacy cost was X but that they got Y back. There is no parity in the selection of drugs. If there were, we would all have the same formulary. Ms. Larson: One of the initiatives we are working on now is an integrated behavioral health model. Within our Medicaid population, the most prevalent disease state is depression. So we are trying to integrate a behavioral health specialist within primary care. Studies show that, especially in Northern Minnesota, there is a shortage of behavioral health providers, there is a shortage of hospital space for these people, and they are ending up in the emergency rooms or in jail. We’re trying to reach these patients earlier by having the behavioral health specialist embedded in primary care clinics. This new model does not currently exist in the health care payment structures. We
Hamid R. Abbasi, MD, PhD, FACS, FAANS, is a board-certified neurosurgeon with the Tristate Brain and Spine Institute, with locations in Edina, Alexandria, and Crookston. Dr. Abbasi has extensive experience in minimally invasive spine surgery, including minimally invasive correction of deformities and scoliosis, and is among the small number of surgeons who have performed the highest number of minimally invasive OLLIF (Oblique Lateral Lumbar Interbody Fusion) procedures. Other practice areas include surgical pain management, complex spine surgery, trauma and spinal stabilizations, spine and spinal cord tumors, brain tumors, pituitary tumors, brain hemorrhage and non-emergent trauma vagal nerve stimulator, peripheral nerve, and carpal tunnel. Lee Beecher, MD, DLFAPA, FASAM, is president of the Minnesota Physician-Patient Alliance (MPPA), a nonprofit organization committed to improving health care. He is a distinguished life fellow of the American Psychiatric Association, a fellow of the American Society of Addiction Medicine, an adjunct professor of psychiatry at the University of Minnesota, and a member of the editorial board of Clinical Psychiatry News. Now retired, Dr. Beecher maintained a solo practice in adult and addiction psychiatry in St. Louis Park for more than four decades. E. John English, MD, is currently affiliated with PrimaCare Direct, a cooperative of Minnesota clinics offering unlimited primary care access for a low monthly fee of $75. A family practice physician, Dr. English retired from the Apple Valley Medical Clinic in 2008, which he founded in 1978 with four other physicians. Board-certified by the American Board of Family Practice, he also served as medical director and chairman of the board of Minnesota Healthcare Network, a group of independent practicing primary care physicians. Melissa Larson, MBA, is vice president of operations for Integrity Health Network, LLC, and Integrity Health Innovations, a Medicare-approved ACO. Her responsibilities include health plan contracting, reimbursement analysis, and working closely with member clinics to develop operational and collaborative strategies for successful emerging payment models. Ms. Larson has more than 20 years’ experience in health care, including 10 years in clinic administration. Crystal Lumi, MD, FACS, is in independent medical practice as Crystal Lumi, MD, PLC. Board-certified in surgery, she graduated from the University of Minnesota Medical School; served a residency in surgery at Marshfield Clinic/St. Joseph’s Hospital in Marshfield, Wis.; and served as a fellow in bariatric, metabolic, and minimally invasive surgery at the University of Minnesota Medical School. Susan McClernon, PhD, MA, is faculty director for the Health Services Management and Applied Business programs at the University of Minnesota. She recently led the development of a new Bachelors of Applied Science in Health Services Management at the University of Minnesota Twin Cities campus, a degree program that now has over 70 students in its first year. She is also the president and CEO of Innovative Healthcare Leadership, LLC, a health care consulting firm, which has been serving health care organizations since 2007. She is an active Fellow in the American College of Healthcare Executives and was named Hospital Administrator of the Year in 2007 by Minnesota Hospital Association’s HealthCare Auxiliary.
ABOUT THE MODERATOR Mike Starnes has been the publisher at Minnesota Physician Publishing since 1986. His duties include the production of MedFax, Minnesota Physician, Employee Benefits Planner, and Minnesota Health Care News; directing the Minnesota Health Care Consumer Association; and hosting the Minnesota Health Care Roundtable.
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MINNESOTA HEALTH CARE ROUNDTABLE “ I’m still waiting for a taker to help me educate the new generation of surgeons.” Hamid R. Abbasi, MD, PhD, FACS, FAANS Mr. Starnes: In other words, they would rather pay more for something that works less well. Dr. Abbasi: This is the reality. I’m being cynical now, but insurance companies know that if they delay, pretty soon it will become a different insurance company’s problem. Sometimes we have to circle back a year later with a different insurance company and so, if we are cynical about it, the method pays off. It pays to unload the problem to a different insurance carrier.
are fortunate enough to have some grant funding to try new things and to develop a working model, but at this time we only have a limited source of funding. Mr. Starnes: Let’s go back to hard scientific procedures. Hamid, you were involved with the OLLIF [Oblique Lateral Lumbar Interbody Fusion] surgical procedure for spinal fusion. It seems to have great outcomes, but how do the payers handle access to this procedure? Dr. Abbasi: I’m reminded of what Crystal said. She talked about a bariatric procedure that works, but the payers say, “We want those people to be motivated, so they should lose 10 percent of their weight first.” On paper, that sounds realistic, but when you dig deep down, you see that there are shortterm financial reasons that have very little to do with patient care. The first spinal surgery I was involved with took nine hours, and when I was in residency, we still spent seven hours. With OLLIF, we do it now in 35 minutes. The patient walks out of the hospital or surgical center two hours after the surgery. This is not about the surgical skills of one surgeon or the selection of a certain patient; it’s about a new procedure. This is the Kobayashi of hot dog eating. We published our data, and we have scientific proof that it costs less, cuts the surgery time to less than half, cuts the blood loss to one-tenth, and usually patients walk out of the surgery center on the same day. This data is available to insurance companies, but many of them deny the procedure, sometimes saying, “It’s not on our list.”
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Dr. Lumi: Exactly. As we said before, the insurance company that is supposed to pay for it doesn’t want to pay for it. If they can find ways to delay paying for it or make it somebody else’s problem, that’s to their long-term benefit. Mr. Starnes: Payment policies cause many perverse incentives and have a ripple effect. If we solved the payment issue, then you would still have malpractice concerns or first-to-fail concerns. Even if a procedure like OLLIF is proven best, how am I going to do the number of procedures required to get good at it, and how is that going to happen? How does that slow the adoption of innovation? Dr. Abbasi: You practically named the problem. It is not good enough for one surgeon being able to do that, and it is not about one single center’s result. You need to show that you can repeat the same result somewhere else, and that is where we as a community need to come together. It takes 40 procedures to get efficient at OLLIF. I call them 40 cases of hell, because, as a private surgeon who doesn’t have a huge institution behind me, I’m responsible for every single one of those patients. If we decide as a society or as a medical community that this is truly good for our patients, we have to coach surgeons in the procedure, teach them, mentor them. That is what I do with our Inspired Spine initiative. I know that if I just go on a weekend course to teach somebody a new method, they will not become proficient, so we bring them to us. We ask them to gather their cases and prepare them with an experienced surgeon to coach them through that new procedure. Many of these procedures are so new that
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you cannot learn them in any university or residency program. As a matter of fact, I’m the only surgeon in the upper Midwest performing the OLLIF procedure and even though I have offered to teach residents in the local community, I’m still waiting for a taker to help me educate the new generation of surgeons. Ms. McClernon: We are caught between two systems when we innovate. We are trying to use scientific processes and to gather evidence showing the efficacy and the value of the product. At the same time, things are innovating so quickly. Oncology might be one model. Collaboratives have worked together to collect data, moving it from a university-only system out into community-based systems. They do this by partnering, by gathering data more quickly across a broad spectrum. The adoption of innovation moves more quickly as a result. Mr. Starnes: Does anyone have insight into the role the FDA [Food and Drug Administration] plays in hampering or otherwise slowing innovation? Ms. McClernon: I was involved with the new Watchman device, which is placed in a part of the heart to reduce the risk of stroke. I happened to have a personal family member get involved in the trial phase, and it worked beautifully. My brother, who is a training and development person working with the company, was trying to get FDA approval, but they were running into complications. So he got some of the top cardiologists that were performing this procedure together, and they went through the process. They identified the key steps, and from that they rebuilt the training. They reduced complications to the point where they finally got FDA approval. Dr. Abbasi: We need to put a structure in place that encourages people to go out, bring their methods out, and let their success become a community success. I can tell you from personal experience how painful that process is, how slow that process is. It is a double-edged sword. Dr. Beecher: Another dimension that concerns me a great deal as a psychiatrist is the question of what we call things. In behavioral health, we talk about a DSM-V, this tremendously expanded lexicon of different states of normal and beyond, and we correlate things using statistical analysis. Under the Affordable Care Act, we have so-called mental health parity, which tries
MINNESOTA HEALTH CARE ROUNDTABLE to ensure that mental health patients and chemically dependent people have access to care. But we talk about behavioral health and mental health as if we know what those are. Not only do we say that we know what they are, but we talk about how we are going to pay for them and how we are going to capitate for them and how 80 percent of our pharmacology is coming through primary care for major mental illness. We have a crisis in our state hospital system right now. We have segregated mentally ill people from the rest. We have been doing that for ages, ever since I was a young doctor. But this idea of somehow correlating diagnosis with treatment is a tricky business. Mr. Starnes: When organizations focus on innovation, do they forget that the doctor/patient relationship is really the most important part of health care? Dr. Beecher: We are shifting our older notions of a doctor/patient relationship to an organization/consumer or an organization/enrollee relationship. That is not a pernicious thing necessarily, but how can an intelligent patient or consumer access information to make a sound decision? If you do, how are you going to pay for it, and what kind of vehicles do you have in the insurance market that allow a selection of different alternatives? The government has decided that we are going to guarantee that everyone can be issued insurance, without assessing individual risk. Now UnitedHealthcare is saying, “Hey, we don’t want to play that game anymore in the insurance exchanges, we are not making any money, so we are going to withdraw.” Organizations are going to make decisions based on their own self-interest, and it will lead to political discussions about what type of health care system we want to have. Bernie Sanders says that we have a right to health care, we are going to have Medicare for all, yet our Medicare system is in terrible shape. We haven’t figured out how to allocate resources. If we do not have competition among not only the insurance companies, but also the providers of care, how is the consumer going to make rational decisions? Our deductibles are also increasing, so now, unless you are on Medicare, you have a $5,000 deductible to deal with. Ms. McClernon: The issue of deductibles and copayments initially seems devastating. The good news is that it makes the consumer/patient get in the game. You look at it and say, “Hey, I have a decision on where
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the first $5,000 of my health care goes.” I’ve been making different decisions myself, and I’m seeing others make different decisions. I think that could be a positive way of getting us back into a part of the financing of our own health care. If it gets us to start taking responsibility, individually and for our families, I think that is a positive in the system. But it does cause hardship and leads some people to avoid seeing the doctor. Dr. English: I would agree, but somewhere between the $5,000 and, say, $25,000, if you plugged in the old-time indemnity insurance model, you could actually get people incentivized. The way it works now, when somebody gets sick with a major illness, they know they are going to blow through that $5,000. All bets are off after that. There is no incentive for them to be involved in the delivery of a $100,000 procedure that could come down in cost, but the patient, to really be involved, has to be involved incrementally. Granted, you are not trying to blow somebody out of the water, so there has to be a stop loss. I don’t know what level to pick for that to where you are no longer responsible, but I would add one caveat: that 80/20 indemnity, that works. Mr. Starnes: How can patients contribute to the adoption of medical innovation?
