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Vo l u m e X X X , N o . 6 S e p t e m b e r 2 016

Value-based purchasing What this means for your practice By Vicki Olson, BSN, MS


he national trend is to measure quality performance across settings. Ambulatory care and care provided in other settings need to work seamlessly together. Many hospital quality measures now account for care provided before the hospitalization, and 30 days after discharge.

America’s gun violence The importance of social health By Chris Johnson, MD “I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.” Hippocratic Oath, 1964 version by Louis Lasagna of Tufts University


n June 12, 2016, a 29-year-old ma n na med Oma r Mateen opened fire in the gay nightclub, Pulse, in Orlando, Florida. He used a SIG Sauer MCX semi-automatic rifle and a

Glock-17 9 mm semi-automatic pistol. He shot and killed 49 people and wounded 53 others before being killed by police. This was just the most recent chapter in what has become an all too familiar “American tale.” Orlando has now entered our cultural memory of mass shootings alongside other cities such as Newtown and Columbine. These types of attacks strike the U.S. more than America’s gun violence to page 10

Background In 2001, the Centers for Medicare & Medicaid Services (CMS) started the pay-for-reporting programs and in October 2012, Medicare began rewarding hospitals that provided high-quality care for their patients through the Hospital Value-Based Purchasing (VBP) Program. Hospitals paid under the Inpatient Prospective Payment System (IPPS) are paid for inpatient acute care services based on quality of care— not the volume of services they provide. The Hospital Readmissions Reduction Program (HRRP) was implemented the same year, and the Hospital Acquired-Condition Reduction Program (HACRP) the following year. None of these programs impacted critical access hospitals, children’s hospitals, or VA hospitals.

Value-based purchasing to page 12

is for Cardiology.

University of Minnesota Health Heart Care specialists have a deep understanding of academic medicine and clinical research. Leaders in heart-care interventions for over a generation, we make innovative care our mission. This expert knowledge translates into advanced clinical care tailored for each patient. Through our clinic trials, our patients are at the forefront of groundbreaking care and treatment options. We’ve transformed lives with major breakthroughs in valve replacements, transplants, cardiac resuscitation and other pioneering techniques to treat heart disease. With multiple centers and clinic locations throughout the region, some of the best heart care providers are just a heartbeat away. Learn more about our expert, innovative care at The University of Minnesota Health brand represents a collaboration between University of Minnesota Physicians and University of Minnesota Medical Center. Š 2016 University of Minnesota Physicians and University of Minnesota Medical Center






The importance of social health By Chris Johnson, MD

What this means for your practice


Value - Based  Reimbursement:   

By Vicki Olson, BSN, MS





A look at Hillary Clinton’s and Donald Trump’s health care policies



Physicians and school nurses By Camille S. Murphy, MA, RN, and Emily Onello, MD

A new way to pay for health care

NEUROLOGY26 Studying brain injury By Molly Hubbard, MD, and Uzma Samadani, MD, PhD

Thursday, November 3, 2016 • 1:00-4:00 PM


The Gallery (lobby level), Downtown Minneapolis Hilton and Towers

Growing up trans The unique mental health needs of transgender youth By Lindsay M. Narayan, MA, LMFT, BCBA


Dialectical behavior therapy Building a balanced satisfying life By Lane Pederson, PsyD, LP, DBTC


Exposure and response prevention An effective method for treating OCD By Tracey K. Lichner, PhD, LP


PROFESSIONAL UPDATE: ONCOLOGY Increasing clinical trial enrollment By Toni Kay Mangskau


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 purchasing 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: • Don Flott, Director of Utilization and Integration Services, Mayo Medical Laboratories • Allison LaValley, MBA, Executive Director, athenahealth • David Melloh, JD, Chair, Health Law Practice Group at Lindquist & Vennum LLP • Ross D’Emanuele, JD, Co-Chair, Health Care Industry Group at Dorsey & Whitney LLP • Lisa Simm, MBA, Manager of Risk Management, Coverys Sponsors include: • athenahealth • Lindquist & Vennum LLP • Mayo Medical Laboratories • Dorsey & Whitney LLP • Coverys

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Community Hospitals Experience Increase in Outpatient Care The Minnesota Department of Health has released a report on key indicators of service use and financial performance between 2011 and 2014 for Minnesota’s 132 community hospitals, offering an initial impression of how the Affordable Care Act has impacted the hospital industry in Minnesota. The report shows a decline in inpatient admissions in 2014, with a 3 percent drop in acute care admissions and a .05 percent drop in patient days, continuing the downward trend from previous years. However, the decrease from 2013 to 2014 was most significant and represents about half of the overall decline for the time period. “It appears shorter stay hospitalizations were either avoided at increasing rates or treated more regularly in outpatient settings, thereby changing the composition of the remaining inpatient population,” the report said. The average length of stay per admission increased slightly, from


4.26 days per admission in 2011 to 4.48 days in 2014. Outpatient utilization increased at a rate of 7.5 percent from 2013 to 2014, with an increase of 1.8 million visits, due to an increase in outpatient department visits as outpatient surgeries and emergency department visits stayed relatively the same. There was an unexpected 0.6 percent decline in the number of emergency department (ED) visits from 2013 to 2014, following increases of 3.9 percent from 2011 to 2012 and 0.9 percent from 2012 to 2013. “Based on previous research assessing ED use and health insurance coverage, we expected that expanded health insurance coverage, and specifically access to public program coverage, would result in a net increase in ED levels,” the report said. Overall, financial performance of Minnesota hospitals was strong in 2014 with higher operating margins (7.7 percent) compared to earlier years and a continued increase in net assets (5.8 percent). “Our findings from this brief may indicate a new landscape in hospital care, with fewer uninsured patients coinciding with continued trends away from


inpatient care, and increases in outpatient care through additional clinics and higher use in those clinics,” the report said. “As a whole, hospital spending continues to be a major driver of health care costs, with inpatient and outpatient spending accounting for just over half of per capita spending growth in 2013 (20.9 percent and 30.6 percent respectively).”

Children’s Opens Pediatric Simulation Center Children’s Minnesota has announced the opening of its new onsite pediatric simulation center, funded by a $1.25 million gift from Michael and Judy Wright. The 8,000-square-foot Michael and Judith Wright Family Pediatric Simulation Center features an exact replica of the hospital’s intensive care unit room for health care providers and medical students to have a safe and realistic place to train and practice high-risk procedures and team communication in simulated scenarios. The center is located at the

Children’s Minnesota Minneapolis campus and was scheduled to begin simulations in August. “This dedicated, onsite simulation center means we can continuously improve the care we provide by frequently training our teams on complex procedures and how to function and communicate in chaotic, high-stress situations in a low-risk setting,” said David Dassenko, MD, medical director of the pediatric cardiac intensive care unit at Children’s Minnesota. The center uses computerized infant- and child-sized mannequins and has simulated sights and sounds to replicate the physical and mental stresses and challenges that would occur in a clinical environment in an emergency situation. Technicians can run three simulations simultaneously from the control room. After the simulations, practitioners meet in a debriefing room to review video playback and analyze what went well and where there are opportunities for change and improvement. Children’s Minnesota plans to use the technology to share simulations for conferences and webinars in the future. Children’s Minnesota staff participated in over 4,000 hours

of training at offsite locations or inpatient units as space was available in 2015. The new facility is dedicated to these simulations and located onsite, allowing easier access for clinicians across the Children’s Minnesota system and clinicians in the region.

Nearly 1 in 5 Mental Health Bed Days Potentially Avoidable The Minnesota Hospital Association (MHA) has conducted a pilot study showing that nearly 1 in 5 days mental and behavioral health patients spend admitted to inpatient community hospital psychiatric units is potentially avoidable, meaning they would have been more appropriately treated in a different care setting. The study is the first of its kind. It tracked mental health patients admitted to inpatient psychiatric units at 20 hospitals and health systems across the state between March 15 and April 30, 2016 and found that of the 32,520 total mental health bed days at all 20 hospitals, 6,052 (19 percent) were potentially avoidable. Using those numbers, MHA estimates that there are about 48,000 potentially avoidable days each year at the 20 hospital locations. There are 147 hospitals in Minnesota. “On any given day, approximately 134 patients across these 20 hospitals could have been treated in a more appropriate care setting,” the study’s authors wrote. “Mental illnesses affect us all. Behind these numbers are patients and families who are not getting the care they need in the right place at the right time,” said Rahul Koranne, MD, chief medical officer at MHA. “On any given day, 134 patients across these 20 hospitals could have been more appropriately served in a different care setting. Bottlenecks exist throughout the mental health care delivery system, resulting in patients remaining in community hospitals for extended periods of time—which in turn means that hospital beds are unavailable to others in the community experiencing mental health crises.” MHA’s study identified 26 reasons why these days occurred, which can all be grouped into two categories—64 percent of potentially avoidable days were due to

lack of space in a state-run mental health hospital, residential treatment center, nursing home, group home, chemical dependency treatment services, or other setting; and 30 percent were due to social service or government agency delays, including identifying an appropriate treatment location for a patient, completing agency approvals, other administrative processes, or resolving legal proceedings involving the patient. The most frequently cited reasons were lack of beds at state-run Community Behavioral Health Hospitals (14 percent of potentially avoidable days); chemical dependency treatment facilities (11 percent); Intensive Residential Treatment Services (10 percent); and Anoka Metro Regional Treatment Center (7 percent). In addition, 8 percent of potentially avoidable days were due to a delay in a patient’s legal proceedings, including civil commitment.

Essentia Health to Rebuild, Double Size of Pierz Clinic Essentia Health has announced plans to build a new Pierz clinic, with construction beginning this fall a few blocks south of the current location along Minnesota Highway 25. The new Essentia Health St. Joseph’s– Pierz Clinic will be double the size of the current clinic’s 2,100 square feet. It will include seven exam rooms, a procedure room, and increase primary care, specialty care, and rehabilitation services. “The community needed more access to specialists and rather than asking patients to drive, which can be both a time and cost barrier to getting care, we put a priority on expanding our space to bring the specialists here to Pierz,” said Bill Palmer, clinic administrator at Essentia Health. “We currently have an internal medicine physician, Dr. Tyler Dunphy, and orthopedic surgeon Dr. Paul Thompson visiting the clinic a few times a month. However, there are more needs and the larger clinic will allow for more specialists to join family medicine physicians Drs. Kelli Leland and Ted Trueblood.”

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Opioid Prescriptions Common Among Medicare Recipients at Hospital Discharge A study from the University of Minnesota School of Public Health has found that new opioid use after hospitalization is common among Medicare beneficiaries. Researchers analyzed a 20 percent random sample of pharmacy claims from Medicare beneficiaries hospitalized in 2011 who did not have an opioid prescription claim in the 60 days before hospitalization. They found that among 623,957 hospitalizations, 92,882 (14.9 percent) were associated with a new opioid claim. Among 2,512 hospitals, the average adjusted rate of new opioid use within seven days of hospitalization was 15.1 percent. Results also showed that the likelihood of post-discharge opioid prescribing varied widely across hospitals even after accounting for patient characteristics, severity, and diagnoses.


“We know that even short-term opioid prescriptions can lead to long-term use,” said Pinar KaracaMandic, PhD, associate professor in the School of Public Health and senior author of the study. “We must try to understand why hospitals vary in their post-discharge opioid prescriptions. It’s concerning that very large variations in postdischarge prescribing remain, especially with abuse so prevalent today.” Among hospitalizations with an opioid claim within seven days of hospital discharge, 32,731 (42.5 percent) of 77,092 were associated with an opioid claim 90 days after discharge. “One of the more glaring and possibly problematic findings was nearly 40 percent of patients with a new opioid prescription filled the prescription 90 days after their discharge, suggesting long term-use,” said Karaca-Mandic. She added that current hospital incentives to promote adequate pain control could be used with other measures that aim to target and promote appropriate opioid use in order to reduce large variations in rates of opioid prescribing after hospital discharge. There is


LETTERS To the editor: I appreciate the excellent August article by Ginny Adams ti tl e d , “ Te r m in a tin g th e provider/patient relationship,” but I differ with her on one key point. After almost 30 years in practice and having terminated relationships with a dozen or more patients, I would suggest that when termination clearly has to happen, it is in fact a desirable outcome for both the physician and the patient. There are some physician/patient dyads that are just not healthy or repairable, and to continue them does not help either party, and in fact often makes both parties worse. This is absolutely in contradiction to placing the well-being of the patient first, while also protecting your own well-being (a key concept in preventing

a system that offers incentives for better pain management in place currently, however there are no

burnout). I have had the experience several times of having these patients later tell me that “firing” them was the best thing that happened, and thanking me for doing it. It was the stimulus they needed to take their behavioral problems seriously enough to finally seek the help they needed to improve, help they were either unable or unwilling to accept through me. There is definitely some risk in the short term from a liability viewpoint, and Ms. Adams is of course paid to counsel us from that viewpoint, but if our main concern is really doing what is best for the patient, there are times when doing your best means you are not the right provider for this patient. Glenn Nemec, MD Stellis Health

measures on appropriateness of opioid prescribing.