Dr. Beecher: My take on that is that the driving force for medical cannabis in Minnesota has nothing to do with pain relief. It really has to do with the fact that a lot of people in this state believe that marijuana should be legalized, that it should be available as it is in Oregon and in other states. This was a compromise position and it is unique. In no other state has anybody ever set up a system in which a physician is supposed to make a diagnosis and a pharmacist is supposed to decide the dosage for a drug that hasn’t been approved for anything that anybody is claiming it is for and then the commissioner of health is now empowered to say that it is okay for pain. This is really a political maneuver. Mr. Starnes: Sounds like some bad innovation. What about the idea of patient satisfaction? Melissa, we are so worried about whether patients are satisfied. Does this throw a monkey wrench into innovating? Ms. Larson: I believe so. We all know that it is important to engage patients and make sure that they are satisfied. But say you have brilliant surgeons with terrible bedside manners — how would the patient rate their value? What is it that the patient is valuing? Do they want a good outcome from their surgery or do they just want to feel good when they are speaking with the surgeon? That is a case where patient satisfaction can sometimes get in the way of good medical results.
Dr. English: The best example of where patients can be effective is medical marijuana. There is not a lot of science on this, this hasn’t been studied, this isn’t evidence-based medicine. Some people Dr. Lumi: When we talk about medical had anecdotal stories, and there is nothing innovation, there is often the “wow” factor. wrong with that, but the medical system is “Oh, I had my based on the scientific method, and it can gallbladder take years to figure out whether something taken out works. Anecdotal medicine is the exact opposite. It is one person saying, “I took this juniper berry juice for two weeks and I’ll tell you that “ Cost is the issue it works.” With medical that drives all marijuana, some patients got together, I’m sure they the others.” used the Internet as a platE. John English, MD form, and then they went up to the Legislature, and it passed. So the patients have input? Absolutely. I would hate to be sitting on an FDA panel. They are going to get nothing but pressure, and it will increase exponentially with the new drugs coming out.
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MINNESOTA HEALTH CARE ROUNDTABLE robotically.” It doesn’t matter to them that it cost twice as much, that they have bigger incisions than they would have had with traditional laparoscopy, that they have higher complication rates and the hospital is eating the bill because the payment for a standard laparoscopic gallbladder removal and a robotic gallbladder removal is the same even though the cost may be tripled. But patients say, “Oh, I had it done robotically.” It’s the shiny factor. You have to take a little step back and realize that patients aren’t always engaged in their health, and may have a variety of motives for what they choose. I always get a little irritated about the term “health care,” because most patients are not interested in caring for their health. They are interested in caring for their illness. They want illness care. They don’t want to see a doctor, they don’t want to be involved in eating right or exercising or doing anything else that might promote their health, they just don’t want to have a cold when they visit Aunt Sue down in Florida, because that would be inconvenient. Mr. Starnes: What can patients do to speed the development and adoption of medical innovation? Ms. McClernon: Health care has its own language, with its own ABCs and terms. Research shows that the more literate patients are about health and health care systems, the better their outcomes. We need to remind ourselves that we created this huge language and complex system, and ask ourselves how we can unwind that. We have to listen to our patients and get them involved in that process. This emphasis on patient satisfaction, where Medicare payments to health systems are based in part on patient experiences, is a crude way to get to it, but it has our attention now, economically, which is what we probably needed. We also need to remind patients how much their own behavior can impact their health.
people know words, it doesn’t mean they truly know what they mean or what their impact is. Assessing health literacy takes a lot of time, and time is one of the things that we don’t have in abundance in the examination room. If we are going to look at the economics of paying physicians for performance, and part of your performance is tied to your patient’s satisfaction, and patient satisfaction is based on them understanding what you have said, then you have a real problem. Ms. Larson: I believe that clinics, physicians, and providers need to look at what they communicate to patients and make sure that what they say is meaningful. Under the “meaningful use” mandates, we are required to provide a post-visit summary. Our EHRs [electronic health records] spit out a bunch of information, but is it truly useful? Does it tell the patient anything? When I visited my doctor, my post-visit summary told me what I came in for and what drugs I was on, but it didn’t tell me anything in between. We need to make sure that we communicate what we need to communicate, and we need to communicate in a manner that is good for our patients. Dr. Abbasi: It is not always easy to combine our many decades of experience and schooling in a 15-minute or a half-hour conversation, but I see that as our failure as providers or doctors. I have a hobby — quantum physics — and nobody could ever explain quantum physics the way I understand it. When I asked about it, they would say,
“ There is a difference between ‘health’ and ‘health care.’” L ee Beecher, MD, DLFAPA, FASAM
Dr. Lumi: Assessing health literacy is very difficult. Working in oncology and in bariatric surgery, there is a pantheon of words that the everyday layman may understand, but if I ask a patient, “What is a protein?” half the time I get a blank look. They can’t really define what a protein is. A famous senator, when asked how he would define pornography, once said, “Well, I can’t define it but I know it when I see it.” Many of my patients would say, “Well, I would know what a protein was if I saw it.” Health literacy is kind of a sticky wicket. Just because
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“Because we don’t understand it either.” Sometimes doctors have trouble communicating information. I have a busy practice, and sometimes I’m late and sometimes my patients are angry because they had to wait an hour to see me, but it is extremely rare that a patient leaves my examination room and is unhappy. I often hear them say, “Doctor, I’m so happy, this is the first time I really understood what is going on.” We need to give our patients a little more credit. We need to explain complex procedures in terms that they understand. For example, I always compare a disc to a tire of a car. Everybody understands what it means to have a flat tire. It would be futile if you tried to communicate with them as if they were doctors who had gone through med school, but if we put it in other terms, we can communicate the essence. If we cannot do that, then we have a problem in our education system. Mr. Starnes: In terms of involving the patients in speeding the adoption of innovation, how could social media be applied? I mean, how can we get those cell phones to help this? Dr. Abbasi: Technology has made information available to everybody. Remember those big encyclopedias that you had to buy? You’d spend something like $10,000 and have 40 volumes in your library, paying them off every month over 10 years. Now all of us have a smart phone. Not everything on the Internet is correct, but whose fault is that? How much time did I take out of my busy clinical life to put expert information out there, so that my patient does not have to rely on some shady person from somewhere else? I’m saying that because I was doing exactly that last night until 1:30
MINNESOTA HEALTH CARE ROUNDTABLE in the morning. I was putting information about minimally invasive spinal fusion surgery on my social media. This is exactly what it takes, and it is not easy. You have to stay awake until 1:30 in the morning, get the information, put it out, but you will find in the long run that it helps you. You can send a patient to your web page to see your post and to listen to a patient who has gone through the same surgery. We have to put information out there ourselves. If not us, who else? Dr. Beecher: I’m sure that Facebook and some of the newer media are being used, but there are some real privacy issues. How do you maintain boundaries when you have all of this information out there? If we want to involve patients in adopting innovation, we need to admit the complexity of the system, admit that we are just as befuddled by it. We are all working on that, but it is a partnership issue with the patient. It’s also a partnership among ourselves. If we delegate to a social worker or to an expert on the economy or insurance or whatever, it is not enough for that individual just to put it into the EHR and walk away. There has to be some sense from the patient that this answers their questions and it is an ongoing relationship. When in doubt, we need to refer to the patient’s needs and complaints. Many times we get off on our own tangent or something and it is not just because they haven’t gone to medical school and don’t understand what a protein is. It is because we are not relating this to their particular needs, that’s the key to it. Mr. Starnes: Are there other ways in which social media could drive the adoption of innovation? Ms. McClernon: We have FitBit devices and health apps on our phones that track our steps and calories. I often think if we just bought that $100 FitBit for each of our patients, we probably would gain a lot. Mr. Starnes: What role can direct-toconsumer advertising play in adopting medical innovation? Dr. Beecher: I’m fundamentally a capitalist at heart and I believe in the free market, but holy cow, you watch television and see the commercials for Viagra and Eliquis — my goodness, you almost get nauseated, and you might develop the side effects that they are telling you about just from watching the commercial. Obviously, these things are being supported by