MEDICUS Sarah Kottke, MD, and Bjorn Westgard, MD, MA, have joined the Board of Directors at Guild Incorporated, a nonprofit organization aimed at helping people with mental illness lead quality lives by providing integrated treatment and services. Kottke is the lead physician for Geriatric Psychiatry–United Hospital at Allina Health where she provides inpatient Sarah Kottke, MD geriatric psychiatry care in addition to psychiatric consultation for both adult inpatient psychiatry and a partial hospitalization program. She has worked with Guild throughout her training as a psychiatrist as well as working as a psychiatric provider at United Hospital. Kottke earned her medical degree at the University of Minnesota Medical School where she currently also serves as an assistant professor in the department of psychiatry. Westgard is a practicing emergency physician, medical anthropologist, and researcher at Regions Hospital, Hennepin County Medical Center, and the HealthPartners Institute for Education and Research. He has been highly involved in studying health care disparities and how they manifest in the emergency department in order to develop ways of working with patients, community members, and providers to improve Bjorn Westgard, MD, MA care and costs. Westgard earned his medical degree as well as a master of arts degree in anthropology at the University of Illinois–Urbana/Champaign. He also serves as an assistant professor in the emergency medicine department at the University of Minnesota Medical School. Jakub Tolar, MD, PhD, has been named executive vice dean of the University of Minnesota Medical School. He has been affiliated with the school for 24 years in roles as varied as student, resident, fellow, faculty, physician, administrator, and mentor. In his new position, Tolar is focusing on implementing the school’s strategic plans for scholarship and research. Jakub Tolar, In addition, he serves as director of the UniMD, PhD versity of Minnesota Stem Cell Institute and as a member of multiple professional organizations. Tolar also has a clinical practice through the University of Minnesota Masonic Children’s Hospital. He earned his medical degree at Charles University in Prague, Czech Republic and his PhD in molecular, cellular, developmental biology, and genetics from the University of Minnesota. Mark Stuckey, DO, has joined Hutchinson Health where he will practice general family medical care, preventive medicine, endoscopic procedures, emergency medicine, and sports medicine. Stuckey earned his doctor of osteopathic medicine degree at Des Moines University College of Osteopathic Medicine and participated in the Mankato Family Residency Mark Stuckey, DO Program, which is supported through the Mayo Clinic Health System and the University of Minnesota. His special interests include sports medicine, preventive care, and emergency medicine. He also performs vasectomies, colonoscopies, and endoscopic procedures.



The 2016 Presi What are the biggest challenges facing health care delivery today? Despite the progress represented by the Affordable Care Act (ACA), we have more to do to finish our long fight to provide universal, quality, affordable health care to everyone in America. We must do more to improve access to primary care, dental care, mental health care, and affordable prescription drugs. And with Hillary Clinton our population continuing to grow and age, our health care system must be equipped to meet our changing needs. We must support our health care professionals, who work long hours to ensure their patients get the best possible care. We must bring down out-of-pocket health care costs, and expand affordable health care access regardless of families’ immigration status. We must address immediate health care issues—from Alzheimer’s, to autism, to mental health, to substance use disorders to Zika. We must improve our public health infrastructure, and evaluate environmental factors that affect the well-being of many Americans, especially those that are low income. We must also protect women’s health care and their right to make personal health decisions. How do you propose to solve these problems? I support policies that protect and expand access to care. First, I will work with governors to expand Medicaid in every state, so

I support policies that protect and expand access to care. access to care no longer depends on where you live. It is a disgrace that 19 states have left 3 million Americans without health insurance by refusing to expand Medicaid. Second, I will get health care costs under control. I’ve put forth comprehensive plans to address increasing out-of-pocket and prescription drug costs. Third, I will fight to give Americans in every state the choice of public option insurance, and to expand Medicare by allowing people 55 years or older to opt in while protecting the traditional Medicare program. I also will fight to expand our system of Federally Qualified Health Centers, helping establish universal primary care. Please tell us the positive and negative results of the Affordable Care Act. Thanks to the ACA, 20 million more Americans have health insurance, regardless of their gender or preexisting condition. The ACA brought the number of Americans covered to 90 percent—a historic achievement. However, too many individuals still lack affordable insurance and access to primary care, dental care, and mental health care. This access disproportionately affects people of color, and the millions of Americans living in rural communities. Further, due to the unwillingness of 19 states to expand Medicaid, nearly 3 million low-income Americans remain uninsured. As president, I will work with governors to



expand Medicaid, allow Americans over the age of 55 to buy into Medicare, and engage physicians and doctors to achieve our health care goals. I will also double the funding for primary care services at community health centers over the next decade. We will move our country closer to universal coverage and fight so location does not determine care. What role should government play in controlling pharmaceutical costs? We must deal with skyrocketing out-of-pocket health costs, specifically, the high prescription drug prices that burden hardworking Americans. Every month, approximately half of all Americans take a prescription drug—a proportion that increases to 90 percent when looking at seniors. We must hold pharmaceutical companies accountable to lower drug costs. To do that, we will deny tax breaks for direct-to-consumer advertising, and demand instead that these companies invest in R&D to receive taxpayer support. We must spur competition for prescription drugs to drive down prices. In addition to supporting the policies that help provide American consumers greater choice, I will require that health insurance plans place a monthly limit of $250 on covered out-of-pocket prescription drug costs for patients with chronic or serious health conditions. Further, I will demand higher rebates for prescription drugs in Medicare. Individuals fighting illness or coping with age should not be further burdened by the stress of affording care—we will help ease that burden. If you could fix health care without any obstacles (political or otherwise), how would you do it? Throughout my career, I have fought so that all Americans could have affordable health insurance—a basic right. There have been obstacles in this fight, but more important, there has been opportunity. As first lady, when Congress defeated health care reform, I worked with Democrats to help create the Children’s Health Insurance Program (CHIP). Today, I am proud to say that this program has provided coverage to over 8 million children. As president, I will continue to fight for universal health care. The Affordable Care Act made great strides, but we must do more to help insure the 10 percent of Americans still without coverage. We will also provide families the opportunity to buy health insurance on the exchanges, regardless of immigration status. There will always be obstacles, but I believe meaningful changes in access will help us begin to fix health care, and ensure that everyone in our great country leads a long and healthy life.

sidential Race Editor’s note: With every presidential election we pose questions to the candidates about their health care policies. The Trump campaign did not respond to our request. As of press time (8/25/16) we visited the Trump campaign web site and, to be as fair as possible, we excerpted the following comments organized as closely as possible in response to our questions.

Biggest challenges Providing healthcare to illegal immigrants costs us some $11 billion annually. If we were to simply enforce the current immigration laws and restrict the unbridled granting of visas to this country, we could relieve healthcare cost pressures on state and local governments. To reduce the number of individuals needing access to programs like Medicaid and Children’s Health Insurance Program we will need to install programs that grow the economy and bring capital and jobs back to America. The best social program has always been a job—and taking care of our economy will go a long way towards reducing our dependence on public health programs. Proposed solutions Completely repeal Obamacare. Our elected representatives must eliminate the individual mandate. No person should be required to buy insurance unless he or she wants to. Modify existing law that inhibits the sale of health insurance across state lines. As long as the plan purchased complies with state requirements, any vendor ought to be able to offer insurance in any state. By allowing full competition in this market, insurance costs will go down and consumer satisfaction will go up. Allow individuals to fully deduct health insurance premium payments from their tax returns under the current tax system. Businesses are allowed to take these deductions so why wouldn’t Congress allow individuals the same exemptions? As we allow the free market to provide insurance coverage opportunities to companies and individuals, we must also make sure that no one slips through the cracks simply because they cannot afford insurance. We must review basic options for Medicaid and work with states to ensure that those who want healthcare coverage can have it. Affordable Care Act Since March of 2010, the American people have had to suffer under the incredible economic burden of the Affordable Care Act—Obamacare.

This legislation, passed by totally partisan votes in the House and Senate and signed into law by the most divisive and partisan President in American history, has tragically but predictably resulted in runaway costs, websites that don’t work, greater rationing of care, higher premiums, less competition and fewer choices. Obamacare has raised the economic uncertainty of every single person residing in this country. As it appears Obamacare is certain to colDonald Trump lapse of its own weight, the damage done by the Democrats and President Obama, and abetted by the Supreme Court, will be difficult to repair unless the next President and a Republican congress lead the effort to bring much-needed free market reforms to the healthcare industry. But none of these positive reforms can be accomplished without Obamacare repeal. On day one of the Trump Administration, we will ask Congress to immediately deliver a full repeal of Obamacare. Pharmaceutical cost Remove barriers to entry into free markets for drug providers that offer safe, reliable and cheaper products. Congress will need the courage to step away from the special interests and do what is right for America. Though the pharmaceutical industry is in the private sector, drug companies provide a public service. Allowing consumers access to imported, safe and dependable drugs from overseas will bring more options to consumers.

Require price transparency from all healthcare providers. Ideal fix Allow individuals to use Health Savings Accounts (HSAs). Contributions into HSAs should be tax-free and should be allowed to accumulate. These accounts would become part of the estate of the individual and could be passed on to heirs without fear of any death penalty. These plans should be particularly attractive to young people who are healthy and can afford high-deductible insurance plans. These funds can be used by any member of a family without penalty. The flexibility and security provided by HSAs will be of great benefit to all who participate. Require price transparency from all healthcare providers, especially doctors and healthcare organizations like clinics and hospitals. Individuals should be able to shop to find the best prices for procedures, exams or any other medical-related procedure. Block-grant Medicaid to the states. Nearly every state already offers benefits beyond what is required in the current Medicaid structure. The state governments know their people best and can manage the administration of Medicaid far better without federal overhead. States will have the incentives to seek out and eliminate fraud, waste and abuse to preserve our precious resources. SEPTEMBER 2016 MINNESOTA PHYSICIAN


America’s gun violence from cover

any other country. According to a 2016 study published in Violence and Victims (a bimonthly peer-reviewed journal covering interpersonal violence and victimization), the U.S. was home to nearly a third of the world’s mass shootings from 1966 to 2012 despite the fact that we comprise just 5 percent of the world’s population. As health care providers, it is our responsibility to worry especially about what causes premature morbidity and mortality for our patients. Gun violence has to be part of that conversation. In 2013, according to the CDC, there were 33,636 firearm deaths in the U.S. and another 73,505 non-fatal gun injuries. Gun violence is the No. 2 cause of death behind car accidents and unintentional injury for ages 15–35. This marks gun violence as a genuine public health crisis.


Guns and suicide Despite the dramatic nature of mass shootings and their ability to dominate the news cycle, by far the greatest number of gun deaths in the U.S. is caused by

And despite the press that assault rifles get, the most common firearm used is the handgun. Of the many thousands who die by gunfire each year, assault type rifles kill only 300

Gun violence is the No. 2 cause of death behind car accidents and unintentional injury for ages 15–35.

suicide. According to CDC data, around 60 percent of all U.S. gun deaths are suicide deaths. In 2014, there were 21,300 gun suicides to go along with around 11,000 gun homicides, and another 500 accidental deaths.


to 400 on average. So the gun advocates who state that banning assault rifles alone will not dramatically impact the number of gun homicide deaths in this country do have a point. Does the rate of gun suicide provide us with a health care opportunity? Could we save many of the 20,000 who die by gun suicide each year if gun access was greatly restricted? Unfortunately, it is hard to answer that in the affirmative. If suicide represented an act that was overwhelmingly impulsive and fleeting, then you would expect countries that did not have access to firearms to have substantially lower suicide rates. But we don’t see that. According to the 2007 Small Arms Survey, Japan has one of the lowest rates of gun ownership in the world at 0.6 per 100 people (compare that to the U.S., which has about 100 guns for every 100 people). However, at almost 20 deaths per 100,000 population, their suicide rate is nearly twice ours. I say this not to diminish the importance of trying to intervene and help those with severe depression and a risk for self-harm. I say this merely to point out that the evidence suggests suicide is too complex a phenomenon to think it can be dramatically altered by legislation solely directed at gun access.

U.S. gun ownership and gun violence There is no other way to say it— America has an extraordinary amount of guns. According to estimates from the Congressional Research Service, there is one gun for every adult American, or about 300 million guns in our country today. That actually represents half of all the privately held guns in the world. On the other hand, data from the General Social Survey show that the percentage of households owning guns has actually declined in recent years from approximately 50 percent in 1960 to about 35–40 percent today. While fewer households today have gun owners, those that do own multiple guns. America also has an extraordinary amount of gun violence—approximately 30 gun homicides per million of a population that is nine times the rate of Canada, 20 times the rate of Australia, and a staggering 50 times the rate of the United Kingdom. Which nations share similar rates of gun homicide with us? Well, according to the United Nations Office on Drugs and Crime, our comparables are Peru, Chile, and Argentina— nations with only a quarter of our gross domestic income per person. If there is encouraging news, it is that the U.S. is actually less violent now than in decades past, despite the political rhetoric you may have heard recently. According to the CDC, our gun homicide rate in 1980 was 6.0 per 100,000 and in 1993 was 7.0 per 100,000. Today, it is much less at 3.4 per 100,00 and holding fairly constant since the early 2000s. Is it just about access? Is gun violence related to gun access? I have to say that part of me wanted the answer to be a simple “Yes.” However, the relationship between gun ownership and violence is not terribly robust. There are countries with far fewer guns and much higher homicide rates and countries with significant gun ownership

and far lower homicide rates. For example, South Africa has only 13 guns per 100 citizens, yet the gun homicide rate there is more than five times higher than ours. In Brazil, the gun ownership rate is even lower with about nine guns per 100 people, yet their homicide rate is six times higher. Conversely, our neighbors to the North have a gun ownership rate about a third of ours, yet their gun homicide rate is nine times less. Australians are also fond of their firearms, yet their gun homicide rate is 20 times less than ours. While the rate of gun ownership to gun homicide is not so clear-cut, there is at least one conclusion we can reach from the data that must be said explicitly—guns do not make you safer. They may make you feel safer, but the statistics show a different reality. If the presence of an armed populace led to general safety through mutual deterrence, then the U.S. would be the safest nation on Earth. But it isn’t. We have the highest rate of gun homicide of any developed nation. Further, the lack of an armed citizenry does not invite roving bands of “bad guys with guns” eager to exploit the vulnerable population. If that were true, nations such as Britain and Japan would be suffering the torments of gangs pillaging their way from one neighborhood to the next. But they aren’t. Japan and Britain are safer than we are. The importance of social health There has been a great deal of study in the last several decades in both public health and social science to try and identify why the U.S. suffers such disproportionate violence compared to other rich, democratic nations. After dozens of studies looking at many different social, historical, ethnographic, and economic factors, researchers think a pattern is emerging. The truth is the U.S. shows all the myriad pathologies of a society that is too economically divided and socially stratified. The reason for this conclusion

is that the U.S. fails to compare favorably to other developed countries in multiple areas of social health such as percentage of the population incarcerated, rate of teenage pregnancy, rate of childhood poverty, life expectancy, and lack of social mobil-

Guns do not make you safer.

ity. All of these factors are seen to correlate with high levels of social division. We have known for some time now that the health outcomes of the U.S. patient population lag behind other countries despite the fact that we dramatically outspend them on health care services. Such unexpected outcomes have given rise to studies of the “social determinants” of health care. The Robert Wood Johnson Foundation reviewed the medical and public health literature and published their Health Policy Brief in 2014. They found that medical intervention accounted for less than 15 percent of what determines a patient’s overall health outcome. So to continue to throw massive expenditures into the health care industry to improve patient’s lives is a very inefficient use of resources.

.450 indicating higher levels of social stratification than Russia (.420) and more comparable to that of Peru (.453) and Argentina (.455). By contrast, Canada is markedly more equal at .321 and Australia is even more so at .303. The nations of Brazil and South Africa tip the inequality scales at .519 (Brazil) and .625 (South Africa) and you will recall that they have much higher rates of gun violence despite low gun ownership. In case you were wondering, the most unequal nation is apparently Lesotho, the tiny island nation that is entirely surrounded by South Africa. Forty percent of Lesotho’s population lives below the international poverty line of $1.25 U.S. per day. When a country has high levels of income stratification and does poorly on one measure of social dysfunction, you can predict it will do poorly in most others. That describes the U.S. today. We incarcerate our population like no other country

in the world. According to the Bureau of Justice Statistics, we have 5 percent of the world’s population and 22 percent of the world’s prisoners. Our teen birth rate is much higher as well. UNICEF calculated the number of women in the U.S. under 20 giving birth per 1,000 teens at 52. This is four times the European Union average. In the U.S., more than 20 percent of children live in poverty. Compare that to Australia at 14 percent and Canada at 15 percent. Finally, we are not the universal “land of opportunity” that we hear frequently promulgated by our political leaders, right or left. When researchers compared earnings from fathers to sons from one generation to the next (in something called the Earnings Elasticity Measure) they found that the U.S. was more socially rigid than almost

America’s gun violence to page 38

The price of division The U.S. is singular in its division of “haves” and “havenots” in the developed world. A measure of the division of resources among a population is something called the “Gini coefficient.” Developed by Italian economist, Corrado Gini, it is a zero to one scale with zero being total equality and one being total inequality (i.e., one person literally has all of a nation’s assets). The U.S. scores disproportionately high on this scale. We come in with a Gini score of SEPTEMBER 2016 MINNESOTA PHYSICIAN


Value-based purchasing from cover

This article describes all three hospital incentive programs, and explains how your care can make a difference. The hospital VBP Program The Hospital VBP began in 2011. It is an incentive program where 2 percent of the

back what was withheld, with potentially additional monies. How does the program work? A hospital’s performance is compared to a baseline performance and they are rewarded for both improvement and reaching toward the national benchmark performance, which is the mean of the top decile of performance of all eligible hospitals in the baseline period.

How many of your patients have advance directives?

reimbursement is withheld and then, by law, is distributed back to all hospitals based on performance. The result is that some hospitals receive a penalty and lose money, while others gain


Measures are determined annually and are matched to larger categories, called domains that are weighted (see Figure 1) and result in a final score, called a total performance score. It is


this score that is compared to the performance of all hospitals (3,041 in 2015) that were eligible for the VBP program. CMS determines the curve that distributes all the withheld money back to the hospitals based on their performance. HRRP and HACRP The two other hospital incentive programs are penalty programs. For these two programs, hospitals are not able to earn additional monies, they either stay even or lose monies. CMS determines an adjustment factor for each hospital that is applied, going forward, to every DRG payment in the applicable fiscal year, reducing the hospital’s payment from CMS if the factor is less than 1,000. In the HRRP, hospitals are penalized up to 3 percent of their Medicare payments if they have excess readmissions for AMI, heart failure, pneumonia, and COPD patients; and surgical patients undergoing a total hip or knee arthroplasty or CABG procedure. The measures for this program are determined annually, but the HRRP and VBP programs have no overlapping measures and by federal law, the VBP program cannot include readmission measures.


Example of FY 2018 Value-Based Purchasing Domain Weighting & Measures (Payment adjustment effective for discharges from October 1, 2017 to September 30, 2018)



EFFICIENCY AND COST REDUCTION 25% PATIENT AND CAREGIVERCENTERED EXPERIENCE OF CARE/CARE COORDINATION HCAHPS Survey Dimensions Communication with nurses Communication with doctors Responsiveness of hospital staff Pain management Communication about medications Cleanliness and quietness Discharge information CTM-3 3-item Care Transitions Measure Overall rating of hospital

EFFICIENCY AND COST REDUCTION MEASURES MSPB-1 Medicare spending per beneficiary

The HACRP applies a 1 percent penalty to the bottom 25 percent of hospitals based on their performance on reducing patient infections and surgical adverse events or harm. It is set up similarly to VBP, with weighted domains and underlying measures that roll up to a total HACRP score. All the current measures in the HACRP do overlap with the VBP Program, but the scoring determination is different. Where the VBP program has targeted goals, the HACRP compares measure performance to other hospitals and calculates a z-score based on that ranking.


How to improve? The purpose of these programs is to provide an incentive


(Displayed as survival rate) 30-day mortality, AMI 30-day mortality, heart failure 30-day mortality, pneumonia

SAFETY MEASURES Complication/Patient Safety for Selected Indicators AHRQ PSI 90 composite Perinatal PC-01 Elective Delivery Prior to 39 Completed Weeks Gestation (Moved from Clinical Care) Healthcare-Associated Infections (Current standard population data) CLABSI CAUTI SSI Colon SSI Abdominal Hysterectomy C. difficile (CDI)

Source: Lake Superior Quality Innovation Network

20 20 for hospitals to improve and provide the highest quality care, while reducing inefficient or un20% necessary costs impacting the20 20%% care of the patient. There are strategies for impacting your performance on a specific clin% 15% 15 ical measure as well as strategies that can help make system 15% 15%% changes that may impact all 15 measures. In working with hospitals across Minnesota, these are some overarching strategies 10% 10% that we have learned. %


10 • Make reducing infections 10 10%% a priority. Reducing infections is one of the top health care priorities, and CMS includes infections in 2 of 3 hospital incentive % so imprograms because it5is 5% %%5% portant to reduce this prevent- 55 %


Overall Medicare Spending per Beneficiary by Claim Type 1–30 Days after Discharge, State and National Comparison 16.23% 16.23% 15.18% 15.18% 16.23% 16.23 16.23%%

15.18 15.18 15.18%%


13.31% 13.31% 13.31% 13.31 13.31%%

10.14% 10.14% 10.14% 10.14 10.14%%




% %% 4.48 4.484.48

% 5.41 5.41 5.41





% 4.21 4.21%4.21

3.85% 3.85 3.85%% 3.85 3.85%%

% 3.54%%%3.543.54 % 3.54 3.54 able harm to patients. Compared % % % 2.222.22 %% 2.22 to the rest of the nation, Minne-2.22 2.22 sota does not perform as well % %%% % % % %% % %% % 0.59 % 0.49 0.5% 0.5% 0.59 0.59 0.59 0.59% on catheter-associated urinary 0.5%0.5 0.49 0.5 0.5 0.5% 0.50.5 0.49% 0.49 0.49 0.5 tract infections (CAUTI) and the Overall Percent of Spending Overall Percent of Spending targeted surgical site infections Overall Overall Overall Percent Percent of ofSpending Spending Overall Overall Percent Percent of of Spending Overall Percent Percent of Spending of Spending Overall Overall Percent Percent ofSpending Spending of Spending after Discharge (State) after Discharge (Nation) after afterDischarge Discharge(State) (State) after afterDischarge Discharge(Nation) (Nation) (SSI) measured in these proafter Discharge after Discharge (State) (State) after Discharge after Discharge (Nation) (Nation) grams. Avoiding catheter use is Home Home Health Health Agency Agency Hospice Inpatient Outpatient Skilled Nursing Nursing Facility Facility Durable Durable Medical Medical Equipment Equipment Carrier CarrierCarrier Home Health Agency Hospice Hospice Inpatient InpatientOutpatient OutpatientSkilled Skilled Nursing Facility Durable Medical Equipment a key strategy to reduce Home CAUTIs Health HomeAgency Health Agency Hospice Hospice InpatientInpatient Outpatient Outpatient Skilled Nursing Skilled Facility NursingNetwork Facility Durable Medical Durable Equipment Medical Equipment Carrier Carrier Source: Lake Superior Quality Innovation and using a surgical site bundle of improvement strategies are important to reduce SSIs. good place to start is by evaluat• Look at end of life care. How ing how you are doing as far as many of your patients have readmissions and post hospitaladvance directives? How many ization deaths. are in hospice before the last • Look at the culture and belief few weeks of life? Hospitals are systems within your medical group. expensive places to provide endof-life care, so evaluating your Does your staff accept compliuse of hospice services can help cations and hospitalizations as identify opportunities to bet- an expected outcome, or do they ter utilize care. Having end of always evaluate if something life conversations with families could have been done differently is crucial to having a plan that and strive to improve care? Conmaintains dignity and quality of sider starting a patient advisory life for patients late in the course group if you do not have one in place in order to incorporate of their life-limiting illness. the voice of the patient and their • Connect with your partners families into your daily care. across settings. Check with your • Start understanding the pacommunity hospital to see if tient cost for the whole episode they have a care transition group of care. Both hospitals and clinof partners working on reducing readmissions and patient ics have the same measure atdeaths in that first vulnerable tributed to them, the Medicare month after a hospitalization. Spending per Beneficiary meaTeam up with your partners sure. The data for this measure

in the community to manage individual patients and identify the best way to provide care by using community resources. A