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Pharma, who has “ The insurance company been kicked out of that is supposed to the doctor’s office pay for it doesn’t as primary care want to pay for it.” doctors have given up their practices Crystal Lumi, MD, FACS and gone into big systems. The reps used to bring their computers in to show us their studies, but all of that stuff is now going directly to the consumer because they have to go through the [pharmacy and therapeutic] committees and the [pharmacy benefit managers] and through the other organizational steps to get the drugs approved. So I’m of two minds. The patients should have choice, but I don’t think they are getting choice through this direct-to-consumer advertising, which of my teachers knew it. This rep came to must be costing a lot. I’m not sure what the me, educated me. I’m not using all the techalternative is. niques they showed me, I put that through Dr. English: The alternative is more direct-to-consumer advertising. I think it is a great thing. I think it is a horrible thing when the health care systems cut out drug salesmen. It is actually a perversion. The assumption here, apparently, is that the health care systems know what’s best for patients more than the drug people do, especially in primary care. Primary care covers everything, so as a doctor, you should have some vague knowledge of what each medication does, even if you’re not prescribing it. I really looked forward to visits from drug salesmen when they used to come in. If you got to know them, they would say, “I just want to tell you that some doctors are using this medication for this condition. You should know about it, too.” That is invaluable. If you are actually a practicing physician, actually seeing people, that’s your livelihood, you need these tips. You can’t go through journals. That’s a full-time job, paging through journals or studies. So the answer, as far as I’m concerned, is more direct-to-consumer advertising. No filters. Dr. Abbasi: I’m totally with John on that. There is a huge value in the free market society. Obviously we have to learn as well in med school to be critical. You shouldn’t take everything they say as truth and you have to digest it through your own intellectual capacity, but I can tell you from my residency that I learned many things from that new method that was developed. None
my own intellectual and training and inquisitive mind, but I cannot overemphasize how important that was for me. Ms. McClernon: I was in the administrative wings when we moved the pharmaceutical companies out. It was very difficult for them to be in between physicians, and yet we lost a lot when we kicked them out, because they were often giving us samples for patients who didn’t have funding, and we were learning techniques. I think it challenged our own pharmacy people to have to work together. I think the easy answer, often times, is just to mandate it out. The pharmaceutical companies, we know, are very innovative, and that is why we have direct advertising. Essentially that was their end around, to say, “Well then fine, we’ll just go direct to the patient.” All of you clinicians, I’m sure, hear things like, “This should take care of my restless leg syndrome, right?” Dr. Lumi: The advantage of direct consumer marketing is that it develops patient awareness that they may have a medical condition that should be treated. They may have something else — they may actually have a gastric cancer instead of gastric reflux — but it brings them into the office, and gives us an opportunity to intervene in helping to diagnose and treat them. The downside is trying to talk them out of the particular medication that they are certain is going to cure the symptom or the problem
Minnesota Physician-Patient Alliance JULY 2016 MINNESOTA PHYSICIAN
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MINNESOTA HEALTH CARE ROUNDTABLE “ Keep making the system simpler instead of more complex.”
outsourced crowd-managed publication. As long as your paper is within the scientific methods, your paper will get published and the crowd, the people, the folks Susan McClernon, out there, they decide how PhD, MA much impact your paper has, utilizing the wisdom of the crowd. It reminds me of a very old story from the 1800s. [Sir Francis Galton] goes to a market and there is a game in which random people guess the weight of a cow, and whoever is closest gets the cow. They were all wrong, but after the process was over, he averaged their guesses, and that turned out to be within pounds of the actual weight. I think our peer review needs crowd sourcing.
that they may or may not have. That is often very thorny because they will get mad and choose to go to someone else who is happy to sit and think about their golf game for five minutes, let the patient talk, write them a prescription, walk them out the door, and then charge for a level-III visit. So I see it as a double-edged sword. I think that anything that you can do to stimulate patient education, patient engagement, is an innovation in health care. However, we have to make sure that the other side of the sword isn’t sharper. Mr. Starnes: What can be done to improve the peer review process of medical literature that could expedite the adoption of innovation? Dr. Abbasi: We are scientists, but we have the same biases and fallacies of every person. I may believe that my research is more important than your research, or that my opinion is more valuable than your opinion. The traditional peer review process is a long, extensive process. Your paper gets sent to somebody else, and if the topic of his research doesn’t match the topic of your research, all of a sudden questions come back that you believe are not relevant to what you are trying to say. Those who have tried to publish a peer-reviewed paper will know that. Dr. [John] Adler, a neurosurgeon at Stanford, started a website [www.cureus.com] that has essentially
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MINNESOTA PHYSICIAN JULY 2016
Dr. Lumi: If you choose to crowd source peer review and just let all comers criticize your paper, thumbs up/thumbs down, is there going to be a corresponding medical innovation where that idea, that process, that new thing that you are touting, gets carried forth into actual practice? The academic societies or big Pharma or anything else, are not going to accept a crowd-sourced peer review article. They are going to want standardized, peer-reviewed articles. My question is, can crowd sourcing translate into actual medical innovation that is disseminated? Dr. Abbasi: That is a good question. If I start evaluating a physics article, my opinion shouldn’t be equal to somebody who has done 30 years of physics, but my opinion shouldn’t be completely dismissed either. We need to be smart about that. Using the example about guessing the weight of a cow, individuals may be wrong, but the wisdom of the crowd is always more than the sum of individual contributors. Mr. Starnes: Let’s move on and talk about innovation in medical education. Are there some things that have been implemented recently or are there some things that should be implemented? Ms. McClernon: The cross disciplines in education are starting to work together. We are breaking down silos to capitalize on our strengths and produce better outcomes. Most of the clinical people I meet say that understanding more about the industry and the business side of health care would help them. I spent most of my career educating clinicians so that they
Minnesota Physician-Patient Alliance
could speak the language to get the capital and the staff they needed to move forward, and I see that as the role of health care administrators. If we can start that type of thinking earlier in the educational process, we can encourage innovation. For example, in some patient safety studies, multidisciplinary teams from different universities compete with each other on the types of challenges they might face in the health system. They have turned it into an interesting educational process. Mr. Starnes: Anybody else with innovations in medical education? Dr. Lumi: One of the more recent failures in innovation in medical education is the whole issue of certification maintenance within certain specialties. It started as a good idea. Once you became board-certified in a specialty, at intervals you needed to complete certain tasks to demonstrate proficiency until you took your next certification exam. What it evolved into is an extremely expensive, onerous, time-consuming, and worthless process for most physicians, one that has recently been rescinded by the American Board of Medical Specialties. It is a real challenge, in the rapid pace of change within clinical medicine, to remain current in your own specialty, let alone if you are a primary care provider who has to know a little bit about everything. I think that rescinding it was probably the wrong thing to do, but it needs an overhaul. For clinicians to just keep their heads above water, we need periodic checks and balances, because we are human and we are lazy and we would rather sleep in on Sunday mornings than read a medical journal for two hours. I see it as one step forward and two steps back in the whole maintenance of certification. Mr. Starnes: Are there examples of innovation in medicine that have not been slowed by payment policies? Dr. Lumi: When laparoscopic gallbladder removal—cholecystectomy—came out in the late 1980s, there was an overnight surge in people lining up to get their gallbladders out through four small incisions rather than the traditional 6–8-inch incision, week in the hospital, and six-week recovery period. Patient demand drove the implementation of laparoscopic cholecystectomy ahead of the data and the coding standards. There were some complications back then, but many believed that