Value-based purchasing to page 36





n the United States, we are part of a culture where the first thing asked after the news of a baby being born is, “Is it a boy or a girl?” We immediately seek to classify the child into our pre-formulated mental constructs and alleviate our sense of uncertainty. We need to know if we should expect this child to play baseball or play with dolls. There does not appear to be much room for anything in between the two differentiated gender social constructs, and there is very little understanding at all of individuals who may not identify with the gender that was assigned to them at birth. Take a moment and ask yourself the following question: What gender am I? Female? Male? How do you know? What clearly differentiates a male from a female? Some point to anatomy, although we know a percentage of our population is born with ambiguous genitalia. Your hormones? We know that hormone levels vary significantly from

Growing up trans The unique mental health needs of transgender youth By Lindsay M. Narayan, MA, LMFT, BCBA

one person to another, even across prescribed gender lines. Menstruation or lack thereof? Again, this is never a consistent determinant of gender due to the influence of a variety of factors. Genetics? The fact that there are genotypes that fall outside of the typical XX or XY lend credence to the fact that genetics are not a perfect blueprint either. So what exactly defines a man from a woman? It is clear that gender may not be as plainly distinct as our society portrays. Yet, our culture is growing increasingly aware of gender variance. The needs and rights

of the LGBTQ community has been front-page news for decades. Gay marriage has been a hot topic for politicians as well as for the general public. Controversy over gender-specific bathrooms in public spaces is sensationalizing the news. Caitlyn Jenner’s public announcement of her transition shocked a culture that rarely interacts with members of the transgender community. Furthermore, there are increasing numbers of transgender individuals being portrayed on television, including a transgender woman in the hit series, “Orange is the New Black.” However, while the world is increasing in awareness of transgenderism, there is still a great deal of confusion and misinformation available. What is transgenderism? It is important to take a moment to clarify transgenderism. Being transgender refers to being across gender, and note that one’s gender does not determine or indicate anything about one’s sexual orientation. One’s own internal sense of gender is distinctly separate from one’s own internal sense of to whom they are attracted. Transgender individuals may be attracted to a same sex partner, or may not, just as for any other individual in our society. It is important to note that several other groups are also included within the transgender umbrella including, but not limited to: • Drag queen: An affirmed man who dresses in traditional woman’s clothing, often for entertainment. • Cross-dresser: An individual who wears clothing typically associated with the opposite gender.



• Genderqueer: An individual who rejects a strict two gender classification system and identifies instead as both genders, neither gender, or a combination of genders. • Two-spirit: A traditional Native American term that describes an individual who acts as a third distinct gender, performing responsibilities associated with both men and women as their bodies are believed to carry both a masculine and feminine spirit simultaneously. • Intersex: An individual born with ambiguous genitalia. • Gender-variant and gender-nonconforming: An individual whose gender expression does not match the gender they were assigned at birth Sex versus gender We must also clarify the difference between sex and gender. Sex refers to gender identity, and gender refers to gender expression. The University of Minnesota Transgender Commission defines these terms as follows: “Gender identity is one’s internal sense of who they are; being a woman or man, or between or beyond these genders. Gender expression is the external representation of one’s gender identity, usually expressed through feminine or masculine behaviors and signals such as clothing, hair, movement, voice or body characteristics.” It is possible, and actually common to have a transgender individual who know themselves to be say, female, and yet continue to express an outward gender of male. This is especially true of transgender youth who are still in the process of coming out to friends and family. An internal sense of gender identity When transgender individuals are asked about their childhood, they often report a sense of something feeling off about their gender. Even from early childhood, many transgender individuals found themselves

asking, “Why does everyone keep calling me a boy?” Their internal sense of themselves is different from their gendered outward presentation. This is the time when they experience a sense of disconnect between one’s inside knowledge and society’s perception. Adolescence is a period of life marked by the preoccupation with social acceptance and assimilation into societal norms. For transgender youth, adolescence is a time of crisis. In their book, “The Transgender Child,” authors Stephanie Brill and Rachel Pepper note: “As the pubertal changes begin, underlying gender dysphoria can even more strongly emerge in some children … some feel discomfort at the budding of a sexuality they are not ready to embrace.” Up until now, they suffered with the struggle of their internal sense of gender being different from the gender they had been assigned. Now, without permission, their bodies begin to transform and take on secondary-sex characteristics. Their internal sense of self is in stark contrast to how they appear on the outside, and this creates inner turmoil. There is a sense of their own bodies betraying them and the knowledge that addressing the inner conflict is unavoidable. They are faced with the difficult choice of coming out to the world with their affirmed gender, in spite of all the real risks that exist. The physician’s role Physicians are often the first professionals to detect mental health concerns in patients and refer for treatment, and this is certainly the case for transgender youth. Transgender youth will often present with complaints of depression, anger, withdrawal, school problems, and bullying. It is rare that a transgender youth will openly disclose their burgeoning gender affirmation. It is critical that a physician approach a patient’s gender from a position of curiosity, as it is not something that should be assumed. There is also

uncertainty regarding which personal pronouns to use when addressing the patient (e.g., he/ his, she/her, or patient’s name/ their). One may meet with a patient who has “male” listed on the chart, but think of this as only a starting point, not a definitive. Consider asking a simple question such as, “Would it be alright if I asked you to share your gender and preferred per-

transgenderism in youth. This may encourage a transgender individual to share previously undisclosed mental health concerns, including depression, self-harm, and thoughts of suicide. Simply by shifting our mindset to a place of not assuming gender, we could make a significant positive impact on the serious mental health issues in transgender youth.

There is a dire lack of therapists adequately trained in working with transgender youth.

sonal pronoun?” While this question may seem awkward at first, one may find it becomes a regular part of the procedure when getting to know a patient. Asking this introductory question is often innocuous for non-transgender youth, while being powerfully positive for transgender youth. For non-transgender youth, this question can be met with confusion as it is something they have never been asked before. A short explanation could be provided such as, “I understand that this question is confusing for you. There are some individuals who identify as a different gender and it is helpful for me to be respectful of this when providing care.” If the physician approaches this topic with sincere respect and importance, most youth will in turn reflect back a posture of respectfulness and understanding and the rest of the appointment will continue. However, for transgender youth, requesting information about affirmed gender and personal pronoun preference can instantly indicate to the patient that you may be trustworthy and understanding of their struggle, likely something they have not yet experienced. Asking for this information in such a simple way opens the door for difficult dialogues, improves care, and signifies that you are aware of

Behavioral health issues In our culture, babies are either boys or girls, heterosexuality is assumed, and marriage between a man and woman is the accepted path for adulthood. If you live a life outside of these set guidelines, your

way of living is invalidated. Sexual minorities are viewed as unusual, or even immoral or unnatural. Our youth absorb these messages in both overt and covert ways. In 2009, the Gay, Lesbian and Straight Education Network (GLSEN) found that 90 percent of transgender school-aged youth reported hearing peers comment about someone not being masculine enough or feminine enough on a regular basis. Furthermore, more than one-third of transgender youth heard school staff make negative comments about gender identity. Transgender youth internalize a sense of feeling that something is wrong with them and this manifests in a variety of unhealthy ways. Transgender youth are likely to present in therapy with a variety of problems, including

Growing up trans to page 20





hysicians are often the first point of contact for patients with mental health problems, and statistics suggest that front-line physicians will be increasingly called upon to determine effective treatment options for their patients. In fact, the National Alliance on Mental Illness (NAMI) reports that 18 percent of the population suffers from anxiety disorders and that up to 7 percent of adults will have a depressive episode in a given year. In addition, NAMI places the prevalence of any personality disorder in the general population at 9 percent with borderline personality disorder (BPD) at 1.4 percent. That means that tens of millions of Americans experience anxiety, depression, or both, often exacerbated by a personality disorder. Fortunately, the American Psychological Association (APA) reports that a large body of research shows that psychotherapy can be as effective as medication for many mental health


Dialectical behavior therapy Building a balanced satisfying life By Lane Pederson, PsyD, LP, DBTC

disorders, without the same side effects, and that therapy may have prophylactic effects too. This research suggests that patients will benefit from increasing referrals from physicians to therapists, especially those who practice therapies backed by a robust evidence base. Among evidence-based treatments, a skills-based therapy called dialectical behavior therapy, or DBT for short, has emerged as a treatment of choice for a wide array of mental health issues.


The origins of DBT DBT was developed from cognitive behavioral therapy (CBT) nearly three decades ago at the University of Washington to treat women with borderline personality disorder, a mental illness characterized by emotional sensitivity and reactivity; impulsivity; extremes in behavior and relationships; and self-injurious and suicidal behaviors. Among mental health disorders, BPD is considered one of the most challenging disorders to treat, because of its complexity and due to the number of other mental health disorders that coexist with it. Moreover, patients with BPD often seek multiple treatments that place a disproportionate strain on medical systems with their frequent crises that result in expensive physician and emergency room visits as well as extended hospitalizations. Years of failed treatments for patients with these intense problems exposed the glaring need for more effective psychological approaches, which in turn sparked the development of DBT. Research into DBT was prioritized early in its development, and it soon demonstrated its superiority to treatment as usual (TAU) through a number of randomized clinical trials (RCTs). These RCTs resulted in DBT being classified as an evidence-based treatment (EBT) for BPD, and because BPD is so prevalent in mental health settings too, this initial research generated tremendous interest among therapists who have

been trained in DBT by the tens of thousands. Research on DBT over the past couple of decades has exploded too, with over 20 RCTs demonstrating its efficacy for a variety of clinical presentations. How DBT differs from other therapies DBT is different from many therapies in that it emphasizes a highly structured approach that promotes commitment to change and stability while prioritizing and targeting patients’ most intense and problematic behaviors through intensive skills training. As patients practice skills to decrease their most intense and extreme behaviors, eventually the focus turns toward using their skills to function better across all major areas of life. Ultimately, the goal in DBT is to build a balanced and satisfying life, and those who invest in the therapy realize this goal over time. The “D” in DBT stands for d ia lectics, a ph i losoph ica l approach that lies at the heart of DBT and guides the therapy. Dialectics emphasize balance and flexibility in thought and behavior. Guided by this philosophical approach, therapists recognize that clients are doing their best and need to do better and constantly work to balance acceptance in the moment with movement toward change. By holding both ends of the dialectic, DBT therapists respect how and why clients get stuck, while also pushing them toward change. DBT therapists emphasize acceptance through validation, which is the nonjudgmental acknowledgement of what clients feel and experience. Through validation, clients are able to regulate their emotions and learn that they can accept and tolerate feelings that are unbearable and subsequently escape from i nef fe c t ive b eh av ior s . The emphasis on validation makes DBT decidedly more emotion focused compared to the thought focus that is characteristic of CBT. This difference tends

to open clients up to learning skills from four traditional skill modules. These modules have

Physicians are often the first point of contact for patients with mental health problems. their own lexicon for naming and organizing dozens of sk illf ul behaviors, allowing clients to systematically learn and practice them reliably. This reliable practice of skills is what leads to lasting changes. The four main modules include: • Mindfulness: Connecting to the present moment on purpose and nonjudgmentally. Mindfulness practice helps patients be more responsive and effective rather

than reactive. Mindfulness practice also has its own extensive empirical base; practitioners of mindfulness experience psychological, emotional, and physical benefits, and they tend to be more efficient too.

positive emotions, and how to effectively cope with painful emotions. Emotion regulation also emphasizes the importance of self-care behaviors such as balanced sleep, eating, and exercise, all of which are proven to increase mental and physical health.