MINNESOTA HEALTH CARE ROUNDTABLE laparoscopic cholecystectomy was equally safe and equally effective, and there was a huge demand for it. Insurance companies scrambled to keep up with this particular innovation. I trained during that period, and part of my residency training was learning to code and bill. We would charge for open cholecystectomy because there was no code for a laparoscopic cholecystectomy. Within a year, there was a code. A grass roots movement by patients pushed not only the coding system run by the Centers for Medicare Services, but it pushed medical innovation in terms of new instruments, new designs, new operating room designs, changes in how operating rooms were built, and it opened the door to a whole bunch of other innovations. People asked, “Well, if we can take the gallbladder out this way, could we do this and this and this?” That happened in the blink of an eye. Dr. English: There are a couple of examples that affected cardiothoracic surgeons. I once thought that with all of this coronary sponsored by artery disease and the entire population getting older, they could work from dawn until midnight, every day of the week. All of a sudden, overnight, stents came in. I don’t want to say that it decimated their profession, but actually it did. All these people had counted on this open-heart coronary artery bypass, and it went away. Another thing in place right now is femoral artery insertion of an aortic valve. What a deal. You don’t blink an eye. You can be 82, and you can have this valve inserted and walk out of there. Dr. Beecher: Outpatient electroconvulsive treatment is one example of innovation in psychiatric care delivery. It happened in the 60s and 70s, but really came into its own in the 1980s. For people with bipolar disorder, serious depression, even schizophrenia that is out of control and isn’t controlled with antipsychotics, this treatment helped. You could bring people in on an outpatient system involving multidisciplinary care, do a very thorough exam, get the families involved, provide the treatment, and allow people to go home. I did that for many, many years, and I can’t tell you the number of suicidal people that we brought around. They didn’t have to be institutionalized, and we saved thousands if not millions of dollars. There are innovative hospital and clinic systems like Abbott Northwestern, the old Metropolitan Medical Center, and others that have very
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good ECT clinics. This is something that isn’t written up very often, but it is a combination of a treatment that works, that is stigmatized in many ways and not well thought of by many people, even by some in the mental health community, but it really works and if it is done systematically and when needed on a long-term basis it can save lives and save money. Mr. Starnes: What are the most important things that need to be done to change the way payment policies limit quality of life? Ms. Larson: In a perfect world, I would say that we take the power to make decisions out of the insurance company’s hands and give it back to medicine. I think that physicians should be in the driver’s seat for these things and ideally that is what will drive the change. Dr. English: I would say patient empowerment. Physicians shouldn’t necessarily be in the driver’s seat. The patient actually should be in the driver’s seat. We have to meet their expectations. The flip side of that is patient responsibility. Somehow that has to be woven together before we are going to get an answer. Dr. Lumi: My fairy tale world is universal access, where access to medical care is not denied because of age, income, or any other barrier, and that everybody has the opportunity to get not just illness care, but true health care and wellness care.
have to go beyond short-term thinking and focus on long-term, evidence-based health care, not just illness-based systems. I’m also still befuddled by the ACA. Before it passed, we had a Medicaid system, and we had a Medicare system. We could have just taken people who were uninsured and put them into those two systems, instead of creating this complex world of exchanges. We have wasted at least five years chasing the wrong rabbit, I would say. I would like to keep making the system simpler instead of more complex. I’m concerned about corporate medicine. If we lose the incentive of our individual physicians and clinicians to influence care, we will lose out on innovation. Dr. Beecher: There is a difference between “health” and “health care.” That line gets blurred, even in primary care. We need to learn about nutrition, about alcoholism, about smoking, about public health issues and so many other things, but that is not necessarily the health care system’s job. All citizens need to realize we are all paying for this, and we all need to get educated. If we can empower the patients, the reform will have to come through our insurance reform. The ACA went way too far. It actually tried to set up a stakeholder system with everybody around the table, and the insurance companies are now beginning to bail. It is going to be really interesting to see how this plays out.
Dr. Abbasi: We don’t want the government to interfere too much in our patient/doctor relationship. In reality, insurance companies do that every day. I think we all want to be in an environment that considers all aspects, including cost, but I do believe that the intrusion of the insurance companies in the patient/doctor relationship has been “ Patient satisfaction more extensive than can sometimes get what government in the way of good could ever do, and I medical results.” think it needs to be limited.
Melissa Larson, MBA
Ms. McClernon: We need access, but we can have all the access in the world and still not have enough providers, especially in primary care. Patient responsibility and engagement are vital, but we have to help patients navigate a complex health system. We
Minnesota Physician-Patient Alliance JULY 2016 MINNESOTA PHYSICIAN
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INFECTIOUS DISEASES
Z
ika infection is the latest in a series of challenges the microbial world continues to present us with. The challenges can arise from a change in behavior (Zika), acquisition of resistance (gonorrhea, “superbugs”), cross continent importations (West Nile virus, chikungunya), a species jump with adaptation to humans (HIV, SARS), or unknown mechanisms (MERS). Increased global travel and climate change stir this pot. Infectious diseases is clearly the least predictable of medical subspecialties. A world of microorganisms is evolving to take advantage of the resources we present and evolution is a tough opponent. Unfortunately, whenever these challenges arise we start with inadequate knowledge. Although we’re actually pretty good at figuring it out, progress seems painfully slow. This article will summarize the key features of Zika with a focus on what physicians should know.
Zika What physicians need to know By Frank S. Rhame, MD The epidemiology of Zika Zika was first identified during yellow fever studies using Rhesus monkeys in the Zika Forest near Kisubi in Uganda in 1947. (It took me a bit of effort to find the Forest when I was in Uganda in September 2014— it’s not promoted as a tourist destination). Zika is a flavivirus, a large group of about 100 viruses. They include yellow fever virus, dengue virus, St. Louis encephalitis virus, West Nile virus, and Powassan virus. The last two cause occasional cases of encephalitis in Minnesota. Most are arthropod transmitted, usually by mosquitoes. For an excellent review of mosquito-borne diseases by Franny Dorr, see the May issue of Minnesota Physician.
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For the first 60 years of its recognition, Zika was identified as a cause of illness in perhaps 100 sporadic (e.g., apparently unrelated) cases scattered across Africa and later in Southeast Asia. Then, in 2007, Zika caused an explosive epidemic on the island of Yap in the South Pacific. This was a distinct change in the virus’ behavior. The epidemic was well studied by the CDC and local investigators and still provides the best basis for predicting what will happen with the current larger epidemic. Notably, Zika infected about 70 percent of the population of Yap over the first three months and then receded to occasional cases. Beginning in 2009, Zika surfaced again in the islands of French Polynesia. Although, less well studied, it appears to have burned itself out in each island it affected after enough of the citizens had been infected. In March 2015, the real crisis began. Cases were identified in northern Brazil. Genetic studies suggest that the virus was imported from French Polynesia in late 2013. Within a year, Zika had spread to most of South and Central America. The Puerto Rican epidemic exploded in February 2016 and continues. In our hemisphere, only Chile and Canada are likely to escape autochthonous cases. Microcephaly and Guillain-Barré syndrome (GBS) were identified in Brazil and weren’t initially recognized in Yap or French Polynesia but were found retroactively. In February 2016, the WHO identified Zika as a Public Health Emergency of International Concern. There are specific nucleic acid changes that mark the current epidemic isolates as different from the previous sporadic isolates. But which of them cause the change in behavior—whether epidemiologic or
clinical—and the mechanisms remain to be determined. The likelihood that any Zika outbreak in the southern U.S. will be as severe as in the Pacific islands, Central or South America, or the Caribbean is low. Our buildings are better constructed and the use of screens and air conditioners is widespread. We spend less time outdoors, have less standing water, and better environmental control. So far, all mainland U.S. cases have been travel related; no transmission has been recognized here. Clinical manifestations of Zika At least 80 percent of infections are asymptomatic. But the range of illness extends to the severe. Fever, headache, malaise, and rash are common. Symptoms begin 3–14 days after exposure. Zika infection and related infections due to chikungunya and flaviviruses have considerable clinical overlap. The rashes are indistinguishable. There is a tendency for more arthralgia in chikungunya and more conjunctivitis in Zika, but laboratory testing is required to separate the illnesses. Debilitation may last for months. Death is rare; the first U.S. death was in an immunodebilitated person. Infection in childhood appears to be less severe than in adulthood. Zika IgM antibody can be detected in the blood by immunoglobulin M antibody capture ELISA (MAC-ELISA) and confirmed by plaque reduction neutralization titer = PRNT. To date, only the CDC and a few public health labs are doing these tests. IgG testing is complicated by cross-reactivity with related viruses, common in many testing contexts. MDH does the MAC-ELISA but refers positives to the CDC for PRNT confirmation. Zika DNA can be detected in blood, urine, CSF, amniotic fluid, and saliva. Saliva is rarely, if ever, the only specimen positive. Initially, testing was only done at the CDC. In May 2015, the FDA licensed the Trioplex RT-PCR. “Trioplex” because Zika, dengue, and chikungunya can be
run in the same well. Testing is limited to labs qualified by the CDC. MDH has only validated blood and urine testing but other specimens can be forwarded to the CDC. Several commercial PCR tests are available. But most labs, because of potential medicolegal vulnerability, prefer to use public health labs. Zika infection is reportable to MDH. The Roche COBAS PCR test is used for blood screening. The blood PCR usually becomes negative within seven days after onset of symptoms, although persistence up to 20 days has been reported. Urine PCR is more sensitive; it usually becomes negative within 14 days, although persistence up to 20 days has been reported. IgM antibody is detectable for about 12 weeks. Testing is recommended for all symptomatic persons and all asymptomatic pregnant women returning from areas of Zika transmission. The CDC recommends blood PCR testing up to seven days after onset of symptoms, urine testing up to 14 days, and IgM testing up to three months. Testing in other circumstances requires special permission (contact MDH to make the case). Undoubtedly the most disturbing and devastating clinical consequence of Zika infection is brain damage in the fetus. The virus seems to have a special taste for developing neurons in the fetal brain. The resulting brain destruction causes volume loss resulting in microcephaly and mental incapacity extending to the severe. Microcephaly is most often assessed by head circumference, obviously a very blunt instrument. We have virtually no long-term follow up of infected but initially normal appearing infants with head circumference above some threshold. There is little basis for confidence that these babies will be normal. We need to know the precise incidence of fetal brain damage as a function of when during pregnancy maternal infection occurs. The best current estimate of the incidence of microcephaly is 1–10 percent after first trimester infection with little impact on the
baseline rate of 2–12 cases per 10,000 live births after later infection. However, head circumference is an exceedingly crude measure of fetal brain damage. Fetal death, eye abnormalities, intracranial calcifications, and other brain abnormalities have also been described after Zika
assertions that Aedes aegypti is the main vector, possibly assisted by Aedes albopictus. But there are over 43 genera of mosquitoes comprising more than 3,500 species and determination of the range of competent Zika transmitters has hardly begun. It is worth noting
The most disturbing and devastating clinical consequence of Zika infection is brain damage in the fetus. infection. By May 2016, the CDC had 115 pregnant, infected women from Puerto Rico and other U.S. territories and 142 in the U.S. under surveillance so information on incidence rates of various adverse events should begin to emerge. Guillain-Barré syndrome has been associated with Zika infection. So far the association has been assessed in casecontrol rather than prospective studies so there are inevitable methodologic concerns. In April 2016, the WHO announced its conclusion that there was a causal association. In any case, GBS is probably not related to fetal neurotropism. Indeed, GBS arises after myriad infections and the Zika version doesn’t appear to be distinctive. The most common GBS variant, acute inflammatory demyelinating polyneuropathy, seems to predominate but that is generally the case with GBS. Any patient who develops distal tingling, pain, weakness, and numbness less than four weeks after being in an area of Zika transmission should be evaluated for GBS by a neurologist because IVIG is effective treatment. The condition is rare enough that the comparative incidence after Zika and other infections is uncertain. The best current estimate of the incidence of GBS after Zika infection is very roughly 2.5 in 10,000 cases. Mosquito transmission Most Zika virus transmission is by the bite of female mosquitoes (only females seek blood). There have been confident
that in the Yap outbreak, Ae. aegypti was an uncommon species and Ae. albopictus wasn’t found. It was not determined what the main vector was. To be a competent vector a mosquito vector must sustain viral proliferation, because passive transmission doesn’t happen. But there are many known and unknown features of mosquito behavior that influence transmission even when competence
is possible. “Snakers” are more effective than “gulpers.” More than one human bite per mosquito lifetime is needed because transovarial Zika virus passage apparently doesn’t occur. Ae. aegypti is effective because it likes human habitation (it’s sometimes called the “cockroach” of mosquitoes) and bites all day long, when humans aren’t protected by bednets. If Ae. aegypti and Ae. albopictus prove to be the only species causing transmission in the U.S., Minnesota will have little or no in-state transmission. Until global warming increases, we won’t have the former and will have no more than very few of the latter. We have 51 of our own mosquito species in Minnesota. But ponder this nightmare: our principal pest mosquito is Aedes vexans, which was present in Yap. Except for the fact that Zika to page 34
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PROFESSIONAL UPDATE: UROLOGY
P
hysicians, patients, and health regulatory groups such as the U.S. Preventive Services Task Force continue to question, evaluate, and revise the recommendations for prostate cancer screening, diagnosis, and management. Recent advances attempt to balance risk of treatment against the risk of enabling clinically significant disease to progress to an incurable metastatic state.
Telephone Equipment Distribution (TED) Program
Prostate cancer screening Despite the continuing controversy, prostate-specific antigen (PSA) and digital rectal exam (DRE) remain simple, cost effective, and minimally invasive screening tools for prostate cancer—and the only ways to screen for clinically significant prostate cancer while it is still localized to the prostate. The American Urological Association (AUA) fully supports prostate cancer screening. Its PSA screening guidelines are available for review at www.auanet.
Trends in prostate cancer management Balancing treatment vs. risk By Peter D. Sershon, MD, FACS org/education/guidelines/ prostate-cancer-detection.cfm. However, we know PSA results may also be elevated by benign prostate growth, inflammation, and even transiently by ejaculation. Using the following recommendations can decrease the number of unnecessary evaluations for prostate cancer.
days prior to the repeat test. Recent studies have confirmed at least 25 percent of these patients will have their PSAs drop back to normal ranges and will not require evaluation. If the DRE is abnormal or the PSA value is very high, don’t repeat the test but refer the patient to a urologist for evaluation.
Repeat PSA If a patient has a PSA less than 10 ng/ml, no new voiding symptoms, a normal urinalysis, and a normal DRE, wait two to four weeks and then repeat the PSA. Ask the patient not to ejaculate for at least two to three
Treat a presumed infection first If there are new voiding symptoms suggesting a urinary tract infection, or a urinalysis suggesting infection even if no symptoms are present, treat with an appropriate antibiotic for at least two weeks, then repeat the PSA at one month. Using antibiotics to reduce the PSA value is not indicated if there are no new voiding symptoms or abnormal urine. Note: Do not get a PSA if the patient has an obvious infection, because it will likely be elevated.
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MINNESOTA PHYSICIAN JULY 2016
Consider biomarkers There are several U.S. Food and Drug Administration (FDA)-approved blood and urine biomarkers that attempt to stratify risk of a patient harboring a clinically significant prostate cancer (see Figure 1).
In men with an abnormal PSA, biomarkers can provide a high negative predictive value. If the test is negative, then the risk of prostate cancer is considered low. Biomarkers are used most frequently in patients who have already had one negative prostate biopsy. Be judicious using these tests in men who would benefit from treatment if they do have a clinically significant cancer, but the tests can be helpful with a patient who refuses a prostate biopsy, as long as he accepts the risk of missing cancer. As technology improves, we expect a surge in biomarker use over the next several years, which we hope will safely reduce the need for prostate biopsies. Prostate cancer diagnosis The current standard of care for prostate cancer detection is a prostate mapping biopsy using a transrectal ultrasound probe to visualize mapping sites. Tissue diagnosis gives critical information on cancer volume and grade, which currently cannot be reliably obtained by imaging or biomarkers. However, mapping biopsies can miss clinically significant lesions up to 20 percent of the time, especially with a larger prostate or a cancer in an anterior prostate location. Therefore, many patients have endured repeat prostate biopsies, due to either a continued rise in PSA or a high index of suspicion. Several developing avenues aim to improve accuracy and reduce the need for repeat prostate biopsies. At this time, none
Figure 1. F DA approved biomarkers for prostate cancer and their utility Screening and diagnosis: Adjunct to PSA: Is a biopsy required?
Blood
• Phi (Beckman-Coulter) • 4Kscore (OPKO Lab)
Urine
• PCA3 (Hologic/Gen-Probe)
Prostate tissue (negative prostate biopsy)
• ConfirmMDx (MDxHealth)
Treatment: Cancer risk assessment: Is treatment required?