• Distress tolerance: Allows patients to survive and get through a crisis without making their situation worse. Distress tolerance skills replace ineffective coping behaviors such as self-injury, drug and alcohol use, gambling, over-eating, and over-spending. One skill that is characteristic of both distress tolerance and mindfulness is urge-surfing, where patients learn to “ride the wave” of harmful urges without acting on them.

• Interpersonal effectiveness: Helps patients be more effective in relationships. Interpersonal effectiveness emphasizes assertiveness, behaviors that focus on building and maintaining healthy relationships, and behaviors that enhance self-respect. As patients have their needs met through healthy relationships, reliance on professionals tends to decrease.

• Emotion regulation: Teaches patients about emotions, how to achieve emotional balance, how to increase

Because DBT has so much psychoeducation and skills practice, the approach emphasizes a longer course of therapy over

brief interventions. Physicians understand that significant life changes to address illness takes time, and most patients who engage in DBT can expect treatment to take a minimum of six months, with many patients staying in DBT for a year or more. Because many DBT patients have been struggling with their mental health issues for years, a longer length of stay allows for the opportunity to proactively recognize symptoms and to learn how to manage them with skills. The overall goal is sustained improvement. While long-term therapy seems to go against the grain, the research demonstrates that it pays for itself in reduced hospitalizations and other health care costs.

Dialectical behavior therapy to page 21





xposure and response prevention (ERP), also known as exposure and ritual prevention, is an evidencebased psychological treatment for obsessive-compulsive disorder (OCD). To learn how ERP works, it’s essential to first understand the components of OCD. OCD behavior According to the International OCD Foundation, between 2 and 3 million Americans have OCD. A person with OCD has obsessions that are unwanted such as anxiety-inducing thoughts, images, or impulses. Compulsions are behaviors or mental acts that are repeated, or done in a specific manner, in order to reduce the anxiety brought on by the obsession. The obsessive thoughts are typically unrealistic and even though many people with OCD commonly acknowledge this, they still feel compelled to act on them. For example, a person with OCD may be anxious about

Exposure and response prevention An effective method for treating OCD By Tracey K. Lichner, PhD, LP

burglars potentially robbing their home. This person may close and lock their door, leave their house, but then ask themselves, “Did I really lock the door? Maybe I should make absolutely sure.” This obsession causes severe anxiety to the point that they return to the house and check the door. It is not uncommon for an individual with this type of OCD to check and re-check their door as much as 30 times per day. The person with OCD understands this fear

and behavior is unrealistic, but they feel driven to check the door due to the high anxiety caused by the obsessive thought. Effective treatment ERP is a highly effective treatment that can significantly reduce OCD symptoms. The individual is encouraged to confront the anxiety-provoking situation that triggers the obsessions, while refraining from performing the ritual. The person with anxiety about burglary, for example, might practice locking the door once, heading off to work, and resisting the urge to check the door. At first, exposure to anxieties can be very uncomfortable. But if the OCD sufferer practices these exposures for long durations and repeatedly over time, their anxiety will decrease. As therapy progresses, the person learns that their feared consequence (e.g., burglary) does not occur, even if they don’t perform their ritual (e.g., checking 30 times). In ERP, the therapist fully assesses all OCD symptoms and creates a list, or exposure hierarchy, of situations that trigger anxiety for that individual, from least challenging to more difficult. The therapist assists the patient in working gradually up the exposure list, building on successes until anxiety and the urges to perform rituals decrease and the frequency and intensity of obsessions diminish. Habituation sets in Exposure therapy works because anxiety doesn’t have the



power to last forever. Anxiety will only last for so long because a person gets used to it— or, habituates. Think of how your body eventually gets over the initial shock of swimming in a cold lake. After a while you suddenly begin to feel less cold. The same is true of anxiety. Prolonged and repetitive exposures to anxious situations are the best way to reduce symptoms. Anxiety won’t subside if a person only experiences their fear for five minutes. But, if a person participates in an exposure for long enough, perhaps 20 minutes or so, their anxiety will reduce significantly, causing habituation. If they repeat the same exposure every day, for a long enough time to achieve habituation, they will likely conquer that anxiety and no longer have any fear. They also learn that their feared outcome does not take place. Of course, people with OCD can’t just shut off their compulsive behaviors. If they could, many would likely cure themselves in a day. Even people without OCD have a hard time breaking behaviors or routines they’ve done for years. Refrain from OCD compulsions during exposures is difficult, especially at the start of treatment. However, in order for the technique to be successful, a patient must refrain from his or her compulsions during an exposure. If a person doesn’t give themselves enough time to habituate and decrease their anxiety, they’re learning that their compulsion is the only thing that makes them feel better. Instead of reducing compulsions, this reinforces them. Our goal is for patients to learn they don’t need to do their repetitive behaviors to feel relief and they can temporarily ride out the anxiety for a long-term improvement in their OCD symptoms. ERP then and now For a long time, it was widely believed that there was no effective method for treating OCD. It wasn’t until the mid-1960s that the first successful treatment

was provided by Victor Meyer and his colleagues. Their two patients participated in prolonged exposure, with compulsion resistance. The team later expanded their studies and found success with many of their patients. In the 1970s, more clinical researchers began conducting randomized trials to test Meyer’s new method. Stanley Rachman, R.J. Hodgson, and Isaac Marks found that participants not only reduced symptoms but were also able to sustain their recovery for years afterward. In their 1996 review of 12 treatment studies, Edna Foa and Michael Kozak reported that 83 percent of patients who completed ERP therapy were successful in treatment. After following up with these patients, 76 percent were able to sustain their recovery. Today we know exposures can be helpful for treating a wide variety of anxiety symptoms. Exposure therapy has an extensive history of being useful for treating phobias, panic disorder, generalized anxiety disorder, post-traumatic stress disorder (PTSD), and social anxiety. What makes ERP for OCD different is the addition of resistance of rituals to reduce anxiety. Unlike other disorders with many alternatives for treatment, such as PTSD, there aren’t many effective therapeutic models available for OCD. Besides ERP, the only known effective alternative treatment options are medication and certain types of brain stimulation or surgery. However, the expert consensus is that ERP is the treatment of choice for OCD. What to expect in treatment OCD can be quite debilitating, and the level of treatment depends on the severity of symptoms. OCD is often treated in once-a-week outpatient therapy sessions, with homework exercises to bridge the therapeutic work into the individual’s life. Sometimes, specialized outpatient therapy is needed, such as

half-day intensive outpatient or fuller day, partial hospital programs for several days a week. Children, teens, and adults with

some people, medication alone improves symptoms. Data has shown that most of the time, medications partially reduce

Exposure therapy works because anxiety doesn’t have the power to last forever.

more intensive needs may turn to residential treatment. ERP is a core component of the therapeutic intervention at each level of care. Because obsessions and compulsions are so unique to each patient, ERP treatment has to be targeted to the individual. There are an infinite variety of obsessions and compulsions, some so unusual they may seem psychotic to the untrained professional. Although some people can and do make progress with ERP on their own, it’s difficult to be successful without the guidance of a trained therapist. Some professionally guided support groups for ERP do exist. These groups ask participants to do exposures on their own time and then use group sessions to report how the exposures went, as well as receive support and encouragement from others. ERP is an active, and often challenging treatment, which may be intimidating to some. It’s different from traditional talk therapy in an office setting. A good candidate for ERP must be prepared to feel somewhat uncomfortable. But, daily life with untreated OCD is even more uncomfortable and can damage a person’s quality of life. It’s important to focus on the outcome or goal. Trained ERP therapists work very hard to be supportive and help patients do their exposures in a graduated, structured fashion at a pace they can manage. If a person’s OCD interferes with his or her life or causes significant distress, they may benefit from the treatment. For

symptoms. Often, it is easier to obtain medication than it is to access an ERP-trained therapist. If someone with OCD doesn’t have success with medication, then ERP may be the next step. With ERP, many patients have been able to titrate down or completely stop taking their medications. A benefit to exposure therapy is less risk of relapse. If a person who stops medications is equipped with ERP, they have the foundation to sustain recovery.

When using ERP, perhaps the most important lesson a patient learns is to be self-efficacious. Before seeking programming, people with OCD may feel victimized by the disorder because their symptoms control them and the only way they know how to cope is through compulsions. ERP is empowering because it offers an alternative method and gives people more lifelong control over OCD. The clinician’s perspective When designing treatment, therapists may have to use their creativity. As a clinician, coming up with exposures that specifically target a person’s individual symptoms may be one of the most challenging—and enjoyable—aspects of treatment. Professionals have to think through how each exposure will look. And because of the wide

Exposure and response prevention to page 25



Growing up trans from page 15

issues at school, depression, anger, withdrawal, and bullying by peers. In the GLSEN study, only 11 percent of transgender students reported staff intervening when peers made negative comments about gender identity. In addition, 82 percent of transgender students felt unsafe at school, and 46 percent had missed at least one day of school within the past month because they felt unsafe there. Transgender youth experience chronic devaluation and dehumanization. The sense of self-doubt and fear of being “found out” can be all encompassing. Coming out publicly comes with a wealth of risks, including discrimination, rejection, social oppression, loss of friendships, loss of respect by peers or adults, isolation, abandonment, loneliness, abuse, and


being financially cut off or evicted from the family home by parents. Essentially by coming out, being fully accepting of themselves, and being fully authentic, they face the loss of everything they know. It comes as little surprise that transgender youth are at increased risk for depression, substance abuse, anxiety, self-injurious behavior, and suicide.

with transgender youth. In “The Transgender Child,” the authors describe how for pediatricians and therapists, it is likely that they “never had any training or read anything at all on the subject of transgender children” and “may thus bring only their personal opinions and biases, rather than solid, clinical, evidence-based information.” Therapists who work with

For transgender youth, adolescence is a time of crisis.

Therapy The mental health world is striving to keep up with the growing need for therapy that addresses the unique needs of transgender youth. Unfortunately, there is a dire lack of therapists adequately trained in working


this population must be trained in the critical task of supporting the individual through all the unique societal pressures and oppression, and guide them and their families toward understanding and acceptance. In their book “Nurturing Queer Youth,” Linda Stone Fish and Rebecca G. Harvey, family therapists who specialize in working with LGBTQ youth, describe how therapy validates the unique pressures faced by transgendered youth, lessens the sense of isolation, promotes a sense of self, all while supporting the individual and family in understanding and supporting one another. In order to address the unique mental health needs of transgender youth, it is critical that they receive the support of a competent therapist trained in working with this population. The typical approach when working with transgender youth is that of Queer Theory. Therapists utilizing this approach work with the individual to discard the pathologizing messages they have received their whole lives, acknowledge that labels are merely societal constructs, explore the ever-evolving understanding of self, and form a sexual minority identity. Successful therapy includes providing a safe space where all thoughts and feelings are

accepted, promoting difficult dialogues between family members in order to foster growth while maintaining connectedness, and moving beyond tolerance to embrace the positive aspects of sexual minority status. Through this work, transgender youth have an opportunity to transform previous uncertainty, anxiety, depression, anger, and other toxic states into forming an authentic identity with the necessary coping skills and access to resources to maintain their mental health for the long term. While therapists are transforming the prognoses of transgender youth today through mental health therapy, it is important to remember that physicians play a critical role in meeting the needs of transgender youth. Conclusion Our society is indeed shifting in its awareness and understanding of transgenderism. The youth today are experiencing a world where the needs and rights of the transgender community are being discussed in the public sphere. Whereas before transgender youth were forced to explore their gender identity in isolation, they now have countless resources available, both online as well as within a growing number of transgender youth support groups. We are hopeful that the increased awareness as well as increased resources will provide greater care toward the mental health needs of a community that is still struggling. Transgender youth have voices, gifts, and unique ways of seeing the world, and through our support, they will feel empowered to share these gifts with the world.

Lindsay M. Narayan, MA, LMFT, BCBA,

is a therapist with PrairieCare’s Partial Hospitalization Program where she works with children and adolescents presenting with acute mental health concerns. She is a licensed marriage and family therapist and a board-certified behavior analyst.