These tests require biopsy tissue Source: Dr. Peter D. Sershon
• Oncotype DX (Genomic Health) • Prolaris (Myriad Genetics) • Decipher (GenomeDx Biosciences)
should be considered a replacement for the initial transrectal ultrasound biopsy. Multiparametric MRI of the prostate Technological improvement in the MRI of the prostate has enabled the radiologist to evaluate lesions within the prostate better. All suspicious areas can now be marked out on the MRI images and then scored for risk of clinical significance. The higher the score (PI-RAD 1 through 5), the higher the risk of a clinically significant cancer (Gleason grade 7 and higher). Reading and scoring a multiparametric MRI of the prostate has a significant learning curve and a very high intra-observer variability, so it is critical that the radiologist involved has the experience to interpret it correctly. MRI/ultrasound fusion biopsy Another diagnostic advance in MRI technology is the new ability to fuse the MRI
with the standard transrectal ultrasound, creating a “fusion biopsy,� so that suspicious areas marked by the radiologist on the MRI, can be biopsied under ultrasound guidance in the office. The MRI/ultrasound fusion enables us to biopsy suspicious areas outside of the standard mapping biopsy template accurately, decreasing the risk of missing a significant lesion. Conversely, negative
Blood and urine biomarkers While blood and urine biomarkers (see Figure 1) attempt to avoid the need for a repeat prostate biopsy, no biomarker result can currently attain the same level of certainty as tissue analysis. In the near future, some form of blood or urine analysis will routinely be used to stratify patients for prostate cancer risk.
their prostate cancer. Active surveillance and focal therapy may minimize overtreatment for men with low-risk prostate cancer.
We expect a surge in biomarker use over the next several years.
MRIs, or negative biopsies from suspicious areas on an MRI, mean the risk of harboring a significant cancer outside of the more common prostate cancer locations is low. Currently, in Minnesota, the fusion biopsy technology is only available at Metro Urology and Mayo Clinic.
Prostate cancer management From the early days of PSA screening, there has been a reasonable concern about prostate cancer overtreatment. Yet, undertreatment could lead to incurable metastatic disease in men with excellent survival and quality of life outside of
Active surveillance There are multiple, well-established guidelines available for prostate cancer risk assessment, all formulated to give the physician and patient confidence that the patient’s specific cancer can be managed with surveillance. At Metro Urology, we most commonly use the National Comprehensive Cancer Network (NCCN) guideline, which assesses risk based on age, life expectancy, PSA values, and pathologic features of biopsy, including Gleason grade and tumor volume. However, clinical risk assessment can underestimate tumor aggressiveness in 30 percent of patients, which in the past has led to the underutilization of active surveillance. Trends in prostate cancer management to page 32
JULY 2016 MINNESOTA PHYSICIAN
31
Trends in prostate cancer management from page 31
Now, in addition to repeating prostate biopsy within one to two years and carefully following serial PSA values, two new developments have improved the ability to place patients on active surveillance safely. • Tissue biomarkers. There are several FDA-approved tissue biomarkers (see Figure 1) that analyze tumor gene variants on the biopsy specimen to predict risk. Each biomarker has a different predictive capability and uses percent risk in the reports, so the physician must still determine the appropriate threshold at which to trigger treatment for each patient. • MRI of the prostate. Patients who did not have an MRI prior to diagnosis may benefit from imaging if they are deemed at risk for having a more aggressive cancer than noted on
a biopsy. The MRI can also be used to designate candidates for focal therapy. Even with these predictive improvements, the most important step is still repeating the prostate biopsy at the appropriate time to assess for change in tumor volume and Gleason grade.
lesions within the same gland can have different risks of progression. Now, the advent of MRI-targeted biopsies is enabling us to predict, in some patients, which cancer sites within the prostate may be clinically significant. We can then direct focal energy at these lesions using real-time imaging, sparing the rest of the
Personalized risk factor protocols … will be developed and established.
Focal therapy Treatment for localized prostate cancer has traditionally been “whole gland,” most often involving radical prostatectomy or radiation therapy. Many patients have high-risk disease and require this management. In addition, prostate cancer is almost always multi-focal, although different
gland. This minimizes treatment risks and side effects of whole gland treatment, while achieving the same efficacy in survival and metastatic progression. Current FDA-approved energy sources include cryotherapy and high-intensity focused ultrasound (HIFU). A focal therapy treatment protocol, using carefully selected
patients, is currently underway at Metro Urology. Summary If current trends continue, personalized risk factor protocols for prostate cancer will be developed and established, and the use of some variant of biomarker or genomic analysis will identify patients who require evaluation and treatment. Debates over mass screenings and concerns about management will become irrelevant. Until then, we must use the tools available to minimize the risk of both over- and undertreatment of prostate cancer for each individual patient.
Peter D. Sershon, MD, FACS, is a board-certified urologic surgeon with Metropolitan Urologic Specialists. He is chief of surgery and director of the Robotic Surgery Program at United Hospital in St. Paul. He sees patients in St. Paul, Woodbury, and at the Apple Valley Medical Center in Apple Valley.
BEYOND TREATING, THERE’S CARING W E L L A N D BE YO N D Fairview Health Services seeks physicians with an unwavering focus on delivering the best clinical care and a passion for providing outstanding patient experience.
We currently have opportunities in the following areas:
with a Mankato Clinic Career Established in 1916, physician-owned and led Mankato Clinic is 100 years strong and seeking Family Physicians for outpatient-only practices. Over 50% of our physicians are involved in leadership positions and make decisions for our group. Full-time is 32 patient contact hours and 4 hours of administrative time per week. Four-day work week available. Clinic hours are Monday-Friday, 8 a.m.-5 p.m. OB is optional. Call is telephone triage, 1:17, supported by a 24/7 Nurse Health Line. Market-competitive guaranteed starting salary, followed by RVU production pay plan. Benefits include 35 vacation / CME Days annually + six holidays, $6,600 annual CME business allowance and a generous profit-sharing 401(k) plan. We’re just over an hour south of the Mall of America and MSP International Airport. If you would like to learn more about building a Thriving practice, contact:
Dennis Davito Director of Provider Services 1230 East Main Street Mankato, MN 56001 507-389-8654 dennisd@mankatoclinic.com
Apply online at www.mankatoclinic.com
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MINNESOTA PHYSICIAN JULY 2016
• • • • • • • • •
Allergy/Immunology Dermatology Emergency Medicine Family Medicine General Surgery Geriatric Medicine Hospitalist Internal Medicine Med/Peds
• • • • • • • • •
Neurology OB/GYN Orthopedic Surgery Pain Medicine Palliative Care Pediatrics Psychiatry Pulmonary Medicine Urology
To learn more, visit fairview.org/physicians, call 800-842-6469 or email recruit1@ fairview.org fairview.org/physicians TTY 612- 672-7300 EEO/AA Employer
Sorry, no J1 opportunities.
Family Medicine Minnesota and Wisconsin We are actively recruiting exceptional board-certified family medicine physicians to join our primary care teams in the Twin Cities (Minneapolis-St Paul) and Central Minnesota/Sartell, as well as western Wisconsin: Amery, Osceola and New Richmond. All of these positions are full-time working a 4 or 4.5 day, Monday – Friday clinic schedule. Our Minnesota opportunities are family medicine, no OB, outpatient and based in a large metropolitan area and surrounding suburbs. Our Wisconsin opportunities offer with or without obstetrics options, and include hospital call and rounding responsibilities. These positions are based in beautiful growing rural communities offering you a more traditional practice, and all are within an hours’ drive of the Twin Cities and a major airport. HealthPartners continues to receive nationally recognized clinical performance and quality awards. We offer a competitive salary and benefits package, paid malpractice and a commitment to providing exceptional patient-centered care. Apply online at healthpartners.com/careers or contact diane.m.collins@healthpartners.com, 952-883-5453, toll-free: 800-472-4695. EOE
healthpartners.com
Cuyuna Regional Medical Center is seeking two full-time Family Medicine physicians for its Crosby Clinic. Located in the heart of the Cuyuna Lakes Area, CRMC’s Crosby clinic has recruited 22 New and dedicated, quality physicians & APC’s in the last 2 ½ years that, along with the required up-to-date technology, have developed CRMC into a regional resource for advanced diagnostic and therapeutic healthcare services. Our Family Medicine opportunity: • MD or DO • Board Certified/Eligble in Family Medicine, Internal Medicine or IM/Peds • Full-time position equaling 36 patient contact hours per week • Work 4.5 days a week. • 1 in 11 Peds call. (Majority of calls handled by phone consultation) • Practice supported by 14 FM colleagues, APC’s and over 35 multi-specialty physicians • Subspecialty providers—Internal Medicine, OB/GYN, Orthopedics, Urology, Surgery, Oncology, Pain Management and more • Competitive comp package, generous signing bonus, relocation and full benefits • New Residients are encouraged to apply A physician-led organization, CRMC has grown by more than 40 percent in the past three years and is proudly offering some procedures that are not done elsewhere in the nation. The Medical Center’s unique brand of personalized care is characterized by a record of sustained strength and steady growth reflected by an ever-increasing range of services offered.
Contact: Todd Bymark, tbymark@cuyunamed.org (218) 546-3023 | www.cuyunamed.org
North Memorial is hiring MDs, NPs and PA-Cs.