Dialectical behavior therapy from page 17

DBT treatment is most often received in organized programs that consist of a combination of individual therapy, group skills training, skills coaching over the phone, and in some formats group DBT therapy. The amount and length of therapy is largely determined by medical necessity. Patients with high complexity and chronicity of problems will typically need more treatment contact for longer, so DBT is offered across a continuum of care. Many programs are organized exactly like the original treatment model whereas other programs have been expanded into an intensive outpatient (IOP) format that meets several days a week for several hours each day. Of course, patients without a high degree of medical necessity may not need an organized program and

may benefit from only individual DBT therapy. Essential life skills Even though DBT was designed to treat borderline personality disorders and some of the toughest clinical cases, it turns out that the core components of DBT work for nearly everyone. We all need validation, we all benefit from a healthy

settings as well as an explosion of clinical applications far beyond borderline personality disorder. DBT has become a go-to treatment for mental illnesses that challenge therapists in the trenches because it works, as evidenced in both research and practice, and it has played a tremendous role in transforming clinical practice measured by saved and improved lives as

Dialectical behavior therapy ... has emerged as a treatment of choice for a wide array of mental health issues.

amount of challenge to change and grow, and DBT skills are essentially life skills, providing a road map for healthier living. It is therefore no surprise that DBT continues to result in ongoing research on varied clinical diagnoses and treatment

well as by considerable savings in health care dollars. Referring patients When making a referral to a DBT program, consider how long the program has been established and if the program

can cite outcome data to demonstrate clinical effectiveness for its client population. The most effective programs go beyond the empirical basis and monitor outcomes with their clients on a practice level. This use of practice-based evidence recognizes that real-world patients differ in important ways from research populations, and that the most effective treatment tends to be customized to individual patients. DBT is here to stay, and if you have not had a patient who has been helped by this evidencebased treatment, you will in time.

Lane Pederson, PsyD, LP, DBTC,

co-owns Mental Health Systems, PC (MHS), one of the largest DBT practices in the United States, and he is the author of three books on DBT. He has trained over 10,000 professionals across the United States, Canada, Mexico, Australia, and South Africa.





ow often does the following scenario unfold?

Dr. Famiglia sees his patient, Brigitte, a seventh grader, for a well-child visit in the fall. He knows Brigitte well, having delivered her 12 years earlier. A wide range of issues is addressed. HPV and meningococcal vaccines are given, and by all accounts it was a thorough and satisfying encounter. A check-up is planned in a year, and a computer-generated copy of Brigitte’s immunization record is given to her mother. Brigitte’s mother drops off the vaccine record at school. She is surprised when the school nurse calls to say that Brigitte still needs several shots that are required for school attendance. Having just been at the doctor’s office, Brigitte’s mother, doesn’t understand why she was not informed that her daughter needed other shots. This is in fact, a common scenario seen by school nurses throughout the state of Minnesota. This article explores ways to strengthen the

Physicians and school nurses Collaborating to improve immunization rates By Camille S. Murphy, MA, RN, and Emily Onello, MD

partnership between primary care physicians and school nurses, with the goal of improving immunization compliance and communication. Primary care physicians and school nurses share a common goal of improving vaccination rates in order to protect our patients and communities. However, these two professions often work in parallel without the opportunity for partnership and synergy. By taking some small but concerted steps to improve

collaboration, physicians potentially can improve both vaccination compliance and patient experience. All 50 states have immunization laws regarding school attendance, for the purpose of protecting public health—with schools acting as a gatekeeper. High immunization compliance rates provide “herd immunity” to prevent disease outbreaks and protect the most vulnerable. Children that are not compliant with their immunizations may not be allowed to attend school, though there can be varying levels of enforcement by state and school district. School nurse responsibilities Given this legal backdrop, it is important for physicians to understand the school nurse’s duties and responsibilities regarding vaccination compliance. A primary duty of school nurses in Minnesota is to monitor student immunizations, communicate with parents when necessary, and annually report the rate of immunization compliance to the Minnesota Department of Health (MDH). In Minnesota, school nurses generate an Annual Immunization Status Report (AISR) via the MDH Annual Immunization Reporting website. As part of this monitoring duty, school nurses gather proof of vaccination or properly documented exemptions as follows: 1. Notarized conscientious objection: In Minnesota, parents have the right to opt out of the immunization requirement for their child’s school



attendance (for philosophical, religious, or other personal objection). If a parent chooses this option, they must sign a notarized conscientious objection form. 2. Medical exemption: A letter signed and dated by the child’s health care provider. A provider may indicate that immunization(s) is contraindicated for medical reasons or that laboratory confirmation of the presence of adequate immunity exists and the immunization(s) is not required. 3. In a grace period (i.e. catch up schedule): A time period where a child is allowed to attend school while they go through the process of completing a vaccine(s) series. 4. McKinney-Vento Homeless Act (federal): The Act allows homeless students to enroll in school without the standard immunization and medical record documentation during the time they are homeless. Keep in mind that federal law supercedes state law. Clinic vs. school responsibility Both school nurses and physicians share the goal of achieving appropriate immunizations for children and adolescents. However, school nurses and physicians practice in very different settings. The school health care environment is often unfamiliar to the physician and clinic staff, so unintended barriers to communication and collaboration can arise. Health care and educational facilities each have their own regulatory policies and rules, especially pertaining to protecting personal health information. In the health care setting, personal health information is protected under the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). Health care providers may share immunization information with other providers as necessary to make continuing care decisions. In addition, Minnesota’s statute 144.3351 allows health care providers to disclose immunization information to schools without parental authorization.

This disclosure also allows physicians to upload vaccination information onto the state’s website, Minnesota Immunization Information Connection (MIIC), unless a parent or individual opts out. However, in the school setting, immunization records are governed by an additional privacy rule, the Family Educational Rights and Privacy Act (FERPA), which requires parental consent before any student information is shared. The position of the Minnesota Department of Health is that FERPA preempts Minnesota statute 144.3351. Therefore, it appears that immunization data may flow from the clinic to the school, but a parental release is needed for information to flow from the school to the clinic. Improving compliance rates Given the different regulations governing clinics and schools, what can physicians do to help improve immunization compliance rates in children age 18 and younger? The following seven strategies are suggested: 1. Think about vaccinations at every clinic visit, especially during secondary school years. Consider all appointments as an opportunity to review all immunizations and educate parents as needed. Minnesota school nurses have found that parents often do not realize that their children still need shots after kindergarten, especially those required in the secondary school years. School nurses find that secondary students are often missing required immunizations. 2. Remember the primary vaccination series and make sure it is complete. When giving booster shots, physicians should review any earlier vaccination series to ensure that they have been completed. Minnesota school nurses often find sixth graders (approximately age 12) who have had a doctor’s appointment for their seventh grade physical and booster shots, received Tdap, Meningococcal, and HPV, but are missing Varicella # 2, or Hepatitis B # 3. Subsequently, parents become upset when

the school nurse informs them that their child is missing immunizations required for school attendance. 3. Share the news: Any time a shot is given, the clinic should

vaccination records and have developed online statewide immunization registries. Currently, however, there is no nationwide online immunization registry. Therefore, diligent efforts are

It is important for physicians to understand the school nurse’s duties.

share that information with the school. There are multiple avenues by which vaccine information can be communicated from a doctor’s office to the school. These include sending records via fax, providing a copy of the immunization record for a parent or guardian to give to the school nurse, or by updated MIIC data entry. Educate parents that immunization records are important and should be filed with important papers and taken along if they move. Emphasize that immunization records are needed throughout life—for school, college, military service, and possibly for employment. As mentioned, the MIIC is a statewide system that stores electronic immunization records for Minnesota health service providers and the public. However, not all clinics in Minnesota participate in MIIC. Physicians should know if their practice participates in MIIC. If not, they can advocate for clinic participation so that school nurses and other clinics can view immunization data. In current practice, designated clinic staff members (often a medical assistant) enter immunization data onto the MIIC site. 4. Help interstate information sharing: If students have lived in multiple states, their records may be difficult to find. My experience as a school nurse is that the immunization status of such children typically remains unknown for prolonged periods. Despite the fact that there is variability from state to state regarding release of immunization records, most states will share

still required by clinics, school nurses, and families to collect complete vaccine information. In the authors’ experience, it is the neediest of families that would most benefit from assistance in locating immunization records. Families in crisis who have few resources often don’t maintain vaccination records when they relocate. 5. Have a planned response for vaccine hesitant families: It’s inevitable that you will encounter parents who refuse

specific immunizations or want an altered vaccination schedule on the basis of non-scientific personal preference. Several good points are made in Dr. Marie Brown’s article in the March/ April 2014 issue of Family Practice Management: 1) Create a system with your team, making vaccination a front-end priority, rather than an afterthought. 2) The parent may decide to vaccinate their child once they hear that there is no effective treatment for measles, mumps, or polio. 3) The next outbreak of vaccine-preventable disease could be just one airline flight away. 6. Support your local school district efforts to enforce immunization requirements for school attendance. Primary care physicians are trusted community members who can help to communicate the public health benefits of adequate vaccination rates. Physicians already do this when

Physicians and school nurses to page 24



Physicians and school nurses from page 23

they promote the value of vaccinations in their daily medical practice. Physicians should also

7. Consider your pediatric patient’s school nurse as part of the health care team and communicate with them as needed. Consider implanting their contact information into the electronic medical record. The typical well-

IMMUNIZATION RESOURCES Immunization Information for Health Care Providers

4 Immunization Data Sharing and HIPAA Memo dated 5-2014


Most Minnesota schools use electronic health records.

be vocal in support of immunization requirements for school attendance in their communities. Schools vary in willingness to refuse enrollment to students who are lacking immunizations. Historically, Duluth Public Schools were reluctant to take this stand, however, recent experience showed that when state immunization requirements were more firmly enforced (i.e., students could not attend school if vaccines were delinquent), vaccine compliance improved.

child physician visit is 20 to 40 minutes long. But school nurses have the potential to engage with pediatric patients all week long during the school year. Physicians are encouraged to recognize that the school nurse is part of their team when caring for the school-age child. School nurses can be instrumental in carrying out a physician’s care plan in the school setting. Physicians may communicate with school nurses as needed via a parent signed release. Physicians

The Family Educational Rights and Privacy Act (FERPA) and Immunization Data

4 Stories are Powerful—Stories and Tools to Assist with Vaccine Hesitant Families Stories show the severity of vaccine-preventable diseases and how immunizations help protect children and the community. Data and statistics are easily forgotten, but stories get remembered.

4 Vaccines for Teens MIIC FAQ for Health Professionals

4 Minnesota Immunization Law information

4 4 4

may not be aware that most Minnesota schools use electronic health records too! One such system is Infinite Campus, which allows school nurses to view the compliance or non-compliance of required immunizations at a glance. Though state and federal laws can sometimes hinder open communication, the widespread adoption of electronic health records in both clinics and schools offer future opportunity for efficient and important information sharing. Imagine if clinics, schools, and MIIC use digital technology to share immunization data to improve communication and student health. Conclusion A primary public health duty of the school nurse is to monitor and report to MDH the immunization compliance rates of school-age children. The goal of this article is to reinforce the communication between



physicians and school nurses to improve immunization compliance rates, especially in the secondary school-age population. Additionally, please consider including school nurses in your health system’s electronic medical record as part of the health care team caring for the schoolage child. Inclusion in the electronic medical record will foster a stronger collaboration between primary care providers and school nurses. Camille S. Murphy, MA, RN, is a licensed school nurse in Duluth. She was nominated for the 2014 CDC Childhood Immunization Champion Award, which recognizes local immunization champions. Emily Onello, MD, is an assistant professor in the department of Family Medicine and Community Health at the University of Minnesota Medical School Duluth and a practicing physician at the Lake Superior Community Health Center.

Exposure and response prevention from page 19

variety of obsessions and compulsions, treatment can look wildly different from person to person. Exposures can be practiced in the office, clinic, or agency; outside of the office; or in the home. Ultimately, exposures need to be practiced by the individual “where the OCD lives,” whether in their home, socializing with others, or at work. Ideally, over time the individual learns they can manage their disorder with ERP, even without meeting with their therapist weekly. While there is no cure for OCD, ERP offers an opportunity to keep the disorder at a minimal level, so the person can function without OCD anxiety limiting their life. Treatment options and referral It’s important to know the presenting signs of untreated OCD,

because some people are too embarrassed to discuss their unrealistic obsessions or compulsions. A patient may refer to constant fears or unwanted

have or everyday worries, such as finances and work performance, but are more unrealistic or excessive. To meet diagnostic criteria for OCD, a person must

A good candidate for ERP must be prepared to feel somewhat uncomfortable.

thoughts, but they may or may not go into detail about their anxieties. Excessive anxiety or physiological arousal may also present, such as lack of sleep and difficulty sitting still or concentrating. If a person with untreated OCD has contamination concerns, you may notice their hands are unusually rough, which may indicate excessive hand washing. OCD is not related to the routines and preferences we all

have obsessions, compulsions, or both; spend more than one hour per day participating in obsessions or compulsions or be significantly distressed by them; or have OCD symptoms that are not caused by a substance or an alternative disorder. OCD is assessed with the interview-style clinician-administered Yale-Brown Obsessive Compulsive Scale. A screening tool called the OCI-R (Obsessive-Compulsive Inventory-Revised) can be quite

helpful for indicating a need for further assessment by a clinician. The patient completes a self-report measure containing 18 items, which rates their distress with each. A cutoff score of 21 indicates possible OCD. If you believe a patient may have untreated OCD, consider using the OCI-R to screen for symptoms that interfere with their lives. If your patient does meet criteria, refer them to an ERP-trained therapist. The International OCD Foundation website has a list of therapists trained in the use of ERP.

Tracey K. Lichner, PhD, LP, is the clinical director of Rogers Behavioral Health–Minneapolis and is an active member of the Anxiety and Depression Association of America, Association for Behavioral and Cognitive Therapies, and the International OCD Foundation.





n Minnesota, as in the rest of the nation, traumatic brain injury (TBI) is the greatest cause of death and disability in people under the age of 35. Nationally, according to the CDC, TBI leads to almost 2.5 million hospitalizations, emergency department (ED) visits, and deaths. Concussion, also called “mild traumatic brain injury,” has an incidence rate of 600/100,000 patients, and represents 90 percent of head injured patients seen in the ED. Sports and other recreational activities account for almost 20 percent of concussions in those younger than age 19. Despite the high prevalence of brain injury, it is poorly understood. There have been more than 30 consecutive failed clinical trials assessing treatments for brain injury, with zero successful phase III trials. These failures may arise from an inability to objectively quantify radiographically silent injury and identify patients who are likely to have a poorer functional outcome after injury. A lack of sensitive outcome measures for

Studying brain injury A launching point for discovery By Molly Hubbard, MD, and Uzma Samadani, MD, PhD

recovery from brain injury also contributes to the successive failures. Hennepin County Medical Center (HCMC) is attacking brain injury on all fronts by launching a comprehensive study to improve detection and classification; invoking cutting edge therapies such as electroceuticals, hyperbaric oxygen, novel rehabilitative strategies; as well as educating the community about brain injury prevention. Classifying brain injury This spring, we launched the Brain Injury Assessment Study, which is the largest single site TBI study in the country. The

study is sponsored by the diagnostics business of Abbott, the global health care company; the Minnesota State Spinal Cord Injury and Traumatic Brain Injury Grant Program; and the Rockswold Kaplan endowed chair funding at HCMC. It represents a collaboration among several groups including trauma surgery (Dr. Chad Richardson); emergency medicine (Drs. Jim Miner and Johanna Moore); radiology (Dr. Charles Truwit); laboratory medicine (Dr. Fred Apple); brain injury rehabilitation (Dr. Sarah Rockswold); statistics (Dr. David Gilbertson); bioinformatics (graduate student Margaret Mahan); and

neurosurgery (Drs. Thomas Bergman, Walter Galicich, Molly Hubbard, Gaylan Rockswold, and Uzma Samadani). In this study, trauma patients are enrolled directly from the ED and undergo a multimodal assessment in an effort to identify biomarkers differentiating different brain injury subtypes. Serum and plasma will be analyzed for various markers of brain injury and these will be monitored at distinct time points for a full year. Additionally, the study uses a novel eye tracking algorithm to detect eye movement abnormalities classically associated with concussion and structural injury. Some participants in the study will receive MRI and CT scans to attempt to better understand both acute and long-term changes to the brain after trauma. The ultimate goal of the study is to create a multimodal classification scheme for brain injury based on serum markers, eye tracking, and MRI so that therapeutics can be targeted appropriately. Such a classification

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scheme will help clinicians better understand the physiologic changes that occur after TBI. A secondary goal is to establish better outcome measures for brain injury. It is not enough to tell someone they have a concussion, we want to tell them specifically what is wrong with their brain and ultimately how it can be treated. Therapeutic trials for brain injury Recovery after TBI focuses primarily on physical, occupational, and speech therapies to help patients return to their pre-injury status. New studies that are being conducted at HCMC are focused on using interventional devices or therapeutics in the acute phase of injury in an attempt to augment the outcomes with the assistance of additional therapies. Hyperbaric oxygen Dr. Gaylan Rockswold has been a pioneer in the study of hyperbaric oxygen therapy (HBOT) for patients with severe traumatic

brain injury. Patients often have a high mortality after severe TBI and those who survive often have poor outcomes. There have been significant preclinical and clinical investigations that indicate that HBOT improves outcomes in patients with severe TBI. By increasing oxygen delivery to the brain, HBOT helps reduce secondary injury from hypoxia, thus

outcomes in a future phase III trial. Vagus nerve stimulation Further studies at HCMC aim at treating mild and moderate brain injury using electroceuticals, which stimulate neurons to provoke a response rather than rely on exogenous pharmaceuticals. The vagus nerve has an

Despite the high prevalence of brain injury, it is poorly understood.

improving outcomes. Patients with severe TBI may have compromised lung function, either from initial trauma or from acquired pneumonia; thus further information is needed to finetune the treatment paradigm of HBOT. The newest study being developed at HCMC is a phase II trial, aimed at selecting the combination of HBOT treatment parameters that are most likely to demonstrate improvement in

important regulatory function throughout the body and within the central nervous system. It modulates consciousness via thalamic connections to the cortical surface of the brain. Pre-clinical studies have shown that stimulation of the vagus nerve improves outcomes after traumatic brain injury. There is less inflammation and edema in tissue samples, improved wakefulness, and improved performance on

cognition tests. In these studies, however, stimulation requires the surgical placement of a stimulator. While vagal nerve stimulation (VNS) has been done in humans for treatment of seizures and depression, including those associated with prior TBI, for many years, it has not been done specifically for treatment of TBI. Recently, a hand-held non-invasive device that stimulates the vagus nerve directly through intact skin has been developed. Stimulation of the vagus nerve has the potential to alter the recovery from TBI by improving cerebral blood flow, decreasing inflammation, and improving other symptoms associated with TBI such as depression or seizures. We are launching studies looking at non-invasive VNS for treatment of both moderate and mild TBI. Visual rehabilitation Abnormal eye movements have been known to be associated

Studying brain injury to page 34





ccording to the National Center for Health Statistics, Minnesota’s leading cause of death is cancer. The American Cancer Society estimates 1 in 2 men and 1 in 3 women will be diagnosed with cancer in their lifetime. In Minnesota alone, it is estimated there will be over 29,000 new cases diagnosed this year. If you have patients struggling with a cancer diagnosis or at high risk of developing the disease, have you talked with them about research opportunities? In a 2013 poll from Research!America, patients report that 70 percent of doctors have not talked with them about medical research and 8 percent were not sure. In an oft-cited article by R.L. Comis, et al. in the Journal of Clinical Oncology it was noted that, “…the vast majority of adult patients with cancer (greater than 95%) do not participate in clinical trials, even though 70% of Americans are estimated to be inclined or very willing to participate in clinical trials.”


Increasing clinical trial enrollment Providers play an important role By Toni Kay Mangskau In the medical community, there seems to be a disconnect when it comes time to discuss clinical trials. Patients are often interested in learning about possible clinical trials and physicians understand the importance of research, yet the discussion is not happening. How can we make sure that this important dialogue occurs in any type of health care setting? Barriers to patient participation Many research studies have identified physician attitudes, time, and resources as barriers to patient participation. Many patients have commented to me


that they expect their physician to discuss possible research opportunities with them. Some highlights from a 2016 American Society of Clinical Oncology article, “The Role of Clinical Trial Participation in Cancer Research: Barriers, Evidence and Strategies” list the following: • A survey of oncologists in community cancer clinics found that most agreed that clinical trials provide highquality care (87 percent) and benefit enrolled patients (83 percent). • Physician decision or preference was the primary reason for nonparticipation

in half of the patients for whom a protocol was available and the patient was eligible. • The time spent attending to the details of clinical trial enrollment and explaining clinical trials to patients can often be prohibitive for physicians. Physicians have an opportunity to improve the care they provide to their patients. Many studies have identified how patients look to their doctor for information. The Pew Research Center estimates, “70% of U.S. adults got information, care, or support from a doctor or other healthcare professional.” Physicians need to seize the opportunity when patients look to them for reliable information and discuss clinical trials. By having these discussions, physicians may be able to help accelerate medical advancements. It is estimated to take about 12 to 14 years for a drug or treatment to be approved by the Food and Drug Administration (FDA). Most medications or

treatments are studied for six years in the laboratory and then spend six to eight years in clinical trials. It is unfortunate that with so many resources being allocated to research, 20 percent of publicly funded studies fail due to a lack of accrual. At other times studies have to remain open for a longer period of time due to slow accrual. We are at a critical juncture to continue building on earlier research. It doesn’t matter if a clinic is small or in a rural area, you can still talk to your patients about participating in research studies. A 2013 Journal of Oncology Practice article by Somkin, et al. points out, “It is estimated that 85% of patients with cancer are treated in community settings, with an increasing number being treated in integrated health care delivery systems.” With the variety of health care settings in Minnesota, academic centers and community clinics need to work together so patients learn about clinical research opportunities. The

Somkin article goes on to say, “By far, the strongest relationship with accrual was the broad concept of awareness...” You may now be wondering what your role is if you are not an oncologist. Whether you are an internist, surgeon, or other specialist, you

a ‘culture of research’ in a community hospital: Strategies and tools from the National Cancer Institute Community Cancer Center program,” it is mentioned that, “The ability to capture, report and evaluate metrics provided necessary data that help sustain program activities. Ad-

The easiest way to participate in research is [for patients] to give permission for their medical records to be used in chart review studies. can help increase awareness about clinical research. In the Research!America poll, 72 percent of respondents would be very likely or somewhat likely to participate in research if their doctor found a clinical trial and recommended they join. Research benefits are not limited to the cancer community—other disease groups can build on the cancer research model. In the article, “Creating

ditionally, the focused commitment to cancer research became a model for research programs in other disease entities within some of the hospitals.” Understanding the options As a physician you will have the opportunity to refer patients to different clinical research opportunities. Patients may not understand the difference between clinical research and

clinical trials, so here are some important points to bring up when talking with patients. Clinical research Clinical research involves people who volunteer to participate in studies that lead to better ways to prevent, diagnose, treat, and understand health conditions. Here are the types of clinical research: • Prevention studies look at ways to stop diseases from occurring. Options may include medicines, vaccines, or lifestyle changes. • Screening studies test for better ways to detect certain diseases or health conditions. • Diagnostic studies look for better tests or procedures for diagnosing a disease or condition. • Treatment studies test new therapies, combinations of drugs, new approaches to surgeries, or use of integrative medicine. Increasing clinical trial enrollment to page 30