Sioux Falls VA
Health Care System Working with and for America’s Veterans is a privilege and we pride ourselves on the quality of care we provide. In return for your commitment to quality health care for our nation’s Veterans, the VA offers an incomparable benefits package. The VAHCS is currently recruiting for the following healthcare positions: Cardiologist
Physiatrist
Endocrinologist
Psychiatrist
ENT (part-time)
Pulmonologist
Gastroenterologist
Rheumatologist (part-time)
Hospitalist Oncologist
Urologist (part-time)
Orthopedic Surgeon
He needs you.
We are a fiercely independent, physician-led organization. Our physician leaders, including our CEO and VPs see patients every week. Healing defines us. Not bureaucracy. We treat our patients and our employees better. We’re committed to ensuring our providers have fulfilling clinical work, competitive salary and benefits, and work-life balance. Interested applicants may contact: Amy Burt, MD Medical Director, Primary Care Amy.Burt@NorthMemorial.com Todd Gengerke, MD Medical Director, Urgent Care and Convenient Care Medicine Todd.Gengerke@NorthMemorial.com
(605) 333-6852 www.siouxfalls.va.gov Apply online at www.USAJOBS.gov JULY 2016 MINNESOTA PHYSICIAN
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Zika from page 29
most mosquito species don’t support any given arbovirus, there’s no basis for confidence that it couldn’t transmit Zika. We really don’t know the full capabilities of this virus. Controlling transmission Control of mosquito-borne Zika transmission in endemic areas is a two-pronged effort: assiduous personal protection and environmental management. Mosquitoes prefer bare skin but can bite through tight garments. Loose fitting light clothes that cover as much skin as can be tolerated are best. The CDC recommends application of any EPA-approved repellents: DEET (30 percent is best) and picaridin are most often used. Applying permethrin to clothing or using permethrin impregnated clothes is warranted. Use of bed nets when available is mandatory.
Environmental management is critical for fully mitigating risk. Spraying adult pesticides or adding larvicides to standing water are effective but raise citizen anxiety. Spraying in only nonresidential areas is less effective against Ae. aegypti, an urban mosquito. Elimination of standing water, needed for larval development, is a good idea wherever mosquitoes bite humans. In Zika transmission areas, there should be a focus on the 500 meters surrounding the homes of pregnant women. Absent wind, mosquitoes don’t travel around that much. Removing water-holding debris; turning over items to be retained (e.g., wheelbarrows, kiddie pools); draining and refilling ongoing water holding items (e.g., bird baths) every five days; filling natural water-holding holes, often where tree trunks join, with dirt; tightly covering rain and gray water barrels; and stocking lakes with larva-eating fish all help. Unfortunately,
Join the top ranked clinic in the Twin Cities A leading national consumer magazine recently recognized our clinic for providing the best care in the Twin Cities based on quality and cost. We are currently seeking new physician associates in the areas of:
• Family Practice • Urgent Care We are independent physicianowned and operated primary clinic with three locations in the NW Minneapolis suburbs. Working here you will be part of an award winning team with partnership opportunities in just 2 years. We offer competitive salary and benefits. Please call to learn how you can contribute to our innovative new approaches to improving health care delivery.
Please contact or email CV
Joel Sagedahl, M.D. 5700 Bottineau Blvd., Crystal, MN 55429
763-504-6600 erinp@nwfpc.com
www.NWFPC.com
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MINNESOTA PHYSICIAN JULY 2016
legal doctrines impede governmental application of control measures on private property. Improved mosquito traps are now available. The most effective are baited by the luscious smells of mosquito’s human targets or by odors of past larval growth, which, as one might
So far, all mainland U.S. cases have been travel related. expect, attract a mother trying to find a salutary spot to deposit her eggs. Vaccines work for several flaviviruses: yellow fever, dengue, and, in horses, West Nile virus. Active development of killed and attenuated Zika vaccines is underway. Vaccine use and study in pregnant women in early pregnancy, the critical time for its use, will pose difficult problems. Novel mosquito control mechanisms, such as the release of sterile males or mosquitoes infected by Wolbachia, are under active exploration. Wolbachia infection is needed by some insects, harms others, and in the case of Aedes species, renders them poorer Zika transmitters. Transfusion transmitted Zika Although there have only been a handful of documented transfusion Zika transmissions, it is enough to produce a considerable challenge for transfusion medicine. It’s obvious that Zika is in the blood of an acutely infected person: otherwise, how could mosquito transmission occur? The viremic phase is short, about 7–10 days. Since February 2016, U.S. mainland blood collection from all potential donors recently in areas of Zika transmission has been interdicted. But blood collection and component distribution within areas of Zika transmission is more difficult to manage. With Zika infection distributed fairly randomly, infection common, and most infections asymptomatic, donor exclusion doesn’t work. PCR screening for
Zika was not initially available. Pathogen-reduction treatments are applicable to plasma and apheresis platelets only. For the U.S. the issue arose with the epidemic in Puerto Rico. In February 2016, all collection of Puerto Rican blood was suspended; mainland blood was used for all treatment. In April 2016, screening of individual Puerto Rican units with nucleic acid testing began and locally collected units were again used. Of the first 12,777 donations, 68 (0.5 percent) were positive. By early June, the rate was 1.1 percent. A strategy of wholesale donor exclusion would not be applicable if widespread Zika infection arose in the U.S. If cases are spotty, local exclusion would be feasible (e.g., within 100 miles of a case). As the epidemiology of Zika evolves, rapid response by the transfusion community will be needed. Sexual transmission of Zika There have now been at least 15 well-established sexual transmissions reported, all but one from men with symptomatic illness. These are Zika cases in people who haven’t been in Zika endemic areas but have had recent sexual contact with people who have. Male-to-female, female-to-male, and male-tomale transmissions have been documented. All but the femaleto-male transmission have been semen-associated. Semen Zika culture positivity has been documented up to 14 days after infection, with one case possibly at 10 weeks; PCR positivity at least up to 62 days. Secure understanding of the frequency, duration, and determinants (e.g., symptomatic infection versus asymptomatic infection) of semen infectiousness is sorely lacking. There has been anxiety about sexual transmission being a larger contributor to epidemics than most think it to be. The basis for this concern is an excess of Zika cases in women versus men in the 15–60 age group. But this might arise from heightened anxiety about Zika in potentially Zika to page 36
The perfect match of career and lifestyle. Affiliated Community Medical Centers is a physician owned multispecialty group with 11 affiliate sites located in western and southwestern Minnesota. ACMC is the perfect match for healthcare providers who are looking for an exceptional practice opportunity and a high quality of life. Current opportunities available for BE/BC physicians in the following specialties:
You focus on taking care of patients. We’ll take care of the rest. To learn more, visit allinahealth.org/physicianjobs.
• Dermatology • ENT • Family Medicine • Gastroenterology • General Surgery • Geriatrician • Outpatient Internal Medicine
• Hospitalist • Infectious Disease • Internal Medicine • OB/GYN • Oncology • Orthopedic Surgery • Pediatrics
FOR MORE INFORMATION:
Shana Zahrbock, Physician Recruitment shanaz@acmc.com | (320) 231-6353
• Psychiatry • Psychology • Pulmonary/ Critical Care • Rheumatology • Sleep Medicine • Urgent Care
www.acmc.com |
Family Medicine & Emergency Medicine Physicians • • • • •
Great Opportunities
Immediate Openings Casual weekend or evening shift coverage Set your own hours Competitive rates Paid Malpractice
Physician Opportunities Essentia Health delivers on its promise to be “Here With You” and is guided by the values of quality, hospitality, respect, justice, stewardship and teamwork. OPEN POSITIONS INCLUDE:
Cardiology (EP & Noninvasive) Dermatology Endocrinology Emergency Medicine Family Medicine Geriatrics
Internal Medicine Neurology Ophthalmology Orthopedics Rheumatology Urgent Care
EOE/M/F/Vet/Disabled
PLEASE CONTACT
800-882-7310 | www.essentiahealth.org/careers
763-682-5906 | 763-684-0243 michelle@whitesellmedstaff.com www.whitesellmedstaff.com JULY 2016 MINNESOTA PHYSICIAN
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Zika from page 34
Zika disease are advised to defer pregnancy until eight weeks after symptom onset. Women who have Zika exposure (including sexual contact with a potentially infected male) without symptomatic disease are advised to defer pregnancy for eight weeks after exposure.
pregnant women and a greater willingness of women to seek medical attention. Public health recommendations • Males not residing in transmission areas. Males who have clinical Zika disease are advised to defer condom unprotected sexual contact (oral, vaginal, or anal) for six months after symptom onset. Men who have Zika exposure without symptomatic disease are advised to avoid unprotected sexual contact (oral, vaginal, or anal) for eight weeks after exposure. This discrepancy, of course, provides an interest in Zika testing in asymptomatic exposed men, not among those for whom testing is recommended. • Females not residing in transmission areas. Females who have clinical
• People residing in transmission areas. The CDC guidance that people, “should talk to their health care provider about attempting conception,” has been criticized for not being more assertive. But pregnancy is such a personal and contextual issue that it’s hard to take a prescriptive position. I have no trouble strongly advocating deferral of pregnancy until an epidemic abates or vaccination becomes available with a 23-year-old woman who last year got pregnant in her first non-contracepting month. But a 39-year-old nulliparous woman who has just married
the man of her dreams and really wants a child is another matter. There is everything in between. Risk levels vary substantially.
At least 80 percent of infections are asymptomatic. • Pregnant women. Serologic testing should be performed immediately and repeated in seronegative women in the second trimester. Serial ultrasounds to evaluate fetal head circumference should be performed in infected and apparently uninfected women according to complex CDC algorithms. Amniocentesis is controversial. • Potentially infected infants. Transplacental transmission can occur at any time during pregnancy. Parturitional transmission can
occur from mothers with acute infection near term; such infants need close observation during the first four weeks of life. Potentially infected mothers should be evaluated in the standard fashion. But that makes fetal exposure difficult to assess when mothers were untested and the infection occurred more than three months before delivery. In addition to the usual infant evaluation, assessment for microcephaly and intracranial calcification should be performed. Management of known infected infants is rapidly evolving and beyond the scope of this article. Ethical and social issues At least some women living in or visiting Zika endemic areas will elect to defer pregnancy. This will lead to increased contraception use, ordinarily Zika to page 38
Change Lives Boynton Health is a national leader in college student health. We serve the University of Minnesota, delivering comprehensive health care services with a public health approach to campus well-being. Our patients are motivated and diverse undergraduate, graduate and international students, faculty and staff. On campus, you will have access to cultural and athletic events and a rich academic environment. Boynton is readily accessible by transit, biking and walking. With no evening, weekend or on-call hours, our physicians find exceptional work/life balance.
PHYSICIAN Boynton Health is seeking a full-time physician in Primary Care and Urgent Care Clinics. We have in-house mental health, pharmacy, physical therapy, lab, x-ray and other services to provide holistic care of your patients. This position offers a competitive salary, comprehensive benefits, CME opportunities and a generous retirement plan. Professional liability coverage is provided.
To learn more, contact Hosea Ojwang, Human Resources Director at 612-626-1184, hojwang@bhs.umn.edu Apply online at http://www1.umn.edu/ohr/employment and search Keyword 306981. The University of Minnesota is an Equal Opportunity, Affirmative Action Educator and Employer.
410 Church Street SE, Minneapolis, MN 55455 612-625-8400 www.bhs.umn.edu
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MINNESOTA PHYSICIAN JULY 2016
PRACTICE WHERE BEAUTY SURROUNDS YOU
St. Health Cloud VA Care System Brainerd | Montevideo | Alexandria
Opportunities for full-time and part-time staff are available in the following positions:
Family Practice Physician Join a provider-driven not-for-profit organization in our Cook, MN location. Work in a well-established, modern facility. Participate in on-call schedule, share in-patient and after-hours care, (no OB). BC/BE and current or eligible for MN license required. National Health Service Corps loan repayment potential.
WORK-LIFE BALANCE: • Competitive salary • Significant starting & residency bonuses • 4-day work weeks • 51 annual paid days off Ski, hike, run, fish, canoe, kayak, camp and more in nearby state parks, Boundary Waters Canoe Area, Voyageurs National Park and Superior National Forest. Please contact: Travis Luedke, Cook Area Health Services, Inc., 20 5th St. SE, Cook, MN 55723 tluedke@scenicrivershealth.org 218-361-3190
• Associate Chief of Staff, Education • Associate Chief of Staff, Primary Care • Dermatologist • Internal Medicine/ Family Practice
• Physician (Compensation & Pension) • Physician, Extended Care & Rehabilitation • Physician (Pain Clinic)/Outpatient Primary Care
• Occupational Health/ • Psychiatrist Compensation & Pension Physician • Urgent Care Applicants must be BE/BC.
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For more information:
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US Citizenship required or candidates must have proper authorization to work in the U.S. Physician applicants should be BE/BE. Education Debt Reduction Program funding may be authorized for the health professional education that was required of the position. Possible recruitment bonus. EEO Employer.
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Advertise in Minnesota Physician
612-728-8600
Visit www.USAJobs.gov or contact Nola Mattson, STC.HR@VA.GOV Human Resources 4801 Veterans Drive, St. Cloud, MN 56303
(320) 255-6301 JULY 2016 MINNESOTA PHYSICIAN
37
Zika from page 36
opposed by the Catholic church and other faiths. At least some women who have Zika infection during pregnancy, with or without demonstrated fetal abnormality (especially because it becomes detectable fairly late in pregnancy) will elect to have an abortion. This will be opposed by a larger group of people. Latin America has particularly restrictive policies and in the U.S., access to women’s health care can be difficult for the indigent. Some have argued for screening returning travelers and non-U.S. citizens with quarantine for possibly Zika infected persons. But public health authorities have uniformly opposed these matters on grounds of futility. Many of the knowledge gaps identified above require substantial resources to answer. Enhancing surveillance of human infection and mosquito
positivity remains a costly but imperative public health measure. Since current testing is only of people recently in Zika transmission areas, sentinel testing in high-risk areas must be established. Many of the preventive steps needed, e.g., education and assistance in
abortion. But most were wholly unrelated. As of this writing no additional funding for Zika has been passed. In Rio, the Olympics begin Aug. 5 and the Paralympics Sep. 7. Much concern about the implications of Zika has been expressed. But August in
A pregnant woman should seriously consider not going to the Olympics. environmental management, need new funding. President Obama asked for a $1.9 billion appropriation in February 2016. In May, Senate Republicans offered $1.1 billion in new money and House Republicans offered a bill to reallocate $622 million. In June, the Senate bill was blocked by Democrats because it had acquired many features unacceptable to the Obama administration. Some were faintly related to Zika, e.g., concern about funding increasing
the southern hemisphere is not high mosquito time—the biggest problem in Brazil is in the north and we can hope the epidemic will have settled down to become an endemic by late this summer. As to returning visitors producing a global hazard, much of the world is already infected. The main implication is to potentially pregnant visitors and athletes. A pregnant woman should seriously consider not going to the Olympics. Likewise, a fecund woman who
can’t be sure she’s not going to get pregnant. As for the rest, the risks are sustainable (except, perhaps, for the athletes who will have exposure to the tons of untreated feces dumped daily into the ocean). Summary Zika illustrates how each pathogen seems to have its own special wrinkles. Zika’s most distinctive (no other arthropod borne virus can do it) and awful feature is to cause devastating harm to the fetal brain. Like all new pathogens, in the early stages we have major gaps in knowledge. Harm aside, witnessing nature is amazing.
Frank S. Rhame, MD, is adjunct
professor in the Division of Infectious Diseases in the Department of Medicine at the University of Minnesota. He also conducts infectious diseases research and inpatient consultation at Abbott Northwestern Hospital and is a physician at AllinaHealth Uptown Clinic.
Olmsted Medical Center, a 220-clinician multi-specialty clinic with 10 outlying branch clinics and a 61 bed hospital, continues to experience significant growth. Olmsted Medical Center provides an excellent opportunity to practice quality medicine in a family oriented atmosphere. The Rochester community provides numerous cultural, educational, and recreational opportunities. Olmsted Medical Center offers a competitive salary and comprehensive benefit package.
Opportunities available in the following specialties: ENT
Psychiatrist
Rochester Southeast Clinic
Rochester Southeast Clinic
General Surgery Hospital
Psychiatrist – Child & Adolescence
Rochester Southeast Clinic
Ophthalmology Surgeon/ Refractive Surgeon Hospital
Sleep Medicine
Rochester Northwest Clinic
Endocrinology Rochester Southeast Clinic
Send CV to: Olmsted Medical Center Human Resources/Clinician Recruitment 210 Ninth Street SE, Rochester, MN 55904
email: dcardille@olmmed.org • Phone: 507.529.6748 • Fax: 507.529.6622
www.olmstedmedicalcenter.org 38
MINNESOTA PHYSICIAN JULY 2016
Cardiology
Rochester Southeast Clinic
Urology Hospital
rehabilitate a body, we start T owith the mind and soul. If you or someone you know needs rehabilitation after an accident, surgery, illness or stroke, we have a simple premise for you to consider: To recover physically, you need support mentally and emotionally. How positive and how determined someone is can make all the difference. We believe the most effective therapy treats your body, mind and soul. That’s our approach. Post-acute rehabilitation services from the Good Samaritan Society are offered at multiple inpatient and outpatient locations throughout Minnesota and the Minneapolis/St. Paul area.
To make a referral or for more information, call us at (888) GSS-CARE or visit www.good-sam.com/minnesota.
The Evangelical Lutheran Good Samaritan Society provides housing and services to qualified individuals without regard to race, color, religion, gender, disability, familial status, national origin or other protected statuses according to applicable federal, state or local laws. Some services may be provided by a third party. All faiths or beliefs are welcome. Š 2015 The Evangelical Lutheran Good Samaritan Society. All rights reserved. 15-G1553
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MINNESOTA PHYSICIAN
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