Increasing clinical trial enrollment from page 29

• Genetic studies look at what you inherit from your family, and may be independent or part of other types of research. • Quality of life studies explore ways to improve people’s comfort and manage symptoms of chronic illness or treatment side effects. • Chart review studies review information from large groups of people to better understand, detect, control, and treat health-related conditions. When I talk with patients, I mention the easiest way to participate in research is to give permission for their medical records to be used in chart review studies. The benefit of participating in this type of research can be highlighted by an example of a large chart review study at Mayo, which included over 10,000 patient records, showing that CLL patients with low levels of Vitamin D had a significant


difference in cancer progression and death than patients with a normal Vitamin D level. We are building on this earlier research and currently have a Vitamin D treatment study enrolling participants with a variety of blood cancers. If your clinic or health system conducts these types of studies, it would be beneficial if patients understood what participating in a chart review study could mean. The consent process can be automated when patients complete their visit forms and consequently require little or no physician time. Clinical trials A clinical trial is a research study created to answer specific questions about new therapies or new ways of using known treatments. Clinical trials are used to determine whether new drugs or treatments are both safe and effective. Clinical trials take place in phases. For a treatment to become standard, it must first go through two or three clinical trial phases. Phase 1 studies sometimes are


referred to as “dosing” studies. The goal is to find the best dose and figure out the best way to administer the treatment. Phase 2 studies assess if the treatment is effective and Phase 3 studies typically compare the standard treatment to the new treatment. When to enroll in a study? The best time for a patient to consider participating in a clinical trial is when they are newly diagnosed and it is brought up as part of a treatment option conversation. The patient’s “clean slate” may mean that more Phase 2 or 3 treatment studies are open to them and that those studies are further along in the FDA’s approval process. If a patient starts standard treatments before investigating clinical trial options, they may be excluded from participating in specific Phase 2 or 3 trials that compare new treatment to standard treatments as the patient would possibly be randomized to the standard treatment. From the time a patient is newly diagnosed to the time

a patient has exhausted standard treatments, patients need to hear about clinical trial opportunities. The importance of research to future patients We know that today’s clinical trials help develop treatments or possible cures. For example, a patient who was being treated for ovarian cancer came into our Cancer Education Center. She had the same cancer her mother had been treated for 10 years earlier. Her mother had participated in a Phase 1 study that was now the standard treatment this patient was currently receiving. The daughter commented to the staff, “Participating in the study was the last gift my mother gave to the family.” In my role as clinical trials referral coordinator, I talk with thousands of patients and their family members from around the world who contact us for the latest clinical trial information. Many of the callers want to Increasing clinical trial enrollment to page 32



Increasing clinical trial enrollment from page 30

participate in research studies so they can buy more time, but also so their children or grandchildren never have to hear the words, “You have cancer.” They want to be part of a legacy that helps other cancer patients. What can providers do to help? You can help connect patients to clinical trial and study opportunities. When talking with patients, it is important to talk about clinical research along with treatment options. It is important to reassure a patient that you’re going to take good care of them, but still have time to discuss clinical trials. Arming newly diagnosed patients with as much treatment information as possible when facing cancer helps them make the decision on how to proceed. It’s helpful if you have a list of resources to help patients locate clinical trial information, lodging/travel assistance, and organizations able to help them


navigate through insurance and financial issues. This soft introduction to research opportunities in the medical community may make a difference in finding the newest and best treatments for patients. Sometimes, patients may not need to travel to a study location to participate in research, while other times patients may need to visit the study site. Travel requirements vary based on each study. Mayo Clinic recently redesigned its public clinical trials website and it includes a list of resources. Our cancer center has implemented a universal phone number and web form for clinical trial inquiries. We are streamlining the process for patients, family members, and referring providers to contact us for clinical trial information. It is my hope that this will continue to improve our clinical trial participation rates. When patients ask me for guidance when talking with their doctor and prioritizing possible studies to participate in, I tell them to ask these three questions:


1. What phase is the clinical trial? 2. H  ow familiar is the medical community with the medications or treatments? 3. What has earlier research shown?

Please consider discussing clinical trials with patients. It is important not to rule out Phase 1 study participation. Some Phase 1 studies are for initial treatment. Recently, we have been participating and planning for a couple of Phase 1/3 studies. There are many well-designed studies repurposing medications and others studying a medication for the first time in the FDA approval process. Additional guidance I offer patients is that what we learn about one disease can also benefit other diseases. For example, the diabetes medication, metformin, is currently being

studied as a treatment and chemoprevention for multiple types of cancer, and also to see if it can prevent migraine headaches. If you are talking with your patients about clinical trials, please continue to do so. If you are not, please consider discussing clinical trials with patients. Without clinical trial participation, we are unable to answer critical questions our patients are asking about. Physicians should start talking about clinical trials the first time they meet a patient. Only then can we continue to move science forward and offer the best treatments to our patients. Toni Kay Mangskau is clinical trials referral coordinator for the Mayo Clinic Cancer Center and oversees the clinical trials referral office for sites in Arizona, Florida, and Minnesota. Nationally, she has served as a steering committee member for the Summit Series on Cancer Clinical Trials, and was co-chair of the infrastructure/ funding subcommittee to develop a nationwide training program for research staff and to communicate with patients about clinical trials.



Studying brain injury from page 27

with brain injury for more than 3,000 years. While humans have the ability to move their eyes to look at various objects under their own volition, conjugate eye movements are controlled by centers in the brain stem. This conjugate movement is not voluntary and pressure on the third, fourth, or sixth cranial nerves, or the brain stem, lead to abnormalities in the ability to move the eyes in a conjugate manner. Recent studies suggest that as many as 90 percent of patients with concussion may have visual abnormalities. Dr. Sarah Rockswold, who is board-certified in physical medicine and rehabilitation, is currently investigating how visual rehabilitation can promote recovery from mild brain injury in a Minnesota state-funded project. Subjects are being enrolled in a prospective trial that includes a comprehensive assessment and visual rehabilitation program. They are subsequently assessed


with clinical and radiographic outcome measures in conjunction with investigators at the University of Minnesota. Brain injury prevention The Minnesota Healthy Brain Initiative is another study being launched from HCMC’s Brain Injury Research Lab, which aims first to promote public

then be compared to patients enrolled in the other clinical trials described earlier. In addition, state fair attendees can retest at various times during their visit, along with having a breath alcohol assessment, to assess the impact of alcohol consumption on their own cognitive function and visuomotor capability. Since alcohol consumption increases

The ultimate goal ‌ is to create a multimodal classification scheme for brain injury. learning about brain health and safety, with secondary goals of collecting normative data from a healthy, non-injured population. Research assistants from our lab will be stationed at the KARE 11 booth at the Minnesota State Fair where attendees from age four on will be offered an opportunity to undergo various cognitive assessments and eye tracking. This data will be used to establish baseline data that can


risk for trauma, this educational project aims to inform regarding the level of impairment seen after even only a few drinks. Conclusion As the busiest level one trauma center in the state, nestled in the heart of the medtech valley, we are uniquely positioned to drive further research in the field of brain injury. While TBI still presents a diagnostic,

prognostic, and treatment challenge for physicians and therapists, the collaborative studies being conducted are a launching point for discovery. Molly Hubbard, MD, is currently a

neurosurgery resident at the University of Minnesota under the guidance of Dr. Uzma Samadani as a co-investigator on multiple clinical research studies. While her primary interest remains in pediatrics and the effects of traumatic brain injury (TBI) on the developing brain, she is also investigating the long-term outcomes of TBI after a single severe head injury. Uzma Samadani, MD, PhD, is board-certified in neurological surgery, is the Rockswold Kaplan Endowed Chair for TBI Research at Hennepin County Medical Center, and an associate professor of neurosurgery at the University of Minnesota. She serves on the executive board of the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Committee on Trauma and Critical Care, and as Scientific Program Chair for their section at the National Neurotrauma Society Meeting.

OCTOBER 15, 2016


9am – 3pm



Minneapolis Convention Center 1301 2 Avenue South, Hall E Minneapolis, MN 55403 nd



Learn how to be healthy, active and live well with diabetes Make Healthy Food Choices

• Cooking demonstrations • Healthy food sampling • Tasty and healthful recipes

Get Active

• Learn how to work fitness into your everyday life • Fitness demonstrations • Exercise tips

Free Health Screenings • • • • • • • • •

A1C Stroke Risk Assessments Blood Pressure Foot Screenings Diabetes Risk Assessments Eye Screenings BMI (body mass index) Oral Cancer Screenings Kidney Screenings

Ask the Expert

Come prepared with questions for health care professionals who can answer your diabetes questions one-on-one. Learn more about how to manage diabetes and prevent devastating complications.

Family Fun

Interactive entertainment for the whole family.

Faces of Diabetes

Look for areas within the exhibit hall featuring information tailored to meet the specific needs of you and your family.

Visit to print a FREE Metro Transit pass to the event! Follow us for updates at: • Twitter: @DiabetesMN

For more info or to preregister: or call 1-888-DIABETES ext 6592



Value-based purchasing from page 13

comes from Part A and B Medicare Fee-for-Service claims. Seven different claim types are included for the three days prior to the hospital stay, during the stay, and for the time period 30 days after hospital discharge. In looking at the overall percentages of cost in the after-discharge time period (see Figure 2), it appears that we use less home care in Minnesota than the national average. Stratis Health also looked at the public data on Hospital Compare and found that the high performers on managing costs used more home care and hospice (actually more than even the national average in the case of hospice) and had more outpatient costs in the period after discharge. In our analysis of Minnesota data, sepsis was one of the more common diagnoses. Early identification and treatment of sepsis can be


crucial to the patient’s care and reducing cost. • Anticipate and act. Look ahead to see what is being focused on nationally. It takes time to improve clinical care, so understanding early what the national priorities will be allows more time to improve.

identified as new priorities and what may become part of VBP after being publically reported for one year. In your practice, connect finance, quality staff, and clinicians so they work together on defining strategies and evaluating progress. Different perspectives and expertise are required to address the

Consider starting a patient advisory group if you do not have one in place.

requires a different skill set. You will need quality leaders that can understand risk adjustment, are able to set up interim measures for monitoring, and see the big picture to identify improvement opportunities. As a member of the Lake Superior Quality Innovation Network (QIN), part of the Centers for Medicare & Medicaid Services Quality Improvement Organization (QIO) Program, Stratis Health offers technical assistance and support for Minnesota hospitals to be successful in a value-driven environment. Vicki Olson, BSN, MS, is a program

You can do this by paying attention to the annual report on the National Quality Strategy called the National Healthcare Quality and Disparities report. Also be aware of what new measures are added to the inpatient reporting program. This will signal what CMS has


more complicated improvement work focused on outcomes that are evaluated by claims. Improvement work focused on process measures has been the standard for the last 10–20 years. As we move to improve using outcome measures that are evaluated through claims, it

manager at Stratis Health. She leads and supports quality improvement initiatives in Minnesota hospitals related to national and state mandates for quality public reporting and hospital value-based purchasing. She works with the health care community to achieve Medicare’s quality improvement goals in Minnesota through Lake Superior Quality Innovation Network.



America’s gun violence from page 11

all of Europe, and much more rigid than Canada or Japan. Now more than ever, a child’s prospects in the U.S. are determined by what their parents achieved. What can we do to help? It is easy to become overwhelmed when discussing gun violence and other social problems on this scale. But the fact that other capitalist democracies have learned to manage these problems more effectively suggests we can as well. I am not suggesting other countries manage things perfectly. Everyone makes compromises and each system has legitimate criticisms. I will simply state that there is no reason not to try something different given how unhealthy conditions are here right now. There is no shame in borrowing another’s good ideas.


For one, we can admit that the answer to the poorer health outcomes in this country is not going to be solved by the health care industry. These are social problems and they need social

care, we could advocate for more resources for other social goods like education. Doctors have played important roles in public health campaigns before, such as exposing the dangers of

[America has] half of all the privately held guns in the world.

solutions. And the sheer size of the U.S. health care industry, at $3 trillion in spending per year, adversely affects our ability to make other social investments. Rather than advocating for more resources for health


tobacco. Advocating for more action on social disparities could be an important undertaking even if it did not result in increased physician revenue. Arguing for more equity is a tough sell in America. It

certainly does not feel like the culture that we identify with. However, America has had more esteem for equity in times past. Alexis de Tocqueville, in his classic text, Democracy in America, published in 1835 and 1840, commented on the “equality of conditions” that defines the American experience and the positive effect it had on civic relations. It is not beyond our cultural grasp to return to something more in line with those values. After all, our motto in 1782 was “E pluribus unum.” Out of many, one.

Chris Johnson, MD, is an emergency

physician working for Allina Health Urgent Care. He serves on the Minnesota Medical Association Board of Trustees and the Department of Human Services Health Services Advisory Committee.

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

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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MN Physician September 2016  
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America’s gun violence: The importance of social health By Chris Johnson, MD • Value-based purchasing: What this means for your practice By...